Should surgery followed by whole-brain radiation therapy be the standard treatment for single brain metastasis?

This Practice Point commentary discusses the results of a retrospective analysis conducted by Rades et al. that examined surgical intervention followed by whole-brain radiation therapy (WBRT) and WBRT alone in patients with a single brain metastasis. Although three trials have already provided level 1 data regarding the treatment of such patients, there is a disparity in the conclusions of these studies, with two trials favoring surgery before WBRT and the third not finding a benefit with surgery. The number of patients enrolled in each prospective randomized study was, however, small. The retrospective analysis by Rades et al. simply confirms and reinforces the standard practice of surgical resection before WBRT. There are fine distinctions between patients with this malignancy that were not discussed and deserve mention. Not all patients with a single brain metastasis have a surgically resectable lesion, notably individuals who have a tumor in an eloquent region of brain, the deep gray matter, or the brainstem. Other treatments are more appropriate for tumors in these locations and, therefore, the results of the Rades et al. analysis pertain only to patients with resectable tumors.