Invited Manuscript

Journal of Neuro-Oncology

, Volume 96, Issue 1, pp 33-43

First online:

Open Access This content is freely available online to anyone, anywhere at any time.

The role of surgical resection in the management of newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline

  • Steven N. KalkanisAffiliated withDepartment of Neurosurgery, Henry Ford Health System Email author 
  • , Douglas KondziolkaAffiliated withDepartment of Neurological Surgery, University of Pittsburgh Medical Center
  • , Laurie E. GasparAffiliated withDepartment of Radiation Oncology, University of Colorado-Denver
  • , Stuart H. BurriAffiliated withDepartment of Radiation Oncology, Carolinas Medical Center
  • , Anthony L. AsherAffiliated withDepartment of Neurosurgery, Carolina Neurosurgery and Spine Associates
  • , Charles S. CobbsAffiliated withDepartment of Neurosciences, California Pacific Medical Center
  • , Mario AmmiratiAffiliated withDepartment of Neurosurgery, Ohio State University Medical Center
  • , Paula D. RobinsonAffiliated withMcMaster University Evidence-based Practice Center
  • , David W. AndrewsAffiliated withDepartment of Neurosurgery, Thomas Jefferson University
    • , Jay S. LoefflerAffiliated withDepartment of Radiation Oncology, Massachusetts General Hospital
    • , Michael McDermottAffiliated withDepartment of Neurosurgery, University of California San Francisco
    • , Minesh P. MehtaAffiliated withDepartment of Human Oncology, University of Wisconsin School of Public Health and Medicine
    • , Tom MikkelsenAffiliated withDepartment of Neurology, Henry Ford Health System
    • , Jeffrey J. OlsonAffiliated withDepartment of Neurosurgery, Emory University School of Medicine
    • , Nina A. PaleologosAffiliated withDepartment of Neurology, Northshore University Health System
    • , Roy A. PatchellAffiliated withDepartment of Neurology, Barrow Neurological Institute
    • , Timothy C. RykenAffiliated withDepartment of Neurosurgery, Iowa Spine and Brain Institute
    • , Mark E. LinskeyAffiliated withDepartment of Neurosurgery, University of California-Irvine Medical Center



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 extra-cranial disease. There is insufficient evidence to make a recommendation for patients with poor performance scores, advanced systemic disease, or multiple brain metastases.


Brain metastases Surgical resection Stereotactic radiosurgery Radiotherapy Systematic review Practice guideline