Prognostic factors in brain metastases: should patients be selected for aggressive treatment according to recursive partitioning analysis (RPA) classes?

Management of metastatic (parenchymal, leptomeningeal, and epidural) lesions

PURPOSE OF REVIEW

Metastases involving the central nervous system are notorious for the functional neurologic deficits they often cause. For many patients, the overall prognosis is determined by the systemic disease status, but a subset of patients may benefit from more intensive treatment.

RECENT FINDINGS

Patients in a subgroup with brain metastases qualify for more intensive treatments, like stereotactic radiosurgery, the efficacy of which seems to be similar to that of surgery for single brain metastases. Although whole brain radiotherapy after stereotactic radiosurgery decreases the outfield recurrences, there are no indications that it improves survival. So far, studies on radiosensitizers have not resulted in clear evidence of improved outcome for good prognosis in patients with brain metastases. A variety of surgical procedures offer better palliation for a subset of patients with epidural spinal metastases than radiotherapy alone. The roles of the blood-brain barrier and of the blood-cerebrospinal fluid barrier remain a source of discussion. It may be relevant for patients with micrometastases, which can potentially be cured by systemic treatment.

SUMMARY

For many patients with central nervous system complications, adequate palliation can be achieved, but this requires rapid and thorough evaluation of patients with central nervous system symptoms. Early diagnosis and proper patient selection for further and more intensive treatment are the cornerstones of good palliative care in these patients.

Survival following whole brain radiation treatment for cerebral metastases: an audit of 474 patients

BACKGROUND AND PURPOSE

To report the outcome of patients with brain metastases from solid tumors treated with whole brain radiotherapy (WBRT) in a single institution. Given the high proportion of melanoma patients, a secondary aim was to compare our outcomes for patients with melanoma to those with other cancers.

PATIENTS AND METHODS

A retrospective audit identified 474 patients treated between January 1983 and December 1999. Survival was calculated using the Kaplan-Meier method. Cox regression modeling was used for multivariate analysis.

RESULTS

Four hundred and fifty nine patients have died from their disease. The median survival was 4.1 months for the whole group and 3.6 months for the 42% of patients with melanoma. The 1 and 2 year survival was 15 and 5%. Six patients lived beyond 5 years. 105 of 186 patients with a single brain metastasis underwent surgery plus WBRT, and 81 received WBRT alone. Median survival was 8 and 4 months, respectively, (P<0.0001). 30 Gy in 10 fractions was used more commonly in the early part of the study compared to 20 Gy in 5 fractions more recently. There was no difference in survival by time period.

CONCLUSIONS

The survival in this series was comparable to other studies. Performance status, resection, dose, and the presence of extracranial disease appeared to be significant prognostic factors. The survival for the large number of patients with melanoma did not differ from the rest of the cohort.

Posterior Fossa Metastases: Aggressive Treatment Improves Survival

BACKGROUND

Brain metastases are a leading cause of mortality and morbidity in patients with malignancies. Infratentorial location has been considered a negative prognostic factor.

METHODS

This retrospective study evaluated patients with cerebellar metastasis. Statistical analysis assessed age, extracranial disease, performance status and treatment. Patients were categorized by Radiation Therapy Oncology Group recursive partitioning analysis (RPA). Treatment included surgery, stereotactic radiosurgery (SRS) and whole brain radiotherapy (WBRT) alone or in combination.

RESULTS

Of 93 patients, the median survival was 12.9 months for RPA class I, 11 months for class II and 8 months for class III. On multivariate analysis, RPA class was an important predictor for overall survival. However, SRS with WBRT or surgery with WBRT or a combination of SRS, surgery and WBRT, was more favorable than surgery or SRS alone within RPA class II patients.

CONCLUSIONS

Survival of patients with cerebellar brain metastasis is comparable to that of patients with supratentorial brain metastasis using RPA classification. Aggressive multimodality therapy has a favorable impact on survival.

Neurocognitive function and progression in patients with brain metastases treated with whole-brain radiation and motexafin gadolinium: results of a randomized phase III trial

PURPOSE

To report the neurocognitive findings in a phase III randomized trial evaluating survival and neurologic and neurocognitive function in patients with brain metastases from solid tumors receiving whole-brain radiation therapy (WBRT) with or without motexafin gadolinium (MGd).

PATIENTS AND METHODS

Patients were randomly assigned to receive WBRT 30 Gy in 10 fractions with or without MGd 5 mg/kg/d. Monthly neurocognitive testing for memory, executive function, and fine motor skill was performed.

RESULTS

Four hundred one patients were enrolled (251 with non-small-cell lung cancer, 75 with breast cancer, and 75 with other cancers); 90.5% patients had impairment of one or more neurocognitive tests at baseline. Neurocognitive test scores of memory, fine motor speed, executive function, and global neurocognitive impairment at baseline were correlated with brain tumor volume and predictive of survival. There was no statistically significant difference between treatment arms in time to neurocognitive progression. Patients with lung cancer (but not other types of cancer) who were treated with MGd tended to have improved memory and executive function (P =.062) and improved neurologic function as assessed by a blinded events review committee (P =.048).

