A multi-institutional experience with stereotactic radiosurgery for solitary brain metastasis

Treatment of brain metastases from non-small-cell lung cancer (NSCLC): radiotherapy

Brain metastases occur frequently in lung-cancer patients and are associated with a crucial decrease in prognosis and impairment of Life quality. With improved treatment and earlier diagnosis of primary tumour as well as earlier detection of lesions due to improved neuroradiological diagnosis the incidence is apparently increasing. Whole-brain radiation therapy (WBRT) prolongs median survival from 1 to 3-6 months. One-year survival rate after WBRT is approximately 10-20%. Neurological function could be improved with minimal morbidity. However, long-term survival is observed in patients with favourable prognostic factors like controlled primary tumour site, no extracranial disease, good performance status and age <60 years. In these patients individually optimised aggressive treatment strategies are clearly justified. Surgical resection or radiosurgery (RS) combined with adjuvant WBRT prolong survival to approximately 8-11 months. Surgical resection is preferred when rapid relief of increased intracranial pressure is required. The incidence of new brain metastases is low in patients with poor prognostic factors. Palliative RS could be used in these patients to rapidly improve neurological deficits. In locally advanced NSCLC radiosurgery may be used to effectively control brain disease without delay in treatment of the primary tumour site. The role of prophylactic ("elective") cranial irradiation in NSCLC patients as well as the role of combined radiochemotherapy for brain metastases has to be addressed in further clinical trials in the future.

The expanding role of neurosurgeons in the management of brain metastases

BACKGROUND

Brain metastases are the most common type of intracranial tumor. Until recently, whole brain fractionated radiation therapy (WBRT) was the mainstay of treatment, thereby confining the role of neurosurgeons to resection of an occasional solitary, accessible, and symptomatic brain metastasis. Median survival after surgery and radiation typically ranged from 5 to 11 months.

METHODS

We analyzed various demographic incidence reports and our series of brain metastasis patients treated with radiosurgery. During a 15-year interval (1987-2002), radiosurgery was performed on 5,032 patients of whom 1,088 (21.6%) had metastatic brain tumors.

RESULTS

In the United States, 266,820 to 533,640 new cases of brain metastases will be diagnosed in the year 2003. Evidence to date demonstrates that radiosurgery provides effective local tumor control for brain metastases. Important prognostic factors affecting patient survival include the absence of active systemic disease, the patient's preoperative performance status, age, and the number of metastases. Survival and local tumor control rates attained with radiosurgery are superior to those of either conventional surgery or WBRT. The morbidity associated with radiosurgery of brain metastasis is very low, and the mortality rate approaches zero.

CONCLUSIONS

Compelling evidence indicates that radiosurgery is an effective neurosurgical management strategy for intracranial brain metastases. Quite often, favorable tumor control and survival can be achieved without WBRT. With radiosurgery as a therapeutic option, neurosurgeons now have a vastly expanded armamentarium for treatment of patients with brain metastases. The large number of patients with brain metastases who require care by a neurosurgeon for optimal treatment has significant implications for both the patterns of neurosurgical training and practice in the United States.

Stereotatic radiosurgery of 468 brain metastases < or =2 cm: implications for SRS dose and whole brain radiation therapy

PURPOSE

The national standard stereostatic radiosurgery (SRS) dose for brain metastases < or =2 cm is 24 Gy as established by the Radiation Therapy Oncology Group study 90-05, in which planned whole brain radiotherapy (WBRT) was not used. On the basis of our institutional experience, the goal of this study was to determine the optimal SRS dose and influence of WBRT on local tumor control among 468 < or =2-cm metastases.

METHODS AND MATERIALS

Between October 1992 and May 2001, 468 newly diagnosed or recurrent < or =2-cm brain metastases, among 160 patients, were treated with SRS (dose range, 7-30 Gy; median, 20). A total of 240 metastases received planned WBRT (range, 6.75-50.4 Gy; median, 40.5) vs. 228 metastases that did not. The variables tested by multivariate analysis for their potential effect on tumor control included histologic type, site of metastasis, primary diagnosis, tumor volume, SRS dose, newly diagnosed vs. recurrent metastasis, and planned WBRT vs. no planned WBRT.

RESULTS

Follow-up ranged from 1 to 82 months (median 7). On multivariate analysis, the addition of WBRT was the most significant predictor of local tumor control. Overall, patients who received WBRT had superior local tumor control rates (97% vs. 87% in those who did not receive WBRT; p = 0.0001). Patients receiving WBRT and SRS > or =20 Gy achieved local control rates of 99% compared with 91% control rates when treated with WBRT and SRS <20 Gy (p = 0.0029). Increasing the SRS dose to >20 Gy resulted in no improvement in local tumor control and a higher rate of Grade 3 and 4 neurotoxicity, approaching statistical significance (5.9% vs. 1.9%, p = 0.078).

CONCLUSION

First, optimal control of brain metastasis < or =2 cm was seen with 20-Gy SRS combined with planned WBRT. Second, SRS doses >20 Gy resulted in no obvious improvement in local control and appeared to be associated with a greater rate of complications.

Whole brain radiation therapy with or without stereotactic radiosurgery boost for patients with one to three brain metastases: phase III results of the RTOG 9508 randomised trial

BACKGROUND

Brain metastases occur in up to 40% of all patients with systemic cancer. We aimed to assess whether stereotactic radiosurgery provided any therapeutic benefit in a randomised multi-institutional trial directed by the Radiation Therapy Oncology Group (RTOG).

METHODS

Patients with one to three newly diagnosed brain metastases were randomly allocated either whole brain radiation therapy (WBRT) or WBRT followed by stereotactic radiosurgery boost. Patients were stratified by number of metastases and status of extracranial disease. Primary outcome was survival; secondary outcomes were tumour response and local rates, overall intracranial recurrence rates, cause of death, and performance measurements.

FINDINGS

From January, 1996, to June, 2001, we enrolled 333 patients from 55 participating RTOG institutions--167 were assigned WBRT and stereotactic radiosurgery and 164 were allocated WBRT alone. Univariate analysis showed that there was a survival advantage in the WBRT and stereotactic radiosurgery group for patients with a single brain metastasis (median survival time 6.5 vs 4.9 months, p=0.0393). Patients in the stereotactic surgery group were more likely to have a stable or improved Karnofsky Performance Status (KPS) score at 6 months' follow-up than were patients allocated WBRT alone (43% vs 27%, respectively; p=0.03). By multivariate analysis, survival improved in patients with an RPA class 1 (p<0.0001) or a favourable histological status (p=0.0121).

INTERPRETATION

WBRT and stereotactic boost treatment improved functional autonomy (KPS) for all patients and survival for patients with a single unresectable brain metastasis. WBRT and stereotactic radiosurgery should, therefore, be standard treatment for patients with a single unresectable brain metastasis and considered for patients with two or three brain metastases.

Gamma knife surgery in the management of brain metastases from lung carcinoma: a retrospective analysis of survival, local tumor control, and freedom from new brain metastasis

Object. The objective of this retrospective study was to analyze the results of stereotactic radiosurgery performed using a gamma knife in the treatment of 44 consecutive patients with brain metastases from lung carcinoma.

Methods. Forty-four patients with lung carcinoma were treated for metastatic brain tumors by performing radiosurgery with a Leksell Gamma Knife. Twenty-one patients (47.7%) were women and 23 were men. The mean age of the patients was 56 years (range 35–77 years). Twenty-two patients (50%) had solitary tumors and the rest had multiple tumors (two—six lesions). Eighteen patients (40.9%) presented with a recurrent and/or progressive brain disease that previously had been treated with other modalities (surgery, external-beam radiotherapy, or both). Fifteen patients had controlled lung disease and 19 patients had systemic metastases (in lymph nodes, liver, and/or bones) at the time of radiosurgery.

