What is the randomised evidence for surgery and stereotactic radiosurgery for patients with solitary (or few) brain metastases?

Patients with solitary (or few) brain metastases are often treated with surgery (S) or stereotactic radiosurgery (SRS) with or without adjuvant whole brain radiotherapy (WBRT). This review examines the randomised evidence supporting this aggressive approach. A search of MEDLINE, EMBASE and Cochrane databases for published papers and Abstracts on relevant randomised trials was undertaken. Fourteen randomised trials were identified, 11 final reports and 3 Abstracts, investigating various combinations of S, SRS and WBRT. Most of these trials had significant limitations and the results therefore need to be viewed with caution. Surgery and SRS improve local control, maintenance of performance status and survival for favourable prognosis patients with solitary brain metastases relative to WBRT alone, although the absolute survival benefit for the majority is modest. Limited data suggest similar outcomes from S and SRS, but few patients are truly suitable for both options. For multiple (2-4) brain metastases, SRS improves local control and functional outcome but not survival; there is no randomised evidence for S. Adjuvant WBRT also improves intracranial control but not survival; however, the neurocognitive risk : benefit ratio of WBRT remains controversial. Quality of life data are currently limited.