CONCLUSION

Neurocognitive tests are a relatively sensitive measure of brain functioning; a combination of tumor prognostic variables and brain function assessments seems to predict survival better than tumor variables alone. Although the addition of MGd to WBRT did not produce a significant overall improvement between treatment arms, MGd may improve memory and executive function and prolong time to neurocognitive and neurologic progression in patients with brain metastases from lung cancer.

Radiosurgery and radiotherapy for non-small-cell lung cancer metastatic to brain

Non-small-cell lung cancer metastatic to brain represents a common problem in oncology. Treatment modalities include stereotactic radiosurgery (SRS), whole-brain radiotherapy (WBRT), surgical resection, supportive care, or a combination of these options. This review outlines therapeutic strategies for treatment with particular attention to the use of SRS. Radiosurgical technique, radiobiology, dose prescription, patient selection, and results of therapy are discussed. The term SRS describes a radiation procedure that utilizes a three-dimensional stereotactic localization system to precisely treat small intracranial targets with a single, large, highly focal radiation dose. Stereotactic radiosurgery is appealing for several reasons; it is minimally invasive, easily tolerated, and highly effective, and patients return to normal baseline function within 24 hours. Stereotactic radiosurgery provides much higher control rates of treated lesions than does WBRT. Randomized trials are underway to ascertain the optimal role and timing of SRS in relation to WBRT in order to maximize control, survival, quality of life, and neuropsychological outcome.

Gamma knife radiosurgery for patients with multiple cerebral metastases

Although efficacy of gamma knife radiosurgery has been demonstrated in numerous studies, the policies in patients with multiple metastases seem to be unequivocal. The maintained quality of life, the possibility of short hospitalization and the continuation of a systemic chemotherapy are increasingly important arguments in favor of a minimally invasive radiosurgical approach. These factors are particularly emphasized in patients with a dismal prognosis. The current retrospective analysis was undertaken to summarize the clinical results of radiosurgery in patients with multiple cerebral metastases of various primary cancer. Fractionated whole brain radiotherapy (WBRT) was omitted as prophylactic treatment and applied only in cases with general tumor spread. Clinical data of all consecutive patients (n = 215) who received gamma knife radiosurgery for cerebral metastases between January 2001 and January 2003 at the gamma knife Centers of the Karolinska Hospital and H.M. Queen Sophia Hospital (Sophiahemmet) Stockholm were analyzed retrospectively. 172 patients were treated for multiple metastases (198 treatments). The median prescription dose was 22 Gy (range 14-34 Gy). The Kaplan Meier plot shows a median survival (MST) of 7.8 months for patients with multiple cerebral metastases and 13.7 months for patients with single metastases. There was no relation between survival and number of metastases in patients with multiple metastases. Within this group 11.6% (20/172 patients) developed adverse radiation reactions. Tumor recurrences were documented by FDG-PET in 7 patients (out of 172 patients: 4.1%) after a median latency of 10 months after radiosurgery. In summary, gamma knife radiosurgery provides a highly effective and minimally invasive method to treat patients with multiple cerebral metastases even without prophylactic WBRT. Local control and patient survival in the present series of patients is in accordance with other retrospective series of patients with single and multiple metastases.

Brain metastases in patients with cancer of unknown primary

Between January 1985 and December 2000, 916 patients with brain metastases were treated with whole brain radiation therapy (WBRT) at the Department of Radiotherapy, University Hospital Freiburg. In 47 patients, a primary tumor could not be identified (cancer of unknown primary (CUP)). Sixteen patients had a solitary brain metastasis, 31 patients presented with multiple brain metastases. Surgical resection was performed in 15 patients, biopsy alone in 12 patients. WBRT was applied with daily fractions of 2 or 3 Gy to a total dose of 50 or 30 Gy, respectively. According to the recursive partitioning analysis (RPA) classes of the Radiation Therapy Oncology Group for patients with brain metastases none of the patients met the criteria for Class I, 23 for Class II, and 24 for Class III. The median overall survival (OS) for all patients with brain metastases (n = 916) was 3.4 and 4.8 months for patients with CUP (p = 0.45). In patients with CUP (n = 47) the median OS for patients with a single brain metastasis was 7.3 versus 3.9 months for patients with multiple brain metastases (p = 0.05). Median OS for patients with a Karnofsky performance status (KPS) > or = 70 was 6.3 months versus 3.2 months for KPS < 70 (p = 0.01). At multivariate analysis performance status and resection status could be identified as independent prognostic factors for the OS.

Image-guided craniotomy for cerebral metastases: techniques and outcomes

OBJECTIVE

The purpose of the present study was to analyze the outcomes after craniotomies for brain metastases in a modern series using image-guided technologies either in the regular operating room or in the intraoperative magnetic resonance imaging unit.

METHODS

Neurosurgical outcomes were analyzed for 49 patients who underwent 55 image-guided craniotomies for excision of brain metastases during a 5-year period. Tumors were located in critical and noncritical function regions of the brain. A total of 23 craniotomies for tumors in critical brain were performed using intravenous sedation anesthesia; craniotomies for noncritical function brain regions were completed under general anesthesia. The patients were also divided into Radiation Therapy Oncology Group recursive partitioning analysis (RPA) classes on the basis of age, Karnofsky Performance Scale scores, state of primary disease, and presence or absence of extracranial metastases.

