Comparing the Addition of Radiation Either Before or After Surgery for Patients With Brain Metastases

PRIMARY OBJECTIVE: I. To determine if the time to composite adverse endpoint (CAE) (defined as: 1) local tumor progression within the surgical bed; and/or 2) adverse radiation effect \[ARE\], the imaging correlate of post-stereotactic radiosurgery \[SRS\] radiation necrosis; and/or 3) nodular meningeal disease \[nMD\]) is improved in patients treated with pre-resection SRS to the intact lesion versus those treated with post-resection SRS. SECONDARY OBJECTIVES: I. To assess the trajectory of symptom burden in patients treated with pre-resection SRS to the intact lesion versus those treated to the post-resection surgical cavity as measured by MD Anderson Symptom Inventory for brain tumor (MDASI-BT). II. To determine whether there is improved overall survival (OS) in patients with resected brain metastases who undergo pre-resection SRS compared to patients who receive post-resection SRS. III. To compare rates of ARE, the imaging correlate of radiation necrosis, in patients who receive pre-resection SRS to patients who receive post-resection SRS. IV. To determine whether there is increased time to whole brain radiotherapy (WBRT) in patients who receive pre-resection SRS compared to patients who receive post-resection SRS. V. To assess the trajectory of neuro-cognitive function in patients treated with pre-resection SRS to the intact lesion versus those treated to the post-resection surgical cavity as measured by the Montreal Cognitive Assessment (MoCA). VI. To compare rates of nodular meningeal disease in patients who receive pre-resection SRS to patients who receive post-resection SRS. VII. To compare rates of local recurrence in the resection cavity for patients who receive pre-resection SRS to patients who receive post-resection SRS. VIII. To compare rates of local recurrence of intact, non-index metastases treated with SRS. IX. To compare rates of distant brain failure in patients who receive pre-resection SRS to patients who receive post-resection SRS. X. To assess toxicity in the two treatment arms. EXPLORATORY OBJECTIVE: I. To explore if the type of surgical resection (piece-meal versus \[vs.\] en-bloc) may be associated with the rate of nodular meningeal disease. OUTLINE: Patients are randomized to 1 of 2 arms. ARM I: Patients undergo surgery per standard of care. Within 10-30 days after surgery, patients undergo stereotactic radiosurgery for 1 fraction. ARM II: Within 7 days before surgery, patients undergo stereotactic radiosurgery for 1 fraction. Patients undergo surgery per standard of care. After completion of study treatment, patients are followed up every 3 months for 2 years and then every 6 months for additional 2 years.