The median follow-up period was 18.25 months. All patients were followed up for three different end points: 1) death caused by the disease; 2) clinical and/or radiological evidence of progression of the tumor that had been treated with radiosurgery; and 3) appearance of new lesions. At the last follow-up review, 17 patients (38.6%) were alive and 27 (61.4%) had died. Ten patients (22.7%) died as a result of brain disease (failure of local control or new metastases). Controlled primary disease at the time of detection of metastases and the ability to achieve local tumor control after radiosurgery significantly improved the patient survival (p < 0.01). Control of the treated tumor(s) was achieved in 32 of 44 patients (72 tumors) and 10 patients experienced treatment failure. In addition to the 44 patients comprising the study population, two other patients were treated, but died of lung disease too early in the follow-up period to have been assessed. As of the last follow-up review, no new brain metastasis had occurred in 36 patients (81.8% [includes surviving and nonsurviving patients]). The median duration of overall survival was 7 months, the median period of controlled brain disease was 21 months, and the median period of freedom from new brain metastases was 17 months (95% confidence interval 13–19 months).

Conclusions. Gamma knife surgery has significantly reduced the incidence of mortality from brain disease by effectively accomplishing local tumor control in patients with metastatic lung cancer. Local control and freedom from new brain metastases is not influenced by prior external-beam radiotherapy.

Assessment of Irradiated Brain Metastases by Means of Arterial Spin-Labeling and Dynamic Susceptibility-Weighted Contrast-Enhanced Perfusion MRI

RATIONALE AND OBJECTIVES

To assess if preradiation and early follow-up measurements of relative regional cerebral blood flow (rrCBF) can predict treatment outcome in patients with cerebral metastases and to evaluate rrCBF changes in tumor and normal tissue after stereotactic radiosurgery using arterial spin-labeling (ASL) and first-pass dynamic susceptibility-weighted contrast-enhanced (DSC) perfusion MRI.

METHODS

In 25 patients with a total of 28 brain metastases, DSC MRI and ASL perfusion MRI using the Q2TIPS sequence were performed with a 1.5-T unit. Measurements were performed prior to and at 6 weeks, 12 weeks, and 24 weeks after stereotactic radiosurgery. Follow-up examinations were completely available in 25 patients for Q2TIPS and 17 patients with 18 metastases for DSC MRI. The rrCBF of the metastases and the normal brain tissue was determined by a region-of-interest analysis. rrCBF values were correlated with the treatment outcome that was classified according to tumor volume changes at 6 months.

RESULTS

The alteration of the rrCBF at the 6-week follow-up was highly predictive for treatment outcome. A decrease of the rrCBF value predicted tumor response correctly in all metastases for Q2TIPS and in 13 of 16 metastases for DSC MRI. The pretherapeutic rrCBF was not able to predict treatment outcome. The rrCBF values in normal brain tissue affected by radiation doses less than 0.5 Gy remained unchanged after therapy.

CONCLUSION

These preliminary results suggest that ASL and DSC MRI techniques determining rrCBF changes in brain metastases after stereotactic radiosurgery allow the prediction of treatment outcome.

Determinants of outcome in melanoma patients with cerebral metastases

PURPOSE

To analyze prognostic factors, effects of treatment, and survival for patients with cerebral metastases from melanoma.

PATIENTS AND METHODS

All melanoma patients with cerebral metastases treated at the Sydney Melanoma Unit between 1952 and 2000 were identified. From 1985 to 2000, patients were diagnosed and treated using consistent modern techniques and this cohort was analyzed in detail. Multivariate analysis of prognostic factors for survival was performed.

RESULTS

A total of 1137 patients with cerebral metastases were identified; 686 were treated between 1985 and 2000. For these 686 patients, the median time from primary diagnosis to cerebral metastasis was 3.1 years (range, 0 to 41 years). A total of 646 patients (94%) have died as a result of melanoma. The median survival from the time of diagnosis of cerebral metastasis was 4.1 months (range, 0 to 17.2 years). Treatment was as follows: surgery and postoperative radiotherapy, 158 patients; surgery alone, 47 patients; radiotherapy alone, 236 patients; and supportive care alone, 210 patients. Median survival according to treatment received for these four groups was 8.9, 8.7, 3.4, and 2.1 months, respectively; the differences between surgery and nonsurgery groups were statistically significant. On multivariate analysis, significant factors associated with improved survival were surgical treatment (P <.0001), no concurrent extracerebral metastases (P <.0001), younger age (P =.0007), and longer disease-free interval (P =.036). Prognostic factors analysis confirmed the important influence of patient selection on treatment received.

CONCLUSION

This large series documents the characteristics of patients who developed cerebral metastases from melanoma. Median survival was dependent on treatment, which in turn was dependent on patient selection.

Management of brain metastases in patients with melanoma

PURPOSE OF REVIEW

Melanoma is the third most common metastatic brain tumor in the United States and is a major cause of morbidity and mortality. The development of more effective therapies for melanoma brain metastases is a major unmet clinical need and is summarized in this review.

RECENT FINDINGS

Management strategies include symptomatic treatment with corticosteroids and anticonvulsants, and definitive therapy in the form of whole-brain radiation therapy, surgical resection, stereotactic radiosurgery, and systemic therapy. The data on whole-brain radiation therapy show little impact on survival, but there is evidence that it may improve neurologic deficits. Surgery may provide a survival advantage in combination with whole-brain radiation therapy in the management of a single brain melanoma metastasis, compared with whole-brain radiation therapy alone. Stereotactic radiosurgery may offer a survival advantage (in a select group of patients with limited disease) when used alone or in combination with whole-brain radiation therapy, compared with whole-brain radiation therapy alone. Fotemustine, temozolomide, and thalidomide are three agents with high central nervous system penetration that are being actively investigated as part of systemic therapy.

SUMMARY

The currently available therapeutic options offer palliative relief of symptoms in most patients and a survival advantage in selected patients with melanoma and brain metastases. An urgent need exists to further define these treatments in the context of randomized trials, several of which are under way in the United States and abroad.

Irradiation stéréotaxique de première intention des métastases cérébrales

BACKGROUND

The minimal radiosurgical dose required to control cerebral metastases remains unknown. The aim of this study was to test whether a lower peripheral dose than usually delivered could effectively control these lesions or not.

PATIENTS AND METHODS

One hundred and eighty patients presenting 356 lesions were give first-line radiosurgery between 1995 and 2001 in Pitié-Salpêtrière hospital using a 10 MV LINAC. Mean age was 59 years, sex-ratio was 1.65, mean KI was 70. The lung was the most frequent primary site (n=85), followed by melanoma (n=29), kidney (n=21), digestive tract (n=14), breast (n=11), and others (n=20). Seventy-six percent of the patients presented 1 or 2 lesions. Mean tumor Volume was 5.5 cm3. Mean peripheral dose was 14.8Gy, mean isocenter dose was 21.6Gy.

RESULTS

Median survival was 7.6 months, local control rate was 90% at 6 months, 76% at 1 Year and 70% at 2 years. Median "neurological disease free" survival was 15 months. Multivariate analysis demonstrated the influence of two parameters on survival: number of lesions (p=0.001) and KI (p=0.04). The only parameter significantly correlated with disease-free survival was the number of isocenters (p=0.005). Morbidity (grade 2 RTOG) was 7.2% with no perimortality.

CONCLUSIONS

Low peripheral doses delivered by radiosurgery may control brain metastases with the same efficacy and fewer side-effects as the doses usually reported in the literature.

Is there a favorable subset of patients with prostate cancer who develop oligometastases?

OBJECTIVE

To analyze, retrospectively, the patterns and behavior of metastatic lesions in prostate cancer patients treated with external beam radiotherapy and to investigate whether patients with < or =5 lesions had an improved outcome relative to patients with >5 lesions.

METHODS AND MATERIALS

The treatment and outcome of 369 eligible patients with Stage T1-T3aN0-NXM0 prostate cancer were analyzed during a minimal 10-year follow-up period. All patients were treated with curative intent to a mean dose of 65 Gy. The full history of any metastatic disease was documented for each subject, including the initial site of involvement, any progression over time, and patient survival.