RESULTS

There was no perioperative mortality. Gross total resection, as verified by postoperative contrast-enhanced computed tomography or magnetic resonance imaging, was achieved in 96% of patients. The median anesthesia time was 4.25 hours, and the median length of hospital stay was 3 days. In 51 symptomatic cases, there was complete resolution of symptoms in 70% (n = 36), improvement in 14% (n = 7), and no change in 12% (n = 6) postoperatively. No patient who was neurologically intact preoperatively deteriorated after surgery, and 93% of patients maintained or improved their functional status. Only two patients (3.6%) with significant preoperative deficits had increased long-term deficits postoperatively. The mean follow-up was 1 year, and the local recurrence rate was 16%. The median survival of the entire group was 16.23 months (17.5 mo in RPA Class I, 22.9 mo in RPA Class II, and 9.8 mo in RPA Class III).

CONCLUSION

Gross total resection of brain metastases, including those involving critical function areas, can be safely achieved with a low morbidity rate using contemporary image-guided systems. RPA Class I and II patients with controlled primary disease benefit from aggressive treatment by surgery and radiation.

Survival and neurologic outcomes in a randomized trial of motexafin gadolinium and whole-brain radiation therapy in brain metastases

PURPOSE

This phase III randomized trial evaluated survival as well as neurologic and neurocognitive function in patients with brain metastases from solid tumors receiving whole-brain radiation therapy (WBRT) with or without motexafin gadolinium (MGd).

PATIENTS AND METHODS

Patients were randomly assigned to 30 Gy of WBRT +/- 5 mg/kg/d MGd. Survival and time to neurologic progression determined by a blinded events review committee (ERC) were coprimary end points. Standardized investigator neurologic assessment and neurocognitive testing were evaluated.

RESULTS

Four hundred one (251 non-small-cell lung cancer) patients were enrolled. There was no significant difference by treatment arm in survival (median, 5.2 months for MGd v 4.9 months for WBRT; P =.48) or time to neurologic progression (median, 9.5 months for MGd v 8.3 months for WBRT; P =.95). Treatment with MGd improved time to neurologic progression in patients with lung cancer (median, not reached for MGd v 7.4 months for WBRT; P =.048, unadjusted). By investigator, MGd improved time to neurologic progression in all patients (median, 4.3 months for MGd v 3.8 months for WBRT; P =.018) and in lung cancer patients (median, 5.5 months for MGd v 3.7 months for WBRT; P =.025). MGd improved neurocognitive function in lung cancer patients.

CONCLUSION

The overall results did not demonstrate significant differences by treatment arm for survival and ERC time to neurologic progression. Investigator neurologic assessments demonstrated an MGd treatment benefit in all patients. In lung cancer patients, ERC- and investigator-determined time to neurologic progression demonstrated an MGd treatment benefit. MGd may improve time to neurologic and neurocognitive progression in lung cancer.

Radiosurgery followed by planned observation in patients with one to three brain metastases

OBJECTIVE

To analyze the role of radiosurgery alone in patients with brain metastases. There were three specific study goals: 1) to determine whether survival of patients selected for this treatment approach can be predicted successfully by use of the recursive partitioning analysis classification defined by the Radiation Therapy Oncology Group; 2) to evaluate local control; and 3) to identify risk factors of cerebral failure.

METHODS

A total of 101 patients with Karnofsky Performance Scale scores of at least 50 and up to three brain metastases, each 3 cm or less in maximum diameter, were treated with radiosurgery alone. Survival, local control, distant brain freedom from progression (FFP), and overall brain FFP were evaluated according the method of Kaplan and Meier. Risk factors for survival and overall brain FFP were analyzed using the Cox model.

RESULTS

Median survival was 13.4 months, 9.3 months, and 1.5 months for patients in recursive partitioning analysis Classes 1, 2, and 3, respectively (P < 0.0001). At 1 year, local control, distant brain FFP, and overall brain FFP were 91, 53, and 51%, respectively. An interval greater than 2 years between diagnosis of the primary tumor and diagnosis of brain metastases and the presence of a single brain metastasis were associated with significantly higher overall brain FFP.

CONCLUSION

Recursive partitioning analysis classification successfully predicted survival. Radiosurgery alone yielded high local control. Overall brain FFP was highest in patients with an interval greater than 2 years between primary diagnosis and diagnosis of a single brain metastasis.

Temozolomide in patients with advanced non-small cell lung cancer with and without brain metastases. a phase II study of the EORTC Lung Cancer Group (08965)

This study was performed to evaluate the activity of single-agent temozolomide in two groups of chemotherapy-naïve non-small cell lung cancer (NSCLC) patients, with (12 patients) and without (13 patients) brain metastases (BM). Patients in both groups were treated with temozolomide 200 mg/m(2)/day, administered orally for 5 consecutive days of a 28-day cycle. Treatment was continued for up to six cycles, disease progression or unacceptable toxicity. The median number of received cycles was only one in the group with and two in the group without BM, and early disease progression was the main reason for treatment discontinuation. Toxicity was moderate-in the group of patients with BM, the most frequently observed grade 3 or 4 side-effects included thrombocytopenia (17%), granulocytopenia (17%), lethargy (17%); other neurological (17%) and other genitourinary toxicity (17%). Patients without BM experienced anaemia (15%), thrombocytopenia (23%), nausea (15%) and lethargy (15%). This trial was designed according to Simon one-sample two-stage testing procedure and both groups of patients were assessed separately. No objective response was observed in either group and the study was closed after the first step of accrual with the conclusion of a lack of therapeutic activity of single-agent temozolomide in patients with stage IV NSCLC.

