Surgical treatment of brain metastases from melanoma: a retrospective study of 91 patients

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.

Surgical management of cerebral metastases from melanoma: outcome in 147 patients treated at a single institution over two decades

OBJECT

The aim of this study was to review the outcome of patients who underwent surgery for treatment of cerebral metastatic melanoma.

METHODS

A retrospective analysis was performed in 147 patients with cerebral metastases from melanoma who were treated surgically at a single institution between 1979 and 1999. Almost all patients underwent postoperative wholebrain radiation therapy. The mean patient age was 53 years (range 17-76 years); 69% of patients were male. A single cerebral metastasis was identified in 84% of patients, although 56% had synchronous extracranial metastases. The 30-day postoperative mortality rate was 2% and neurological symptoms resolved or improved in 78% of patients. Recurrence of intracerebral disease was seen in 55% of patients and 26% died of intracerebral metastases. Twenty-four patients underwent reoperation for recurrent cerebral disease. The median survival duration from the time of surgery for all patients was 8.5 months; the 3- and 5-year survival rates were 9% and 5%, respectively. Factors that significantly influenced survival on univariate analysis were the number of cerebral metastases (p = 0.015), a macroscopically complete excision (p < 0.05), and reoperation for recurrence (p = 0.02). The presence of extracranial metastases did not significantly influence survival. On multivariate analysis only the number of cerebral metastases significantly affected survival (p = 0.04).

CONCLUSIONS

For the majority of patients with cerebral metastases from melanoma, surgery with adjuvant radiation therapy is a treatment option that improves neurological symptoms and produces minimal morbidity. Long-term survival (> 3 years) most likely occurs in patients with a single cerebral metastasis and no demonstrable extracranial disease. Reoperation for recurrent cerebral disease may be appropriate in selected cases.

The role of surgery for patients with metastatic melanoma

When deciding to perform a resection for metastatic melanoma one should first decide whether the intent of the procedure is curative or palliative. When the resection is palliative, the success of surgical treatment will depend on the presence of identifiable symptoms, the morbidity of the procedure, the course of the disease, and the ability to communicate the treatment goals among surgeon, patient, and family. When the resection is curative, survival will depend on the ability of the surgeon to select patients with a pattern of recurrence suggestive of less aggressive tumor biology. Factors generally found predictive of improved survival, and therefore reflective of tumor biology, include longer disease-free interval, fewer numbers of metastases, and the ability to obtain a complete resection. Resection of metastases in patients who recur within one-year, who present with multiple lesions, and who present with disease that cannot be completely resected, will not result in long-term survival.

Gamma surgery for melanoma metastases in the brain

OBJECT

The aim of this study was to evaluate the usefulness and limitations of gamma surgery (GS) in the treatment of brain metastases from melanoma.

METHODS

Imaging and clinical outcomes in 45 patients treated for 92 brain metastases from melanoma between October 1989 and October 1999 were retrospectively analyzed. Follow-up imaging studies were available in 35 patients with 66 treated lesions. Twenty-four percent of the lesions disappeared, 35% shrank, 23% remained unchanged, and 18% increased in size. No undue radiation-induced changes were observed in the surrounding brain. Clinical data were available in all patients. No deaths or neurological morbidity related to GS was observed. The median survival time, calculated using the Kaplan-Meier method, was 10.4 months from the time of GS. In both univariate and multivariate Cox regression analyses, a single brain lesion and lack of visceral metastases were statistically predictive of a better prognosis. Six of eight patients with solitary metastasis (that is, a single brain metastasis with no primary visceral tumor) were still alive at the close of the study, none of them with disease progression, with a follow-up period ranging between 14 and 82 months. Sixteen patients in this series received adjunctive whole-brain radiation therapy, which had no impact on their survival time or local and distant control of the brain disease.

CONCLUSIONS

Gamma surgery is effective in treating melanoma metastases in the brain. It appears that the radiobiology of a single high dose overcomes the radioresistance barrier, yielding better results than fractionated radiation.