RESULTS

The overall survival rate for the 369 patients was 75% at 5 years and 45% at 10 years. The overall survival rate of patients who never developed metastases was 90% and 81% at 5 and 10 years, respectively. However, among the 74 patients (20%) who developed metastases, the survival rate at both 5 and 10 years was significantly reduced (p <0.0001). The overall survival rate for patients who developed bone metastases was 58% and 27% at 5 and 10 years, respectively, and patients with bone metastases to the pelvis fared worse compared with those with vertebral metastases. With regard to the metastatic number, patients with < or =5 metastatic lesions had superior survival rates relative to those with >5 lesions (73% and 36% at 5 and 10 years vs. 45% and 18% at 5 and 10 years, respectively; p = 0.02). In addition, both the metastasis-free survival rate and the interval measured from the date of the initial diagnosis of prostate cancer to the development of bone metastasis were statistically superior for patients with < or =5 lesions compared with patients with >5 lesions (p = 0.01 and 0.02, respectively). However, the survival rate and the interval from the date of diagnosis of bone metastasis to the time of death for patients in both groups were not significantly different, statistically (p = 0.17 and 0.27, respectively).

CONCLUSIONS

Patients with < or =5 metastatic sites had significantly better survival rates than patients with >5 lesions. Because existing sites of metastatic disease may be the primary sites of origin for additional metastases, our findings suggest that early detection and aggressive treatment of patients with a small number of metastatic lesions is worth testing as an approach to improving long-term survival.

Stereotactic radiosurgery for brain metastases from gastrointestinal tract cancer

BACKGROUND

Outcomes in patients with brain metastases from gastrointestinal tract cancers are not well defined. In this study we used precise, single-session, focal tumor irradiation (radiosurgery) in patients with brain metastases and evaluated the results.

METHODS

Thirty-nine patients had brain metastases from gastrointestinal tract cancer and were treated with radiosurgery. Thirty-two also had whole brain radiotherapy. Primary lesions included colorectal cancer (n = 25), esophageal cancer (n = 11), cholangiocarcinoma (n = 1), duodenal cancer (n = 1), and jejunal cancer (n = 1). Seventy-two tumors were treated.

RESULTS

The overall median survival was 9 months after diagnosis of metastatic brain disease and 5 months after radiosurgery. The 1-year survival rate after radiosurgery was 19%. The last imaging study of 49 tumors showed complete remission (CR) in 3 tumors (6.1%), partial remission (PR) in 27 tumors (55.1%), no change (NC) in 11 tumors (22.4%), and progression in 8 tumors (16.3%). The local tumor control rate (CR, PR, NC) was 84%. Two patients (5.1%) had a new or worsening neurologic deficit after radiosurgery.

CONCLUSIONS

Stereotactic radiosurgery provides reasonable local control of brain metastases from gastrointestinal tract cancer with few side effects. However, it should be used judiciously in patients with active extracranial cancers since the expected survival may be limited.

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.

Stereotactic radiosurgery for multiple brain metastases from breast carcinoma

BACKGROUND

The current study analyzed the feasibility and outcome of stereotactic radiosurgery (SRS) for treatment of brain metastases from breast carcinoma.

METHODS

During an 8-year period, 151 patients with a combined total of 620 brain metastases from breast carcinoma underwent 197 outpatient SRS procedures. Sixty-three percent of all patients had multiple brain metastases. The median tumor volume was 2.2 cm(3) (range, 0.1-20.9 cm(3)). The mean prescribed tumor dose was 19 +/- 4 grays. Local/distant tumor recurrences were treated with additional radiosurgical therapy for patients with stable systemic disease. All patients were categorized according to the Radiation Therapy Oncology Group classification. Survival time and freedom from local tumor recurrence were analyzed using the Kaplan-Meier method. Prognostic factors were identified using the Cox proportional hazards model.

RESULTS

The overall median survival duration was 10 months after SRS. Ninety-four percent of patients did not experience local brain tumor recurrence after radiosurgery. In addition, 70.2% of patients did not have disease recurrence in the brain. Most patients died of systemically progressing malignancy. A Karnofsky performance score > 70 and recursive partitioning analysis Class I were related to prolonged survival in the univariate and multivariate analyses. Age, whole-brain radiotherapy, surgery, number of metastases, chemotherapy, and latency period from diagnosis of the primary tumor to the development of brain metastases did not reach prognostic relevance in the multivariate model. Patients with RPA I, II, and III survived 34.9, 9.1, and 7.9 months, respectively. There was no treatment related permanent morbidity and mortality. The transient morbidity rate was 17%. Sixteen patients exhibited symptomatic transient complications related to treatment.

CONCLUSIONS

The results of the current study indicate that SRS is a feasible treatment concept for selected patients with multiple brain metastases from breast carcinoma.

LINAC radiosurgery for brain metastasis of renal cell carcinoma

The purpose of the study was to evaluate the efficacy and toxicity of stereotactic radiotherapy in the treatment of the brain metastasis of renal cell carcinoma. From 1994 to 2001, 28 patients presenting with 65 metastases of renal cell cancer were treated by radiosurgery. Median age was 55 years (35-75), and median Karnofski performance status ranges between 50 and 100. Seven patients had received whole brain radiotherapy (WBRT) before radiosurgery. Twelve patients were treated by radiosurgery for 1 metastasis, 5 patients for two metastases and 6 for three, and 5 for more than three metastases. One procedure was performed in 22 patients and, 2 or 3 procedures for 6 patients. Median metastasis diameter was 19 mm (5-55 mm). Median metastasis volume was 1.28 cc (0.02-28 cc). Irradiation was delivered by linear accelerator. Median minimal dose (on the 70% isodose) was 14.7 Gy (10.8 Gy, 19.5 Gy), median maximal dose (at the isocenter) 20.5 Gy (14.3 Gy, 39.6 Gy). Median follow-up was 14 months (1-33). Two metastases progressed (3%), 2 and 12 months after radiosurgery. Overall, crude local control rate was 97% and 3-, 6- and 12-month local control rates were 98% +/- 2%, 98% +/- 2%, and 93% +/- 5%, respectively. In univariate analysis, no prognostic factor of local control was retrieved. Median brain disease-free survival was 25 months after RS. the 3-, 6- and 12-month distant brain control rates were 91% +/- 4%, 91% +/- 4%, and 70% +/- 12%, respectively. Median survival duration was 11 months. The 3-, 6-, 12- and 24-month overall survival rates were 82% +/- 7%, 67% +/- 9%, 48% +/- 10%, and 33% +/- 10%, respectively. According to univariate analysis, only site of metastasis was overall survival prognostic factor. Radiosurgery for brain metastasis of renal cell carcinoma is an effective and accurate treatment. The use of radiosurgery alone is an appropriate management strategy for many patients with brain metastasis of renal cell carcinoma. Radiosurgery is efficient even after development of new metastasis appearing after WBRT.

The management of brain metastases

Brain metastases are neoplasms that originate in tissues outside the brain and then spread secondarily to the brain. Metastases to the brain are the most common intracranial tumours in adults. Substantial progress has been made in the treatment of these tumours, and radiotherapy, surgery, and stereotactic radiosurgery are now established treatments. With aggressive treatment, most patients experience meaningful symptom reduction and extension of life.

Comparison of Arterial Spin-Labeling Techniques and Dynamic Susceptibility-Weighted Contrast-Enhanced MRI in Perfusion Imaging of Normal Brain Tissue

OBJECTIVES

To evaluate relative cerebral blood flow (rCBF) in normal brain tissue using arterial spin-labeling (ASL) methods and first-pass dynamic susceptibility-weighted contrast-enhanced (DSC) magnetic resonance imaging (MRI).

METHODS

Sixty-two patients with brain metastases were examined on a 1.5 T-system up to 6 times during routine follow-up after stereotactic radiosurgery. Perfusion values in normal gray and white matter were measured using the ASL techniques ITS-FAIR in 38 patients, Q2TIPS in 62 patients, and the first-pass DSC echo-planar (EPI) MRI after bolus administration of gadopentetate dimeglumine in 42 patients. Precision of the ASL sequences was tested in follow-up examinations in 10 healthy volunteers.

RESULTS

Perfusion values in normal brain tissue obtained by all sequences correlated well by calculating Pearson's correlation coefficients (P < 0.0001) and remained unchanged after stereotactic radiosurgery as shown by analysis of variance (P > 0.05).

CONCLUSION

Both ASL and DSC EPI MRI yield highly comparable perfusion values in normal brain tissue.

Radiation therapy for brain metastases from breast cancer

BACKGROUND

Breast cancer is one of the most common malignancies that metastasize to the brain. Radiation therapy plays a central role in the management of brain metastases.