Radiosurgery Followed by Planned Observation in Patients with One to Three Brain Metastases

OBJECTIVE

To analyze the role of radiosurgery alone in patients with brain metastases. There were three specific study goals: 1) to determine whether survival of patients selected for this treatment approach can be predicted successfully by use of the recursive partitioning analysis classification defined by the Radiation Therapy Oncology Group; 2) to evaluate local control; and 3) to identify risk factors of cerebral failure.

METHODS

A total of 101 patients with Karnofsky Performance Scale scores of at least 50 and up to three brain metastases, each 3 cm or less in maximum diameter, were treated with radiosurgery alone. Survival, local control, distant brain freedom from progression (FFP), and overall brain FFP were evaluated according the method of Kaplan and Meier. Risk factors for survival and overall brain FFP were analyzed using the Cox model.

RESULTS

Median survival was 13.4 months, 9.3 months, and 1.5 months for patients in recursive partitioning analysis Classes 1, 2, and 3, respectively (P&lt; 0.0001). At 1 year, local control, distant brain FFP, and overall brain FFP were 91, 53, and 51%, respectively. An interval greater than 2 years between diagnosis of the primary tumor and diagnosis of brain metastases and the presence of a single brain metastasis were associated with significantly higher overall brain FFP.

CONCLUSION

Recursive partitioning analysis classification successfully predicted survival. Radiosurgery alone yielded high local control. Overall brain FFP was highest in patients with an interval greater than 2 years between primary diagnosis and diagnosis of a single brain metastasis.

Properly selected patients with multiple brain metastases may benefit from aggressive treatment of their intracranial disease

To determine whether properly selected patients with multiple brain metastases benefit from aggressive treatment of their intracranial disease, we reviewed 52 patients having stereotactic radiosurgery (SRS), tumor resection, or both between April 1997 and March 2000. Tumor histology included lung (n = 18, 35%), breast (n = 11, 21%), renal (n = 6, 12%), melanoma (n = 6, 12%), and other (n = 11, 21%). The median patient age was 58 years, the median Karnofsky performance status (KPS) was 90, and the median number of tumors was three. Twenty patients (39%) had progressed after prior radiation therapy. Treatment included multiple craniotomies and tumor resection (n = 5, 10%), radiosurgery (n = 31, 60%), or resection and radiosurgery (n= 16, 30%). Median survival was 15.5 months. The one- and two-year actuarial survivals were 63% and 27%, respectively. Multivariate analysis found radiation therapy oncology group recursive partitioning analysis (RTOG RPA) Class (1 vs. 2/3) correlated with improved survival (Relative risk = 2.60, 95% CI 1.13-5.97, p = 0.03). Class 1 patients (KPS > or = 70, age < 65 years, and controlled primary with no extracranial metastases) survived a median of 19 months whereas Class 3 patients (KPS < 70) survived 8 months. Class 2 patients (all other patients) survived a median of 13 months. Thirty-five patients (67%) had intracranial progression at a median of 8.0 months. Intracranial progression was local (n = 6), distant (n = 23), or local and distant (n = 6); 26 patients with intracranial progression underwent additional brain tumor treatments. Multivariate analysis found patients with radiosensitive tumors (lung, breast, other) had fewer intracranial recurrences compared to patients with radio-resistant tumors (melanoma, renal, sarcoma) (Relative risk = 2.43, 95% CI 1.13-5.10, p = 0.02). The length of survival in our series is quite comparable to historical reports on the management of brain metastasis patients, and supports aggressive intervention for RTOG RPA Class 1 patients and Class 2 patients with controlled primary disease who have a limited number of brain metastases.

Radiosurgery for brain metastases at the Royal Adelaide Hospital: are we treating the right patients?

Although non-randomized data strongly suggest improved outcome from radiosurgery (RS) for brain metastases relative to whole brain radiotherapy (WBRT) alone, selection factors account for much of the observed differences. This retrospective review of the 16 brain metastases patients treated so far with RS at the Royal Adelaide Hospital confirms a median survival of 10.1 months, consistent with recent multi-institutional pooled results and significantly longer than the median survival of 3-6 months typically reported for WBRT alone. The emerging randomized trials comparing surgery, RS and WBRT for brain metastases are reviewed in the context of the Radiation Therapy Oncology Group Recursive Partitioning Analysis prognostic Class concept in order to assess whether we are using this resource intensive technique to treat the 'right' patients. We conclude that it is reasonable to continue our current policy of considering RS primarily for patients of good performance status with solitary brain metastases. We have a flexible approach to adjuvant WBRT which appears to decrease brain relapse, but not improve survival.

Gamma knife radiosurgery for metastatic brain tumors from lung cancer: a comparison between small cell and non—small cell carcinoma

Object. The purpose of this retrospective study was to evaluate the effectiveness of gamma knife radiosurgery (GKS) for the treatment of metastatic brain tumors from lung cancer, with particular reference to small cell lung carcinoma (SCLC) compared with non-SCLC (NSCLC).

