The Role of Surgical Resection

The American Association of Neurological Surgeons & the Congress of Neurological Surgeons

Should patients with newly-diagnosed metastatic brain tumors undergo open surgical resection versus whole brain radiation therapy (WBRT) and/or other treatment modalities such as radiosurgery, and in what clinical settings?

Target population

These recommendations apply to adults with a newly diagnosed single brain metastasis
amenable to surgical resection.


Surgical resection plus WBRT versus surgical resection alone

Level 1 Surgical resection followed by WBRT represents a superior treatment modality,
in terms of improving tumor control at the original site of the metastasis and in the brain
overall, when compared to surgical resection alone.

Surgical resection plus WBRT versus SRS ± WBRT

Level 2 Surgical resection plus WBRT, versus stereotactic radiosurgery (SRS) plus WBRT, both represent effective treatment strategies, resulting in relatively equal survival rates. SRS has not been assessed from an evidence-based standpoint for larger lesions (>3 cm) or for those causing significant mass effect (>1 cm midline shift). 
Level 3
Underpowered class I evidence along with the preponderance of conflicting class II evidence suggests that SRS alone may provide equivalent functional and survival outcomes compared with resection + WBRT for patients with single brain metastases, so long as ready detection of distant site failure and salvage SRS are possible.
Note: The following question is fully addressed in the WBRT guideline paper within this
series by Gaspar et al. Given that the recommendation resulting from the systematic
review of the literature on this topic is also highly relevant to the discussion of the role of
surgical resection in the management of brain metastases, this recommendation has
been included below.

Does surgical resection in addition to WBRT improve outcomes when compared with WBRT alone?

Target population

This recommendation applies to adults with a newly diagnosed single brain metastasis
amenable to surgical resection; however, the recommendation does not apply to
relatively radiosensitive tumors histologies (i.e., small cell lung cancer, leukemia,
lymphoma, germ cell tumors and multiple myeloma).


Surgical resection plus WBRT versus WBRT alone

Level 1 Class I evidence supports the use of surgical resection plus post-operative WBRT, as compared to WBRT alone, in patients with good performance status (functionally independent and spending less than 50% of time in bed) and limited extracranial disease. There is insufficient evidence to make a recommendation for patients with poor performance scores, advanced systemic disease, or multiple brain metastases.