METHODS

The medical records of 36 patients with brain metastases from breast cancer who underwent whole-brain radiation therapy (WBRT) at Kyoto University Hospital between 1993 and 2001 were reviewed. The treatment outcomes were analyzed retrospectively.

RESULTS

The median age at the time of diagnosis of brain metastases was 52 years. Only 4 patients (11%) had a single metastasis, while the others had multiple metastases. Uncontrolled extracranial metastases were present in 26 patients at the time of diagnosis of brain metastases. All patients received WBRT at a median dose of 31 Gy. Eight patients received conventional external-beam boost irradiation, and 2 received boost stereotactic radiosurgery (SRS). The overall median survival time was 7.9 months. Uncontrolled extracranial metastases except for bone metastases and old age were significantly associated with a poor survival rate. Twenty-six patients (82%) showed initial response, but 15 developed CNS failure, including 9 patients whose tumor recurred at the original site, 4 patients who developed tumors elsewhere in the brain and 3 patients who exhibited meningeal spread. The median duration of intracranial failure was 5.0 months. Whole-brain dose, and total tumor dose did not affect intracranial control.

CONCLUSIONS

Radiation therapy yielded a high initial response, but the duration of effect was limited with external beam irradiation alone. New treatment strategies such as adding SRS need to be studied further.

Three irradiation treatment options including radiosurgery for brain metastases from primary lung cancer

PURPOSE

To determine local control and survival rates in 92 patients with 145 brain metastases treated with three options of radiotherapy including stereotactic radiosurgery (SR).

METHODS

Between July 1994 and August 2002, 92 consecutive patients with 145 metastases were treated with a SR, 34 with initially SR alone, 22 initially with an association of whole-brain radiotherapy (WBRT) and 36 with SR alone for recurrent new brain metastasis after WBRT. At time of treatment, extracranial disease was controlled in 46 (50%) and uncontrolled in 46 (50%). Pathologies were adenocarcinoma in 54 cases (59%), squamous cell carcinoma in 14 cases (15%), small cell carcinoma in 10 cases (11%) and miscellaneous in 14 cases (15%). All patients underwent only one treatment fraction for 1 or 2 metastases in 73 cases (83%) and for more than 2 metastases for the others.

RESULTS

The characteristics of patients and metastases in the group treated initially with SR alone and in the group treated initially with WBRT+SR were comparable. Median follow-up was 29 months (18-36). Overall, the median and the 1- and 2-year rates of overall survival were, respectively, 9 months, 37 and 20%. A controlled extracranial disease, a high Karnofsky index and a low number of metastasis were independent prognostic factor of overall survival, respectively, HR 0.53 (95% CI 0.31-0.90, P=0.01), HR 0.95 (95% CI 0.92-0.97, P=0.0002), and HR 0.48 (95% CI 0.25-0.90, P=0.02). Thirteen metastases were not controlled (9%). Six-month and 1-year local control rate were, respectively, 93 and 86%. High delivered dose was an independent prognostic factor of local control, HR 0.41 (95% CI 0.18-0.95, P=0.03). A controlled extracranial disease was favourable independent prognostic factor of brain free-disease free survival, HR 0.47 (95% CI 0.2-0.98, P=0.04). Although there was a trend of a better local control, overall and brain disease free survivals rates in the WBRT+SR group compared to SR alone one, the difference were not statistically different.

CONCLUSION

Local control and survival rates are acceptable for a palliative treatment for the three option of treatment. In this series, the number of patients is not enough great to conclude to the necessity of the association of WBRT to SR. Re-irradiation is a safe treatment after new metastases appeared in previously irradiated area.

CyberKnife frameless single-fraction stereotactic radiosurgery for tumors of the sacrum

OBJECT

The role of stereotactic radiosurgery for the treatment of intracranial lesions is well established. The experience with radiosurgery for the treatment of spinal and sacral lesions is more limited. Sacral lesions should be amenable to radiosurgical treatment similar to that used for their intracranial counterparts. The authors evaluated a single- fraction radiosurgical technique performed using the CyberKnife Real-Time Image-Guided Radiosurgery System for the treatment of the sacral lesion.

METHODS

The CyberKnife is a frameless radiosurgery system based on the coupling of an orthogonal pair of x-ray cameras to a dynamically manipulated robot-mounted linear accelerator possessing six degrees of freedom, which guides the therapy beam to the intended target without the need for frame-based fixation. All sacral lesions were located and tracked for radiation delivery relative to fiducial bone markers placed percutaneously. Eighteen patients were treated with single-fraction radiosurgery. Tumor histology included one benign and 17 malignant tumors. Dose plans were calculated based on computerized tomography scans acquired using 1.25-mm slices. Planning treatment volume was defined as the radiographically documented tumor volume with no margin. Tumor dose was maintained at 12 to 20 Gy to the 80% isodose line (mean 15 Gy). Tumor volume ranged from 23.6 to 187.4 ml (mean 90 ml). The volume of the cauda equina receiving greater than 8 Gy ranged from 0 to 1 ml (mean 0.1 ml). All patients underwent the procedure in an outpatient setting. No acute radiation toxicity or new neurological deficits occurred during the mean follow-up period of 6 months. Pain improved in all 13 patients who were symptomatic prior to treatment. No tumor progression has been documented on follow-up imaging.

CONCLUSIONS

Stereotactic radiosurgery was found to be feasible, safe, and effective for the treatment of both benign and malignant sacral lesions. The major potential benefits of radiosurgical ablation of sacral lesions are relatively short treatment time in an outpatient setting and minimal or no side effects. This new technique offers a new and important therapeutic modality for the primary treatment of a variety of sacral tumors or for lesions not amenable to open surgical techniques.

Safety of multiple stereotactic radiosurgery treatments for multiple brain lesions

BACKGROUND

Stereotactic radiosurgery (SRS) is a widely used therapy for multiple brain lesions, and studies have clearly established the safety and efficacy of single-dose SRS. However, as patient survival has increased, the recurrence of tumors and the development of metastases to new sites within the brain have made it desirable to repeat treatments over time. The cumulative toxicity of multi-isocenter, multiple treatments has not been well defined. We have retrospectively studied 10 patients who received multiple SRS treatments for multiple brain lesions to assess the cumulative toxicity of these treatments.

METHODS

In a retrospective review of all patients treated with SRS using the X-knife (Radionics, Burlington, MA) at Westchester Medical Center/New York Medical College between December 1995 and December 2000, 10 patients were identified who received at least two treatments to at least 3 isocenters and had a minimum follow-up period of 6 months. Image fusion technique was used to determine cumulative doses to targeted lesions, whole brain and critical brain structures. Toxicities and complications were identified by chart and radiological review.

RESULTS

The average of the maximum doses (cGy) to a point within the whole brain was 2402 (range 1617-3953); to the brainstem, 1059 (range 48-4126); to the right optic nerve, 223 (range 14-1012); to the left optic nerve, 159 (range 17-475); and to the optic chiasm, 219 (range 15-909). There were no focal neurological toxicities, including visual disturbances, cranial nerve palsies, or ataxia in any of the 10 patients. There were also no global toxicities, including cognitive decline or secondary tumors. Only one patient developed seizures that were difficult to control in association with radiation necrosis.

CONCLUSIONS

Multiple SRS treatments at the cumulative doses used in our study are a safe therapy for patients with multiple brain lesions.

Assessment of brain metastases with dynamic susceptibility-weighted contrast-enhanced MR imaging: initial results

PURPOSE

To assess if preradiation and early follow-up regional cerebral blood volume (CBV) measurements can help predict treatment outcome in patients with cerebral metastases and to evaluate regional CBV changes in tumor and normal tissue after radiosurgery.

MATERIALS AND METHODS

In 18 patients, dynamic susceptibility-weighted contrast material-enhanced magnetic resonance (MR) imaging was performed with a 1.5-T unit, which allowed an absolute quantification of the regional CBV. Measurements were performed prior to and at 6 weeks and 3 months after therapy. Treatment outcome was classified according to tumor volume changes at 6 months. The regional CBV of the metastases and the normal adjacent brain tissue were determined with a region-of-interest analysis. Regional CBV values were correlated with the patient outcome to assess the sensitivity and specificity of dynamic susceptibility-weighted contrast-enhanced MR imaging.