Methods. Two hundred forty-five consecutive patients meeting the following five criteria were evaluated in this study: 1) no prior brain tumor treatment; 2) 25 or fewer lesions; 3) a maximum of three tumors with a diameter of 20 mm or larger; 4) no surgically inaccessible tumor 30 mm or greater in diameter; and 5) more than 3 months of life expectancy. According to the same treatment protocol, large tumors (≥ 30 mm) were surgically removed and the other small lesions (< 30 mm) were treated with GKS. New lesions were treated with repeated GKS. Chemotherapy was administered, according to the primary physician's protocol, as aggressively as possible. Progression-free, overall, neurological, qualitative, and new lesion—free survival were calculated with the Kaplan—Meier method and were compared in the SCLC and NSCLC groups by using the log-rank test. The poor prognostic factors for each type of survival were also analyzed with the Cox proportional hazard model.

Conclusions. Tumor control rate at 1 year was 94.5% in the SCLC group and 98% in the NSCLC group. The median survival time was 9.1 months in the SCLC group and 8.6 months in the NSCLC group. The 1-year survival rates in the SCLC group were 86.5% for neurological survival and 68.9% for qualitative survival; those in the NSCLC group were 87.9% for neurological and 78.9% for qualitative survival. The estimated median interval to emergence of a new lesion was 6.9 months in the SCLC group and 9.8 months in the NSCLC group. There was no significant difference between the two groups for any type of survival; this finding was verified by multivariate analysis. The results of this study suggest that GKS appears to be as effective in treating brain metastases from SCLC as for those from NSCLC.

Lead-in phase to randomized trial of motexafin gadolinium and whole-brain radiation for patients with brain metastases: centralized assessment of magnetic resonance imaging, neurocognitive, and neurologic end points

PURPOSE

Motexafin gadolinium is a redox mediator that selectively targets tumor cells, is detectable by magnetic resonance imaging (MRI), and enhances the effect of radiation therapy. This lead-in phase to a randomized trial served to evaluate radiologic, neurocognitive, and neurologic progression end points and to evaluate the safety and radiologic response of motexafin gadolinium administered concurrently with 30 Gy in 10-fraction whole-brain radiation therapy for the treatment of brain metastases.

PATIENTS AND METHODS

Motexafin gadolinium (5.0 mg/kg/d for 10 days) was administered before each radiation treatment in this prospective international trial. Patients were evaluated by MRI, neurologic examinations, and neurocognitive tests. Prospective criteria and centralized review procedures were established for radiologic, neurocognitive, and neurologic progression end points.

RESULTS

Twenty-five patients with brain metastases from lung (52%) and breast (24%) cancer, recursive partitioning analysis class 2 (96%), and an average of 11 brain metastases were enrolled. Neurocognitive function was highly impaired at presentation. Motexafin gadolinium was well tolerated. Freedom from neurologic progression was 77% at 1 year. Median survival was 5.0 months. In 29% of patients, the cause of death was brain metastasis progression. The radiologic response rate was 68%. Motexafin gadolinium's tumor selectivity was established with MRI.

CONCLUSION

(1) Centralized neurologic progression scoring that incorporated neurocognitive tests was implemented successfully. (2) Motexafin gadolinium was well tolerated. (3) Local control, measured by radiologic response rate, neurologic progression, and death caused by progression of brain metastasis, seemed to be improved compared with historical results. A randomized phase III trial using these methods for evaluation of efficacy has just been completed.

Brain metastases: treatment options to improve outcomes

In recent years, a broader base of treatment options has evolved to improve the outcome for patients with brain metastases. The selection of the most appropriate intervention for the individual patient is dependent on a careful evaluation of the extent of intracranial tumour, as well as an understanding of patient and tumour characteristics that are important determinants of prognosis. Recent analyses have confirmed good performance status, control of the primary tumour, absence of extracranial metastases and age less than 65 years to be predictors for longer survival. Medical therapy typically includes the use of corticosteroids, and some advances have been made in optimising the use of these agents. Prophylactic use of antiepileptic drugs in patients with brain metastases is generally discouraged. Chemotherapy was previously not considered to have a role in treating brain metastases, but has increasingly become an accepted treatment option. Recent clinical studies have evaluated the integration of chemotherapy with conventional treatments such as radiotherapy and the addition of biological response modifiers. In the past, radiotherapy has been the mainstay of treatment for brain metastases. A number of randomised controlled trials have explored external beam radiation therapy, radiation sensitisers, postoperative whole brain irradiation and prophylactic cranial irradiation. Significant improvements in survival have been demonstrated as a result of prophylactic cranial irradiation in patients with small-cell lung cancer, and improved local control of brain metastases has been achieved with postoperative whole brain irradiation. A number of studies have helped define a more efficient use of external beam irradiation. Radiosurgery in particular has been identified as an important advance in radiation treatment delivery and may provide an acceptable alternative to surgical resection in many patients. Conventional surgery has long had a role to play in establishing the diagnosis, guiding the choice of subsequent therapies and reversing life-threatening complications from brain metastases. The risks of surgery have been reduced with recent improvements in anaesthesia and intraoperative tumour localisation. Recent clinical studies have addressed the role of surgical resection in the management of patients with a single brain metastasis. Survival benefits have been demonstrated in patients undergoing surgical resection in addition to external beam radiation therapy. Despite the improvements achieved in the treatment of patients with brain metastases at first diagnosis, the question of retreatment may arise in due course. The therapeutic options available in this situation include re-operation, radiosurgery and brachytherapy.

