A Trial Comparing Radiosurgery With Surgery for Solitary Brain Metastases

Study Overview
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Brief Summary
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This study examines surgery versus radiosurgery (highly focussed radiation) for the treatment of cancer which has spread to one spot in the brain (solitary brain metastasis). For these two treatment options, it will compare patients' survival times, quality of life, control rate of the brain metastases and side effects. It uses the most rigorous scientific method available called randomisation which minimises biases that exist with other types of studies. It will involve 30 - 40 patients.

Detailed Description
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Primary objectives - to evaluate for solitary brain metastases whether both overall survival and health related quality of life (HQoL) in patients treated with radiosurgery (RS) plus whole brain radiotherapy (WBRT) are non-inferior to those of patients treated with surgery (S) plus WBRT. Secondary objectives - to compare between the two treatment arms time to local and distant brain recurrence, failure free survival, acute and late toxicity. Hypothesis - Patients treated with RS + WBRT have neither worse survival nor worse quality of life than those treated with S + WBRT. Research plan: Trial design - Single-centre prospective randomised Phase III controlled two arm non-inferiority study with the gold standard of surgery (plus WBRT) as the control arm. Blinding to trial arm will not be feasible. Stratification is by Radiation Therapy Oncology Group Recursive Partitioning Analysis (RPA) prognostic Class 1 vs 2 vs 3. Main eligibility criteria - single presumed metastasis on MRI brain; systemic cancer diagnosed within the last 5 years; considered suitable for both S and RS; written informed consent. Main exclusion criteria - surgery indicated for life-threatening raised intra-cranial pressure or tissue diagnosis; surgery contra-indicated by site or medical co-morbidities; leptomeningeal disease; primary is small cell lung cancer, germ cell tumour, lymphoma, leukaemia or myeloma. Radiation - WBRT dose is 30 Gy in 10 fractions over 2 weeks. RS dose is based on lesion size up to 4 cm (15-20 Gy). Surgery - Aim is complete excision. Treatment sequence and patient assessments - Any sequencing of S/RS and WBRT is allowable, as long as the brain treatment is commenced within 2 weeks after, and completed within 6½ weeks after the diagnostic MRI brain. Assessments at baseline, during brain treatment, at 2 and 3 months after commencement, then 3 monthly, with MRI brain at 3 and 6 months, and/or as clinically indicated. Acute toxicity monitored by NCI Common Toxicity Criteria, late toxicity by RTOG/EORTC Late Radiation Morbidity Scheme. HQoL assessed by EORTC QLQ-C30 and QLQ-BN20. Sample size - 30-40 patients over 5 years. Outcomes and Significance: The trial will enable Level I evidence to be applied to this common clinical problem. Patients will be able to make an informed choice based upon valid survival, quality of life and toxicity comparisons.

Official Title
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A Randomised Trial of Surgery Plus Whole Brain Radiotherapy (WBRT) Versus Radiosurgery Plus WBRT for Solitary Brain Metastases

Conditions
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Neoplasm Metastasis, Brain Neoplasm

Intervention / Treatment
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* Procedure: Surgery + WBRT
* Radiation: Radiosurgery + WBRT


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Single presumed brain metastasis on contrast magnetic resonance imaging (MRI) scan within two weeks before commencement of treatment. Systemic cancer diagnosed histologically or cytologically synchronous with, or within 5 years of treatment of the presumed brain metastasis (other than non-melanoma skin cancer and cancer in-situ of the cervix, neither of which would be reasonably attributable as the primary site). Exception - melanoma diagnosed > 5 years previously is allowable in view of the extremely variable natural history of melanoma. Age >= 18 (no upper age limit). Considered suitable for both S and RS by the neurosurgeon and radiation oncologist (see exclusions). Patient must agree to adjuvant WBRT. RTOG RPA Class 1 or 2 (Karnofsky Performance Status [KPS] >= 70 after adequate trial of corticosteroids). RPA Class 3 patients (KPS < 70) eligible if it is considered that the poor performance status is due primarily to the solitary metastasis, aggressive local treatment of which may be expected to restore good performance status. This would ordinarily be associated with minimal systemic disease burden. Accessible for treatment and follow-up. Patient is infertile or is aware of the risk of becoming pregnant or fathering children and will use adequate contraception. Written informed consent Exclusion Criteria: Previous history of brain metastasis(es) Surgery indicated to relieve life-threatening raised intracranial pressure or excision required for tissue diagnosis (no extra-cranial site to biopsy ie unknown primary). However, prior diagnostic (non-excisional) biopsy is allowable - it is acknowledged that the 50% probability of a repeat surgical procedure on subsequent randomisation would not be acceptable to many patients and clinicians. Surgery contraindicated by site (e.g. thalamus, brain stem) or medical co-morbidities. Leptomeningeal disease. Primary is small cell lung cancer, germ cell tumour, lymphoma, leukaemia or myeloma. Prior cranial RT (including RS). Patient is pregnant.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: Surgery + Whole Brain Radiotherapy<br> | Procedure: Surgery + WBRT<br>* Surgery - complete excision of Solitary Brain Metastasis with 30 Gy in 10 fractions over 2 2 1/2 weeks<br>* Other names: S + WBRT;|
| Experimental: RadioSurgery + Whole Brain Radiotherapy<br> | Radiation: Radiosurgery + WBRT<br>* Radiosurgery - Marginal dose based on maximum tumour diameter<br>* Other names: RS + WBRT;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Overall survival and Quality of life |  | Until death or study completion | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Local and distant recurrence |  | Until death or study completion | 
| Failure free survival |  | Until death or study completion | 
| Acute and late toxicities |  | Acute toxicities 6 weeks post RT and late toxicities until death | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Radiosurgery, Brain metastases, Whole Brain Radiotherapy, Neurosurgery, Solitary Brain Metastases, Adult Tumours Metastatic to Brain