RESULTS

The pretherapeutic regional CBV was not able to help predict a treatment outcome; however, the method proved to be highly sensitive and specific for treatment outcome prediction at the 6-week follow-up. A decrease of the regional CBV value helped predict the treatment outcome with a sensitivity of more than 90%. The tumor volume change alone had a sensitivity of only 64%. The measured regional CBV values of normal brain tissue and their ratio were comparable to physiologic data and remained unchanged with therapy.

CONCLUSION

The results suggest that dynamic susceptibility-weighted contrast-enhanced MR imaging is a useful method for the assessment of radiosurgically treated brain metastases. The implemented technique with determination of the arterial input function enables an absolute quantification of the regional CBV and prediction of tumor response.

Radiosurgery for brain metastasis: impact of CTV on local control

PURPOSE

The purpose of the present analysis was to assess whether adding a 1 mm margin to the gross tumour volume (GTV) improves the control rate of brain metastasis treated with radiosurgery (RS).

PATIENTS AND METHODS

All the patients had one or two brain metastases, 30 mm or less in diameter, and only one isocentre was used for RS. There were 23 females and 38 males. The median age was 54 years (34-76). The median Karnofsky performance status was 80 (60-100). At the time of RS, 23 patients had no evidence of extracranial disease and 38 had a progressive systemic disease. Thirty-eight patients were treated up-front with only RS. Twenty-three patients were treated for relapse or progression more than 2 months after whole brain radiotherapy. From January 1994 to July 1995, clinical target volume (CTV) was equal to GTV without any margin (33 metastases). From August 1995 to August 2000, CTV was defined as GTV plus a 1 mm margin (45 metastases). A dose of 20Gy was prescribed to the isocentre and 14Gy at the margin of CTV.

RESULTS

The median follow-up was 10.5 months (1-45). The mean minimum dose delivered to GTV was 14.6Gy in the group without a margin and 16.8Gy in the group with a 1 mm margin (P<0.0001). The response of 11 metastases was never assessed because patients died before the first follow-up. Ten metastases recurred, eight in the group treated without a margin and two in the group treated with a 1 mm margin (P=0.01). Two-year local control rates were 50.7+/-12.7% and 89.7+/-7.4% (P=0.008), respectively. Univariate analysis showed that the treatment group (P=0.008) and the tumour volume (P=0.009) were prognostic factors for local control. In multivariate analysis, only the treatment group with a 1 mm margin was an independent prognostic factor for local control (P=0.04, RR: 5.8, 95% CI [1.08-31.13]). There were no significant differences, either in overall survival rate or in early and late side effects, between the two groups.

CONCLUSION

Adding a 1 mm margin to the GTV in patients treated with RS significantly improves the probability of metastasis control without increasing the side effects.

Treatment options for brain metastases in patients with non-small-cell lung cancer

Brain metastases are a common complication for patients with non-small-cell lung cancer and a significant cause of morbidity and mortality. In the past, treatment of brain metastases and lung cancer focused on symptom palliation with whole-brain radiotherapy (WBRT) and steroids because of the grim outlook for patients. However, recent advances in technology and surgical techniques have created more options for the management of brain metastases, which include surgery, irradiation, stereotactic radiosurgery, and chemotherapy. These aggressive approaches have resulted in an improvement of neurologic outcomes and survival rates of patients with non-small-cell lung cancer. Central nervous system (CNS) metastases can be divided into three groups: solitary CNS metastases with controlled or controllable primary disease, oligometastatic disease (fewer than 3 metastases), and multiple metastases. For patients with solitary CNS metastases, long-term survival is possible. A radical treatment approach involving surgical resection or radiosurgery, followed by WBRT, is recommended. For patients with oligometastatic disease, surgical resection or radiosurgery is considered in selected cases and WBRT is indicated. For patients with multiple metastases, WBRT is recommended. For patients with oligometastatic disease and those with multiple metastases, recent evidence indicates that systemically effective chemotherapy may produce responses and can be instituted safely before radiotherapy. The treatment timing of chemotherapy and radiotherapy should be individualized.

Stereotactic body frame based fractionated radiosurgery on consecutive days for primary or metastatic tumors in the lung

To evaluate the feasibility and treatment outcomes of stereotactic radiosurgery (SRS) using a stereotactic body frame (Precision Therapy), we prospectively reviewed 34 tumors of the 28 patients with primary or metastatic intrathoracic lung tumors. Eligible patients included were nine with primary lung cancer and 19 with metastatic tumors from the lung, liver, and many other organs. A single dose of 10 Gy to the clinical target volume (CTV) was delivered to a total dose of 30-40 Gy with three to four fractions. Four to eight coplanar or non-coplanar static fields were generated to adequately cover the planning target volume (PTV) as well as to exclude the critical structures as much as possible. More than 90% of the PTV was delivered the prescribed dose in the majority of cases (average; 96%, range; 74-100%). The mean PTV was 41.4 cm(3) ranging from 4.4 to 230 cm(3). Set-up error was within 5 mm in all directions (X, Y, Z axis). The response was evaluated by using a chest CT and/or 18FDG-PET scans after SRS treatment, 11 patients (39%) showed complete response, 12 (43%) partial response (decrease of more than 50% of the tumor volume), and four patients showed minimally decreased tumor volume or stable disease, but one patient showed progression disease. With a median follow-up period of 18 months, a local disease progression free interval was ranging from 7 to 35 months. Although all patients developed grade one radiation pneumonitis within 3 months, none had symptomatic or serious late complications after completing SRS treatment. Given these observations, it is concluded that the stereotactic body frame based SRS is a safe and effective treatment modality for the local management of primary or metastatic lung tumors. However, the optimum total dose and fractionation schedule used should be determined after the longer follow-up of these results.

Brain metastases treated with radiosurgery alone: an alternative to whole brain radiotherapy?

OBJECTIVE

Whole brain radiotherapy (WBRT) provides benefit for patients with brain metastases but may result in neurological toxicity for patients with extended survival times. Stereotactic radiosurgery in combination with WBRT has become an important approach, but the value of WBRT has been questioned. As an alternative to WBRT, we managed patients with stereotactic radiosurgery alone, evaluated patients' outcomes, and assessed prognostic factors for survival and tumor control.

METHODS

One hundred seventy-two patients with brain metastases were managed with radiosurgery alone. One hundred twenty-one patients were evaluable with follow-up imaging after radiosurgery. The median patient age was 60.5 years (age range, 16-86 yr). The mean marginal tumor dose and volume were 18.5 Gy (range, 11-22 Gy) and 4.4 ml (range, 0.1-24.9 ml). Eighty percent of patients had solitary tumors.

RESULTS

The overall median survival time was 8 months. The median survival time in patients with no evidence of primary tumor disease or stable disease was 13 and 11 months. The local tumor control rate was 87%. At 2 years, the rate of local control, remote brain control, and total intracranial control were 75, 41, and 27%, respectively. In multivariate analysis, advanced primary tumor status (P = 0.0003), older age (P = 0.008), lower Karnofsky Performance Scale score (P = 0.01), and malignant melanoma (P = 0.005) were significant for poorer survival. The median survival time was 28 months for patients younger than 60 years of age, with Karnofsky Performance Scale score of at least 90, and whose primary tumor status showed either no evidence of disease or stable disease. Tumor volume (P = 0.02) alone was significant for local tumor control, whereas no factor affected remote or intracranial tumor control. Eleven patients developed complications, six of which were persistent. Nineteen (16.5%) of 116 patients in whom the cause of death was obtained died as a result of causes related to brain metastasis.

CONCLUSION

Brain metastases were controlled well with radiosurgery alone as initial therapy. We advocate that WBRT should not be part of the initial treatment protocol for selected patients with one or two tumors with good control of their primary cancer, better Karnofsky Performance Scale score, and younger age, all of which are predictors of longer survival.

The rationale for adjuvant whole brain radiation therapy with radiosurgery in the treatment of single brain metastases

Randomized trials have established the efficacy of focal treatment (either stereotactic radiosurgery or conventional surgery) for single brain metastases. In the past, adjuvant whole brain radiation therapy (WBRT) was routinely given with focal therapy. Recently, the utility of adjuvant WBRT has been called into question. This paper examines the scientific evidence and the arguments, pro and con, concerning the use of adjuvant WBRT in association with stereotactic radiosurgery or conventional surgery.