Malignant germ cell tumors metastatic to the brain: a model for a curable neoplasm? The Freiburg experience and a review of the literature

The aim of this study on malignant germ cell tumors metastasizing to the brain is (a) to report our institutional experience, (b) to present three patients surviving for more than seven years, and (c) to review the literature with regard to long-term survival. From 1985 to 2000, 916 consecutive patients were treated with whole brain radiation therapy for brain metastases at our hospital. Eleven patients had cerebral lesions from histologically proven malignant germ cell tumors. Brain metastases were diagnosed at presentation (n = 2), following complete remission (n = 3), or along with extracerebral tumor progression (n = 6). Seven patients had a single brain metastasis. Three patients underwent resection. Eight patients reached the planned total dose of 50 Gy. Eight patients had chemotherapy. Median survival was 6.6 months. The long-term survivors all had an isolated cerebral relapse after complete remission, presented with a single brain metastasis, and were treated with resection and whole brain radiation therapy to a total dose of 50 Gy. The first patient died from a late relapse 89 months after the diagnosis of brain metastasis, the second patient is well and alive at 95 months. The third patient is currently being treated for a second malignancy originating from the lung. He is alive at 194 months, the longest survival for brain metastases from malignant germ cell tumors ever reported. Altogether, our study demonstrates that advanced extracerebral disease at initial diagnosis and isolated cerebral relapse after complete remission do not preclude long-term survival. Resection and whole brain radiation therapy might result in durable cerebral control with minimal morbidity.

Patients with brain metastases: hope for recursive partitioning analysis (RPA) class 3

PURPOSE

The objectives of the present study were (a) to validate the prognostic classification derived from recursive partitioning analysis (RPA) of the Radiation Therapy Oncology Group (RTOG); (b) to identify prognostic factors in class 3; (c) to examine the impact of treatment related variables on the prognosis in class 3.

PATIENTS AND METHODS

Nine hundred and sixteen patients with brain metastases had resection and whole brain radiotherapy (WBRT, n = 257) or WBRT alone (n = 659) at our institution from 1985 to 2000. Patients were grouped into RPA classes 1, 2, and 3 (n = 67, 441, and 408, respectively).

RESULTS

Median survival of the whole group was 3.4 months. Median survival in classes 1, 2, and 3 was 8.2, 4.9, and 1.8 months, respectively. In class 3, age (<65 years vs. > or =65 years, relative risk (RR) 0.75), status of the primary tumor (controlled vs. uncontrolled, RR 0.86), and the number of brain metastases (single vs. multiple, RR 0.76) were independent prognostic variables. We defined three prognostic subgroups: class 3a (n = 51): age <65 years, controlled primary tumor, single brain metastasis; class 3c (n = 44): age > or =65 years, uncontrolled primary tumor, multiple brain metastases; class 3b (n = 313): all other patients. Median survival in classes 3a, 3b, and 3c was 3.2, 1.9, and 1.2 months, respectively (P < 0.0001). Intra-class comparisons showed that resection followed by WBRT yielded significantly better survival compared with WBRT alone.

CONCLUSION

Our results validate the RTOG RPA classification for patients with brain metastases. The variables age, status of the primary, and number of brain metastases allow the division of class 3 into prognostic subgroups. Even class 3 patients may benefit from more aggressive treatment strategies.

Survival by radiation therapy oncology group recursive partitioning analysis class and treatment modality in patients with brain metastases from malignant melanoma: a retrospective study

BACKGROUND

In a population of patients with brain metastases from melanoma, the authors sought to determine whether various therapies provided any benefit at all, whether local therapy was better than whole brain radiotherapy (WBRT), and whether combined local therapy and WBRT provided any advantage over local therapy alone. They also analyzed survival according to a Radiation Therapy Oncology Group (RTOG) recursive partitioning analysis (RPA) to determine how well the RTOG RPA classes predicted survival in this patient population and whether treatments varied in effectiveness from category to category.

METHODS

A total of 74 patients with brain metastases from melanoma were treated at The Cleveland Clinic Foundation between 1984 and 1998. For this study, the authors reviewed patient charts and confirmed survival status. Survival was compared by treatment modality (surgical resection, WBRT, stereotactic radiosurgery, or WBRT combined with local therapy). Survival also was compared according to the RTOG RPA prognostic classes (Class 1, Class 2, or Class 3), which has not been validated previously in patients with malignant melanoma.

RESULTS

The median survival was 5.5 months for all patients. Survival varied significantly by RTOG prognostic class; The median survival was 10.5 months (range, 2.2-99.2 months) for patients in Class 1, 5.9 months (range, 0.2-43.9 months) for patients in Class 2, and 1.8 months (range, 0.1-6.9 months) for patients in Class 3 (P < 0.0001). Survival analysis showed that combined treatment offered significantly better survival (P < 0.0001; combined vs. other). The median survival was 8.8 months (range, 1.8-99.2 months) for the combined therapy group, 4.8 months (range, 1.2-27.8 months) for the local therapy alone group, 2.3 months (range, 0.2-9.6 months) for the WBRT alone group, and 1.1 months (0.1-3.0 months) for the group that received no therapy.