Brain metastases

Metastatic tumors to the brain are an increasing cause of morbidity and mortality in patients with systemic cancers. Many new therapies used to treat systemic cancers do not penetrate the central nervous system (CNS) and do not protect patients from the development of brain metastases. Surgery, radiosurgery, and radiation therapy are all used to treat brain metastases. It is in our opinion a mistake to use only one or two of these modalities to the exclusion of other(s). The role of systemic chemotherapy is still limited, due to both the issues of drug delivery caused by the blood brain barrier and to the relative resistance of many of these tumors to chemotherapy. Traditionally, brain metastases have been grouped together regardless of the origin of the tumor and have been treated with a single algorithm. As we encounter more patients for whom treatment of the brain metastases is an important determinant of survival, we must tailor our treatment strategies to individual tumor types. Also, we must recognize differences in each tumor's sensitivity to chemotherapy and radiotherapy and differences in their biology.

Surgical management of brain metastases

Metastatic brain tumors are the most common intracranial tumors in adults and the most common cause of neurologic morbidity and mortality in these patients. Recent advances in the management of the primary cancer have resulted in improved prognosis, longer survival, and thus, increased identification of the presence of brain metastases. Data suggest that aggressive treatment of the metastatic brain tumor with surgical resection increases the length of survival in these patients. New techniques, including preoperative functional imaging, stereotactic surgical resection, image-guided neurosurgery, intraoperative ultrasound, and cortical mapping, have aided neurosurgeons in surgical resection and have helped to lower the associated surgical morbidity and mortality. The respective roles of surgery, patient selection, prognostic factors, and radiotherapy are addressed in this review.

Molecular detection of metastatic melanoma cells in cerebrospinal fluid in melanoma patients

Melanoma frequently metastasizes to the central nervous system (CNS). The diagnosis of CNS metastases typically is made following the onset of clinical symptoms. Thus, more sensitive diagnostic approaches are needed to identify subclinical CNS metastases. Currently, standard cytologic analysis of the cerebrospinal fluid (CSF) is limited by its poor sensitivity. A more sensitive assay was therefore developed using multiple reverse transcriptase-polymerase chain reaction (RT-PCR) markers. CSF was collected and assessed by RT-PCR for three known melanoma-associated markers (MAGE-3, MART-1, and tyrosinase) to detect occult metastatic melanoma cells in the CSF of 37 American Joint Committee on Cancer (AJCC) stage IV melanoma patients. Cytologic analysis of CSF was performed on all patients, and immunohistochemistry (IHC) analysis was performed on 33 CSF samples using anti-S100 and anti-HMB-45 antibodies. Only one patient (3%) had tumor-positive CSF cytology and IHC upon entry into the study, whereas 12 patients (32%) were positive for at least one RT-PCR marker. The correlation between CSF RT-PCR positivity of MART-1 and/or MAGE-3 and the development of CNS metastases at 3 mo was significant (p = 0.04). Fifteen of 37 patients (41%) had either positive MRI and/or positive RT-PCR results. Multimarker RT-PCR is more informative and sensitive than cytology/IHC in assessing the CSF of melanoma patients.

Fractionated radiosurgery for brain metastases in 43 patients with breast carcinoma

About 15% of metastatic breast carcinoma patients are diagnosed with brain metastases. Historically, the majority are treated with palliative external whole-brain radiation with a median survival of 4 months. We examined stereotactic radiosurgery's effect on treatment outcome in such patients. Four hundred and fifty four consecutive patients with brain metastases were treated with stereotactic radiosurgery at Staten Island University Hospital, NY, between 1991 and 1999. The medical records of 60 women with histologically confirmed breast cancer were retrospectively reviewed. Forty-three patients (71%) received fractionated radiosurgery (4 x 600 cGy) and form the core of this report. Sixty five percentage had been previously unsuccessfully treated by whole-brain radiation or had recurrence after craniotomy. Survival was calculated by the Kaplan-Meier method. The median age at diagnosis of brain metastases was 52 years, with median interval of 49 months following the diagnosis of tumor primary. Median survival from brain diagnosis reached 13.6 months. Overall median survival from radiosurgery treatment was 7.5 months. Fifteen patients with one or two brain lesions survived a median of 11.5 months. For the fractionated cohort of patients 1- and 2-year actuarial survival was 28.2% and 12.8%, respectively. Three patients are alive at 32, 34 and 64 months, respectively. We conclude that fractionated radiosurgery improves survival of patients with brain metastases from breast cancer, especially those with small lesions, good functional status and no other metastatic disease. These patients should be encouraged to consider radiosurgery, possibly before WBRT. Considering our 7.5 months overall survival including patients with multiple metastases, and patients with progressive brain metastases despite extensive standard therapy and often systemic disease, these results suggest that radiosurgery could benefit breast cancer patients with brain metastases and extend life.