Treatment options for brain metastases in patients with non-small cell lung cancer

Brain metastases are a common complication for patients with non-small cell lung cancer and a significant cause of morbidity and mortality. In the past, treatment of brain metastases and lung cancer focused on symptom palliation with whole brain radiotherapy (WBRT) and steroids because of the grim outlook for patients. However, recent advances in technology and surgical techniques have created more options for the management of brain metastases, which include surgery, irradiation, stereotactic radiosurgery, and chemotherapy. These aggressive approaches have resulted in an improvement of neurologic outcomes and survival rates of patients with non-small cell lung cancer. Central nervous system (CNS) metastases can be divided into three groups: solitary CNS metastases with controlled or controllable primary disease, oligometastatic disease (fewer than three metastases), and multiple metastases. For patients with solitary CNS metastases, long-term survival is possible. A radical treatment approach involving surgical resection or radiosurgery, followed by WBRT, is recommended. For patients with oligometastatic disease, surgical resection or radiosurgery is considered in selected cases and WBRT is indicated. For patients with multiple metastases, WBRT is recommended. For patients with oligometastatic disease and patients with multiple metastases, recent evidence indicates that systemically effective chemotherapy may produce responses and can be instituted safely before radiotherapy. The treatment timing of chemotherapy and radiotherapy should be individualized.

Radiosurgery in patients with renal cell carcinoma metastasis to the brain: long-term outcomes and prognostic factors influencing survival and local tumor control

OBJECT

Renal cell carcinoma is a leading cause of death from cancer and its incidence is increasing. In many patients with renal cell cancer, metastasis to the brain develops at some time during the course of the disease. Corticosteroid therapy, radiotherapy, and resection have been the mainstays of treatment. Nonetheless, the median survival in patients with renal cell carcinoma metastasis is approximately 3 to 6 months. In this study the authors examined the efficacy of gamma knife surgery in treating renal cell carcinoma metastases to the brain and evaluated factors affecting long-term survival.

METHODS

The authors conducted a retrospective review of 69 patients undergoing stereotactic radiosurgery for a total of 146 renal cell cancer metastases. Clinical and radiographic data encompassing a 14-year treatment interval were collected. Multivariate analyses were used to determine significant prognostic factors influencing survival. The overall median length of survival was 15 months (range 1-65 months) from the diagnosis of brain metastasis. After radiosurgery, the median survival was 13 months in patients without and 5 months in those with active extracranial disease. In a multivariate analysis, factors significantly affecting the rate of survival included the following: 1) younger patient age (p = 0.0076); 2) preoperative Karnofsky Performance Scale score (p = 0.0012); 3) time from initial cancer diagnosis to brain metastasis diagnosis (p = 0.0017); 4) treatment dose to the tumor margin (p = 0.0252); 5) maximal treatment dose (p = 0.0127); and 6) treatment isodose (p = 0.0354). Prior tumor resection, chemotherapy, immunotherapy, or whole-brain radiation therapy did not correlate with extended survival. Postradiosurgical imaging of the brain demonstrated that 63% of the metastases had decreased, 33% remained stable, and 4% eventually increased in size. Two patients (2.9%) later underwent a craniotomy and resection for a tumor refractory to radiosurgery or a new symptomatic metastasis. Eighty-three percent of patients died of progression of extracranial disease.

CONCLUSIONS

Stereotactic radiosurgery for treatment of renal cell carcinoma metastases to the brain provides effective local tumor control in approximately 96% of patients and a median length of survival of 15 months. Early detection of brain metastases, aggressive treatment of systemic disease, and a therapeutic strategy including radiosurgery can offer patients an extended survival.

Brain metastases

Brain metastases are one of the most feared complications of cancer because even small tumors may cause incapacitating neurologic symptoms. This article reviews the epidemiology, clinical features, treatment, and prognosis of brain metastases from system malignancies.

Lung cancer. Special treatment issues

This chapter of the Lung Cancer Guidelines addresses patients with particular forms of non-small cell lung cancer that require special considerations. This includes patients with Pancoast tumors, T4N0,1M0 tumors, satellite nodules in the same lobe, synchronous and metachronous multiple primary lung cancers (MPLC), and solitary metastases. For patients with a Pancoast tumor, a multimodality approach, involving chemoradiotherapy and surgical resection, appears optimal provided appropriate staging has been carried out. Patients with central T4 tumors that do not have mediastinal node involvement are uncommon. When carefully staged and selected, however, such patients appear to benefit from resection as part of the treatment as opposed to chemoradiotherapy alone. Patients with a satellite lesion in the same lobe as the primary tumor have a good prognosis and require no modification of the approach to evaluation and treatment from what would be dictated by the primary tumor alone. On the other hand, it is difficult to know how best to treat patients with a focus of the same type of cancer in a different lobe. Although MPLC do occur, the survival results after resection for either a synchronous presentation or a metachronous presentation with an interval of < 4 years between tumors are variable and generally poor, suggesting that many of these patients may have had a pulmonary metastasis rather than a second primary lung cancer. A thorough and careful evaluation of these patients is warranted to try to differentiate between patients with a metastasis and those with a second primary lung cancer, although criteria to distinguish them have not been defined. Finally, some patients with a solitary focus of metastatic disease in the brain or adrenal gland appear to benefit substantially from resection.

Lung cancer. Palliative care

The majority of patients who acquire lung cancer will have troublesome symptoms at some time during the course of their disease. Some of the symptoms are common to many types of cancers, while others are more often encountered with lung cancer than other primary sites. The most common symptoms are pain, dyspnea, and cough. This document will address the management of these symptoms, and it will also address the palliation of specific problems that are commonly seen in lung cancer: metastases to the brain, spinal cord, and bones; hemoptysis; tracheoesophageal fistula; and obstruction of the superior vena cava.

Successful treatment with stereotactic radiosurgery for brain metastases of endometrial carcinoma: a case report and review of the literature

Brain metastases from endometrial carcinomas are rare and the treatment is usually difficult. Here, we report a patient with stage IV endometrial carcinoma whose brain metastases showed complete remission after stereotactic radiosurgery using a gamma-knife. A 48-year-old woman underwent removal of a single brain metastatic lesion, and one month later underwent hysterectomy for endometrioid-type G3, endometrial adenocarcinoma. After hysterectomy, a cranial magnetic resonance imaging (MRI) demonstrated multiple brain metastases and the patient received two courses of stereotactic radiosurgery and six courses of chemotherapy. Complete response of the brain lesions was obtained, and she is well without recurrence 38 months after the second stereotactic radiosurgery.

Prospective study of stereotactic radiosurgery without whole brain radiotherapy in patients with four or less brain metastases: incidence of intracranial progression and salvage radiotherapy

This prospective study was conducted to evaluate the treatment outcome after stereotactic radiosurgery (SRS) alone with special attention to its influence on intracranial freedom from progression (FFP), local control, time to whole brain radiotherapy (WBRT), and survival. Forty-one patients with brain metastases who met the inclusion criteria were enrolled in this prospective cohort and treated by SRS alone between January 1998 and September 2001. The overall local control rate was 76%. The one year actuarial intracranial FFP was 33%. Ten patients (24%) had relapse at treated site. Twenty-three patients (56%) had intracranial progression with a median time of 4.25 months (1-24.6). Salvage radiotherapy was given in 21 patients (51%). Only 12 (29%) patients required WBRT with the median time to WBRT after SRS of 4.85 months. Nine patients (22%) underwent additional SRS at the median time of 5 months after the first procedure. The median survival was 10 months. At the time of follow up, 16 patients (39%) were still alive with a range of 6-31 months. This prospective study suggests that the omission of WBRT in the initial treatment of patients with SRS for four or less brain metastases may allow up to 70% of patients to avoid WBRT.

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.

Gamma knife radiosurgery for intracranial metastatic melanoma: a 6-year experience

Object. The purpose of this study was to evaluate retrospectively the effectiveness of stereotactic radiosurgery for intracranial metastatic melanoma and to identify prognostic factors related to tumor control and survival that might be helpful in determining appropriate therapy.