CONCLUSIONS

Adding WBRT to local therapy may improve survival in this group of patients: Combined therapy was superior to WBRT alone. The RPA classification scheme likely has prognostic value for patients with brain metastases from malignant melanoma. Prospective studies are required to overcome selection bias and confirm these results.

Karnofsky performance score as a predictor of survival in soft tissue sarcoma

Forty-six consecutive patients with nonmetastatic, large, high-grade soft tissue sarcomas were treated with surgical resection and radiation therapy but no adjuvant chemotherapy. Clinical and radiographic followup ranged from 36 to 90 months (mean, 50 months). One patient died of unrelated causes 10 months after the completion of radiation and surgery, leaving the oncologic outcome of 45 patients to be evaluated. Twenty-seven of 45 patients (60%) survived with an average followup of 50 months. The limb salvage rate was 91% and local control was obtained in 43 of 45 patients (96%). During the time of the study, 73% of patients could have been offered chemotherapy. However, only 53% of patients who died of their disease would have been candidates for chemotherapy trials because of medical comorbidities. More importantly, patients with a Karnofsky performance score of 80 or more had a significantly better survival rate than patients with a Karnofsky performance score less than 80 without the use of chemotherapy. Current chemotherapy trials that exclude patients because of medical comorbidities are introducing bias toward improved survival that may not be attributable to the chemotherapy. If a real survival benefit of adjuvant chemotherapy exists, it would be most evident in the largest (> 15 cm) high-grade tumors. Aggressive metastasectomy seems to be most beneficial for patients with isolated nodules.

Phase I/II clinical trial of concurrent radiochemotherapy in combination with topotecan for the treatment of brain metastases

The prognosis of patients with brain metastases is very poor. In this phase I/II study we tested the feasibility, dosage, toxicity and tumour efficacy of a concurrent radiochemotherapy regimen including topotecan. Twenty patients were recruited between July 1998 and February 2000 (9 women, 11 men) and treated with a whole-brain irradiation of 40 Gy (some patients were also given a boost) in combination with topotecan given as a 21-day continuous infusion in a dosage of 0.4 to 0.6 mg/m2/day. The median survival was five months (95% Confidence Interval (CI): 2-8 months). In 13 of 20 patients, it was possible to evaluate the remission with computed tomography (CT) scans or magnetic resonance scans. We detected four complete responders (CRs), two partial responders (PRs), and one progressive disease (PD). 6 patients had stable disease (SD). An intracerebral recurrence was experienced in 3 patients, 3 patients experienced spinal lesions. Systemic progression of cancer outside the central nervous system (CNS) was dominant in 9 of 20 patients. A reversible, non-cumulative haematological toxicity mainly occurring from a dose of 0.5 mg/m2/day and above was dose-limiting for this type of therapy. Combined concurrent radiochemotherapy with topotecan is feasible in spite of various pretreatments. Myelosuppression was the dominant toxicity, which was reversible and manageable. We recommend a dose of 0.4 mg/m2/day of topotecan as a 21-day continuous infusion therapy in combination with radiotherapy.

The diagnosis and management of brain metastases

The median survival after whole-brain irradiation of patients with brain metastases is 4 months. Because half the patients with brain metastases die of systemic cancer, for most the benefit of intensive local treatment (surgery or stereotactic radiosurgery) of brain metastases will be minimal. In particular, patients with controlled systemic disease and one to three brain metastases are candidates for intensive local treatments. Combined local treatment with whole-brain irradiation therapy improves the local control of brain metastases in comparison with whole-brain irradiation only. After the local treatment of brain metastases by either surgery or radiosurgery, overall survival is not adversely affected if whole-brain irradiation is only administered as salvage treatment at the time of relapse. New randomized trials are needed, however, to investigate this further. The response rate of brain metastases to chemotherapy is similar to the response rate of the primary tumour and non-cerebral metastases.

Radiosurgery for brain metastases: who may not benefit?

PURPOSE

To select a group of patients with brain metastases for whom stereotactic radiosurgery (SRS) may not be beneficial.

PATIENTS, MATERIALS, AND METHODS

Actuarial survival of 87 patients with brain metastases treated with SRS between July 1993 and May 1999 was retrospectively analyzed under stratification by the Score Index for Stereotactic Radiosurgery for Brain Metastases (SIR). To identify the group of patients most likely to survive less than 6 months after SRS, Cox model survival curves were calculated for all SIR values, and Kaplan-Meier survival curves were calculated for two SIR subsets (0-5 and 6-10) and were compared by log-rank test.

RESULTS

Overall median survival after SRS was 6.88 months. The stratification of patients into two SIR subsets (0-5 and 6-10) sustained statistical significance regarding survival with p = 0.0001. The median survival time for the group of patients with SIR between 0 and 5 was 4.52 months (95% confidence interval of 2.82 to 5.84 months). Survival probability at 6 months for this group of patients with poor prognosis was 35.6%.

CONCLUSION

Patients with brain metastases and SIR of 5 or lower have an expected median survival of less than 6 months after treatment with radiosurgery. Thus, radiosurgery may not be beneficial for this group of patients.

