Postoperative Radiotherapy in the Treatment of Single Metastases to the Brain

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Abstract
FOR PATIENTS with single metastases to the brain and limited systemic disease, 2 randomized trials1,2 have shown that surgical resection combined with postoperative whole-brain radiotherapy (WBRT) is superior to treatment with WBRT alone. (Although it should be noted that 1 randomized trial3 failed to show a benefit from surgery.) Postoperative radiotherapy was used in all of the previous randomized trials assessing the efficacy of surgery in the treatment of single brain metastases because it was felt to be effective both in destroying any tumor left in the operative bed and in eliminating undetected micrometastases elsewhere in the brain. However, the rationale for postoperative WBRT is based on unproven assumptions. Given that most metastases are discrete masses and do not infiltrate diffusely into the brain, it is possible that metastases are capable of being totally removed by surgery. Also, improvements in neuroimaging, especially contrast-enhanced, high-resolution magnetic resonance imaging (MRI), may make it possible to detect small metastases and the residual tumor and make the routine use of postoperative WBRT unnecessary.