Methods. Twenty-four patients with intracranial metastases (115 lesions) metastatic from melanoma underwent radiosurgery. In 14 patients (58.3%) whole-brain radiotherapy (WBRT) was performed, and in 12 (50%) chemotherapy was conducted before radiosurgery. The median tumor volume was 4 cm3 (range 1–15 cm3). The mean dose was 16.4 Gy (range 13–20 Gy) prescribed to the 50% isodose at the tumor margin. All cases were categorized according to the Recursive Partitioning Analysis classification for brain metastases. Univariate and multivariate analyses of survival were performed to determine significant prognostic factors affecting survival.

The mean survival was 5.5 months after radiosurgery. The analyses revealed no difference in terms of survival between patients who underwent WBRT or chemotherapy and those who did not. A significant difference (p < 0.05) in mean survival was observed between patients receiving immunotherapy or those with a Karnofsky Performance Scale (KPS) score of greater than 90.

Conclusions. The treatment with systemic immunotherapy and a KPS score greater than 90 were factors associated with a better prognosis. Radiosurgery for melanoma-related brain metastases appears to be an effective treatment associated with few complications.

Gamma knife radiosurgery for brain metastases: a primary therapeutic option

Object. The aim of this retrospective study was to assess the role of gamma knife radiosurgery (GKS) as a primary treatment for brain metastases by evaluating the results in particularly difficult cases such as oncotypes—which are unresponsive to radiation—cystic lesions, and highly critical locations such as the brainstem.

Methods. Treatment of 804 patients with 1307 solitary (29%), single (26%), and multiple (45%) brain metastases was evaluated. Treatment planning parameters were as follows: mean tumor volume 4.8 cm3 (range 0.01–21.5 cm3), mean prescription dose 20.6 Gy (range 12–29 Gy), and mean number of isocenters 6.5 (one–19). In unresponsive oncotypes such as melanoma and renal cell carcinoma, the mean target dosages were higher. Cystic metastatic lesions were initially stereotactically evacuated and then GKS was performed. Patients with brainstem metastases were treated with lower doses. Conventional radiotherapy was used in only a minority (14%) of selected cases. The overall median patient survival time was 13.5 months, and the 1-year actuarial local progression-free survival rate was 94%, with a mean palliation index and functional independence index of 53.8 and 52.5 weeks, respectively. The local tumor control rate was 93%, with a mean follow-up period of 14 months. In the overall series, and especially in the unresponsive oncotypes, systemic disease progression was the main limiting factor with regard to patient life expectancy.

Conclusions. Gamma knife radiosurgery seems to be the primary treatment option for patients harboring small-tomedium size (≤ 20-cm3) brain metastases with reasonable life expectancy and no impending intracranial hypertension. Results are better than with those obtained using whole-brain radiotherapy and comparable to the best selected surgery—radiation series, even in oncotypes unresponsive to therapeutic radiation, cystic tumors, and tumors located in the brain stem.

Survival and pattern of failure in brain metastasis treated with stereotactic gamma knife radiosurgery

Object. Gamma knife radiosurgery (GKS) has become a well-established treatment modality in the management of selected patients with brain metastasis. The authors review the management patients with these tumors treated at a single center.

Methods. Between 1994 and 2002, 458 consecutive patients with metastatic brain disease underwent GKS. There were 1305 lesions treated in 680 separate sessions. The histological diagnosis was melanoma in 231 (50%), lung cancer in 94 (20.5%), breast cancer in 38 (8.3%), renal cell carcinoma (RCC) in 29 (6.3%), colon carcinoma in 13 (2.8%), unknown primary site in 14 (3.1%), and other in 39 patients (8.5%). The median tumor volume was 0.9 cm3 and the median volume treated was 2.3 cm3. The median radiation dose was 18 Gy prescribed to a median isodose of 60%; the median dose was 20 Gy in melanoma, sarcoma, and RCC. Whole-brain radiotherapy (WBRT) either prior to or following GKS was performed in 114 patients (25%). Follow up ranged from 3 to 84 months with a median of 9 months.

The median survival for all patients was 9 months and depended on tumor histology. Survival ranged from 6 months for patients with colon carcinoma, unknown primary tumors, and other tumors to 17 months for those with breast cancer. Median survival in patients with melanoma was 8 months. In multivariate analysis Karnofsky Performance Scale score (< 70 vs > 70), status of systemic disease (yes vs no), histological diagnosis, and total intracranial tumor volume were the only significant factors influencing survival. The number of brain metastases (one–five), WBRT (yes vs no), and age were not significant. Pattern of failure was different in patients with melanoma compared with those with other diagnoses. Cause of death in patients with melanoma was in 50% of the cases due to systemic disease and in 42% due to central nervous system causes, whereas it was 70% for the former and 23% for the latter in patients with other diagnoses. The treatment was well tolerated with significant late toxicity requiring craniotomy for removal of a necrotic focus in only 20 patients (4.7%).

Conclusions. Gamma knife radiosurgery provided an excellent palliation with low incidence of toxicity. A Phase III prospective randomized trial is required to define the role of WBRT in combination with GKS.

Radiosurgery for non-small cell lung carcinoma metastatic to the brain: long-term outcomes and prognostic factors influencing patient survival time and local tumor control

OBJECT

Lung carcinoma is the leading cause of death from cancer. More than 25% of those patients with lung cancer develop a brain metastasis at some time during the course of their disease. Corticosteroid therapy, radiotherapy, and resection have been the mainstays of treatment. Nonetheless, the median survival for patients with lung carcinoma metastasis is approximately 3 to 6 months. The authors examine the efficacy of gamma knife radiosurgery (GKS) for treating non-small cell lung carcinoma (NSCLC) metastases to the brain and evaluate factors affecting long-term patient survival.

METHODS

A retrospective review of 273 patients who had undergone GKS to treat a total of 627 NSCLC metastases was performed. Clinical and neuroimaging data encompassing a 14-year treatment interval were collected. Univariate and multivariate analyses were performed to determine significant prognostic factors influencing patient survival. The overall median patient survival time was 15 months (range 1-116 months) from the diagnosis of brain metastases. The median survival was 10 months from GKS treatment in those patients with adenocarcinoma and 7 months for those with other histological tumor types. In patients with no active extracranial disease at the time of GKS, the median survival time was 16 months. In multivariate analyses, factors significantly affecting survival included: 1) female sex (p = 0.014); 2) preoperative Karnofsky Performance Scale score (p < 0.0001); 3) adenocarcinoma histological subtype (p = 0.0028); 4) active systemic disease (p = 0.0001); and 5) time from lung cancer diagnosis to the development of brain metastasis (p = 0.0074). Prior tumor resection or whole-brain radiation therapy did not correlate with extended patient survival time. Postradiosurgical imaging of brain metastases revealed that 60% decreased, 24% remained stable, and 16% eventually increased in size. Factors affecting local tumor control included tumor volume (p = 0.042) and treatment isodose (p = 0.015). Fourteen patients (5.1%) later underwent craniotomy and tumor resection for tumor refractory to GKS or a new symptomatic metastasis.

CONCLUSIONS

Gamma knife surgery for NSCLC metastases affords effective local tumor control in approximately 84% of patients. Early detection of brain metastases, aggressive treatment of systemic disease, and a therapeutic strategy including GKS can afford patients an extended survival time.

Gamma knife radiosurgery for renal cell carcinoma brain metastases

Object. The purpose of this study was to clarify the effectiveness of gamma knife radiosurgery (GKS) in achieving a partial or complete remission of so-called radioresistant metastases from renal cell carcinoma (RCC) and to propose guidelines for optimal treatment

Methods. During a 5-year period, 29 patients (19 male and 10 female) with 92 brain metastases from RCC underwent GKS. The median tumor volume was 4.7 cm3 (range 0.5–14.5 cm3). Fourteen patients (48%) also underwent whole-brain radiotherapy (WBRT) before GKS, and two patients (6.8%) after GKS. The mean GKS dose delivered to the 50% isodose at the tumor margin was 16.8 Gy (range 13–30 Gy). All cases were categorized according to the Recursive Partitioning Analysis (RPA) classification for brain metastases. Univariate analysis was performed to determine significant prognostic factors and survival.