Brain metastases: still an 'orphan' disease?

The diagnosis of brain metastases from systemic cancer has been associated with a poor prognosis. In fact, most chemotherapy clinical trials exclude patients with metastatic disease. In the past, clinical and basic research activity in this area has been only moderate. Recent developments in clinical trial design, as evidenced by recursive partitioning analysis and complemented by new treatment strategies in neurosurgery and radiotherapy, suggest a change in attitude and approach to the management of brain metastases. The role of chemotherapy will require more focused investigation, but recent advances in our understanding of the biology of brain metastases suggest that the next generation of chemotherapy treatments will involve targeting specific pathways of metastatic disease.

Brain metastases and non-small cell lung cancer. Prognostic factors and correlation with survival after irradiation

A total of 250 patients with brain metastases from non-small cell lung cancer (NSCLC) were treated with irradiation of their brain metastases. The median overall survival was 3.1 (95% CI: 2.7-3.5) months. 32/250 patients presenting with solitary brain metastasis underwent surgical resection. Their 1-year survival rate of 58% was significantly better than 89/250 patients with a solitary lesion but without surgery (14%, P=0.001). Patients with an absent or controlled primary tumor (101/250, 40.5%) had a 1-year survival rate of 26% as opposed to 11% for patients presenting with an active primary tumor (P=0.051). Patients presenting with metastases to the brain only showed a significant survival advantage over patients with extracranial metastases (1-year survival of 21% vs 6%, P=0.001). Karnofsky performance score, neurofunction status and response to steroids were also identified as prognostic factors. The total dose whole brain irradiation (WBI) was prognostic of significance with a 1-year survival of 35% for 30 Gy and boost, 23.5% for 30 Gy and 4% for the patients irradiated to a dose of 20 Gy WBI (P=0.001). When patients were grouped into the RTOG RPA (Recursive partitioning analysis) classes, patients within class I (73/250) had a 1-year survival of 28.5%, patients in class II (145/250) a survival of 14% at 1 year and patients into class III only a 6% 1-year survival rate. In a multivariate analysis, surgical resection, neurofunction class, metastatic extent and WBI dose remained significant prognostic factors. Although survival remains poor, there needs to be a continued interest in these patients, probably by participating in clinical trials.

Phase II study of temozolomide in heavily pretreated cancer patients with brain metastases

PURPOSE

To determine the efficacy, tolerability, and safety of temozolomide in heavily pretreated patients with solid tumors and brain metastases.

PATIENTS AND METHODS

Twenty-seven of twenty-eight enrolled patients with brain metastases from solid tumors received temozolomide (150 mg/m2/day for five days every 28 days). Twelve patients had non-small-cell lung cancer, five patients had small-cell lung cancer, four patients had breast cancer, and seven patients had other solid tumors. The majority of the patients had multiple metastatic sites, a poor performance status, and had been heavily pretreated. The primary end points were objective response rate, time to progression, and overall survival. Secondary end points included safety and tolerability, and neurologic performance status.

RESULTS

A partial response was achieved in 1 (4%) of 24 evaluable patients. Disease stabilization was observed in four (17%) patients. Overall median survival was 4.5 months and median time to progression was 3 months. Improvements in clinical neurologic status were achieved in 10 (37%) patients. Treatment with temozolomide was well tolerated. Four patients had grade 3 nausea and vomiting. No grade 4 toxicity or treatment-related deaths were observed.

CONCLUSIONS

Temozolomide demonstrated encouraging activity in the treatment of brain metastases in heavily pretreated patients with solid tumors, and was safe and well tolerated.

Single Brain Metastasis

The management of single brain metastases has evolved substantially over the last decade. The advent of triple-dose contrast-enhanced MRI scans has improved the radiologists' capacity to resolve small tumors, and, thereby, has resulted in a declining percentage of brain metastases classified as single. Only 25% to 30% of brain metastases are single; single brain metastases in the absence of systemic metastases are termed solitary. Randomized trials suggest that patients not in imminent danger of herniation are best managed initially with dexamethasone 2 to 4 mg administered orally twice daily. The routine use of prophylactic anticonvulsants is discouraged. Patients with refractory progressive systemic tumor likely to prove fatal within 3 to 6 months should receive fractionated whole brain radiotherapy. Patients with highly radiosensitive primary tumors such as small cell lung cancer, lymphoma, and germinoma should also receive whole brain radiotherapy. Patients with inactive or controllable systemic cancer and good performance status benefit from the addition of local strategies like surgery or radiosurgery to whole brain radiotherapy. Although surgery and radiosurgery have not been compared in a randomized controlled trial, data suggest that results are similar. Consequently, for most metastases that fall within the size constraints of radiosurgery (3.5 cm or smaller in diameter), radiosurgery is preferred for its relatively noninvasive nature. Patients with larger or cystic tumors, with obstructive hydrocephalus, or neurologic instability despite corticosteroids are best treated with craniotomy. Fractionated whole brain radiation following surgical or radiosurgical management of single brain metastasis appears to decrease the risk of recurrent brain metastasis, although it has not been shown to improve survival. We recommend its use in most patients, although patients with tumors likely to be highly resistant to fractionated radiotherapy or at high risk of radiation neurotoxicity may reasonably defer its use.