The overall median survival was 7 months after GKS treatment. Age, sex, Karnofsky Performance Scale score, and controlled primary disease were not predictors of survival. Combined WBRT/GKS resulted in median survival of 18, 8.5, and 5.3 months for RPA Classes I, II, and III, respectively, compared with the median survival 7.1, 4.2, and 2.3 months for patients treated with WBRT alone.

Conclusions. These results suggest that WBRT combined with GKS may improve survival in patients with brain metastases from RCC. Furthermore, this improvement in survival was seen in all RPA classes.

Gamma knife radiosurgery and brain metastases: local control, survival, and quality of life

Object. The purpose of this paper was to describe the clinical outcome in patients with brain metastases who underwent gamma knife radiosurgery (GKS).

Methods. The authors retrospectively reviewed the clinical courses of 54 patients with brain metastases who underwent 62 GKS procedures. This series covered a 43-month period. A total of 174 lesions were treated: 38 patients harbored solitary whereas 24 patients harbored multiple metastases. The authors assessed outcome by examining local disease control, survival, and quality of life.

The overall local control rate was 85%; the mean time to failure of local control was 10.5 months; and median survival was 8.4 months. Median survival, evaluated by the log-rank test, was greater among patients with a single metastasis (p = 0.043), breast cancer (p = 0.021), and those who had undergone multiple GKS procedures for local failure (p = 0.009). The initial Karnofsky Performance Scale (KPS) score and whole-brain radiotherapy were not significantly related to median survival. The KPS scores tended to remain stable through the follow-up period. There were no morbidities or deaths attributable to the procedure.

Conclusions. Results in this series suggest that GKS can be an effective tool for the control of brain metastases. A prospective investigation should be performed to validate trends seen in this retrospective study.

[Intracerebral radiotherapy under stereotaxic conditions]

Stereotactic radiosurgery is used for treating several brain diseases. Radiosurgery is a non-invasive alternative to surgery for brain metastases, and randomized trials are on going to assess the role of radiosurgery. Radiosurgery has been advocated for patients with small benign meningioma or with vestibular schwannoma, but there is no proof of efficacy and safety of radiosurgery in comparison with other treatments. Radiosurgery can obliterate 80-90% of small arteriovenous malformations, but no information exists on the survival of treated compared with untreated patients. The limited information available suggests that radiosurgery should be fully evaluated in well-designed prospective studies.

Local recurrence of metastatic brain tumor after stereotactic radiosurgery or surgery plus radiation

In this study, we compared the recurrence of metastatic brain tumors after radiosurgery versus after surgery plus radiation, and analyzed the factors associated with the recurrence of brain metastases. Twenty-eight and 35 patients with metastatic brain tumors underwent radiosurgery (52 lesions) and surgery plus radiation (46 lesions), respectively, between 1995 and 2001. The median tumor volume was 1.55 ml (range: 0.02-10.4 ml) in radiosurgery patients and 17.9 ml (range: 0.26-195 ml) in surgery plus radiation patients. The median radiosurgical tumor central and margin doses were 28.9 and 23.8 Gy (range: 20-35 and 25-15 Gy), respectively. The median total dose was 46.7 Gy (range: 30-63 Gy) in the surgery plus radiation group. The recurrence time from surgery plus radiation group (25 months) was significantly longer than that from the radiosurgery group (7.2 months) (p = 0.0199). The factors affecting the recurrence of brain metastases after radiosurgery were size, central dose of radiation and histology (colon vs. others). No factors affected the recurrence of brain metastases after surgery plus radiation. To avoid early recurrences of metastatic brain tumors, surgery plus radiation is the preferable therapeutic modality. The size and histology of brain metastases, and the dose of radiation should be considered for the effective treatment of tumors by radiosurgery.

Small-volume image-guided radiotherapy using hypofractionated, coplanar, and noncoplanar multiple fields for patients with inoperable Stage I nonsmall cell lung carcinomas

BACKGROUND

Occasionally, medically compromised and/or elderly patients with nonsmall cell lung carcinomas (NSCLCs) cannot be treated surgically. We investigated small-volume hypofractionated image-guided radiotherapy (IGRT) without the need for breath control in patients with inoperable Stage I NSCLCs.

METHODS

Between September 1996 and September 1999, 22 patients with Stage I NSCLCs, including 19 males and 3 females, were treated with IGRT. Among these patients, there were 13 Stage IA and 9 Stage IB tumors. The tumors ranged in size from 14.2 to 58.5 mm, with a median size of 26.7 mm. Of the 22 patients, 19 were unfit for surgical treatment due to poor pulmonary function, complications, and/or advanced age and 3 refused surgery. Computed tomographic scans (CT) of the primary tumor were taken during three respiratory phases and they were analyzed to determine the planning target volume, which included only the primary tumor with allowances for respiratory movement. The radiation doses administered at the edge of the moving tumor during normal breathing were 80% of the prescribed dose, either 48 or 60 Gy given in eight fractions over 2 weeks. Clinical evaluation, chest CT scan, and pulmonary function tests were performed before irradiation and at regular intervals for the post-IGRT follow-up. The median follow-up period was 24 months (range, 2-44 months; mean, 21.8 months) (at least 24 months for survivors).

RESULTS

Of 17 tumors assessed at the initial follow-up 2-6 months after treatment (5 complete responses, 11 partial responses, and 1 progressive disease), 16 (94%) were controlled locally. One local recurrence was observed during the follow-up. The lung carcinoma-specific survival rate at 1 year was 94% and the 1-year actuarial recurrence-free survival rate was 71%. The lung carcinoma-specific survival rate at 2 years was 73% and the 2-year actuarial recurrence-free survival rate was 67%. The treatment was well tolerated and no major side effects were observed. Localized radiation pneumonitis was observed in all patients who were examined by CT scan, but the patients were asymptomatic. Parameters of pulmonary function, including vital capacity, total lung capacity, and diffusion capacity for carbon monoxide, decreased very little or not at all, indicating that IGRT rarely deteriorated pulmonary functions.

CONCLUSIONS

Small-volume hypofractionated IGRT without breath control is a feasible and beneficial method for the curative treatment of patients with Stage I NSCLCs. It has the potential of a high local tumor control rate and low morbidity.

Repeated gamma knife surgery for multiple brain metastases from renal cell carcinoma

OBJECT

The aim of this study was to evaluate the therapeutic profile of repeated gamma knife surgery (GKS) for renal cell carcinoma that has metastasized to the brain on multiple occasions.

METHODS

Data from this study were culled from a single institution and cover a 6-year period of outpatient radiosurgery. A standard protocol for indication, dose planning, and follow up was established. In cases of distant or local recurrences, radiosurgery was undertaken repeatedly (up to six times in one individual). Seventy-five patients harboring 350 cerebral metastases were treated. Relief from pretreatment neurological symptoms occurred in 72% of patients within a few days or a few weeks after the procedure. The actuarial local tumor control rate after the initial GKS was 95%. In patients free from relapse of intracranial metastases after repeated radiosurgery, long-term survival was 91% after 4 years; median survival was 11.1+/-3.2 months after radiosurgery and 4.5+/-1.1 years after diagnosis of the primary kidney cancer. Survival following radiosurgery was independent of patient age and sex, side of the renal cell carcinoma, pretreatment of the cerebrum by using radiotherapy or surgery, number of brain metastases and their synchronization with the primary renal cell carcinoma, and the frequency of radiosurgical procedures. In contrast, survival was dependent on the patient's clinical performance score and the extracranial tumor status. Tumor bleeding was observed in seven patients (9%) and late radiation toxicity (LRT) in 15 patients (20%). Treatment-related morbidity was moderate and mostly transient. Late radiation toxicity was encountered predominantly in long-term survivors.

CONCLUSIONS

Outpatient repeated radiosurgery is an effective and only minimally invasive treatment for multiple brain metastases from renal cell cancer and is recommended as being the method of choice to control intracranial disease, especially in selected patients with limited extracranial disease. Physicians dealing with such patients should be aware of the characteristic aspects of LRT.

Feasibility of frameless single-fraction stereotactic radiosurgery for spinal lesions

Object

The role of stereotactic radiosurgery for the treatment of intracranial lesions is well established. Its use for the treatment of spinal lesions has been limited by the availability of effective target-immobilizing devices. In this study the authors evaluated the CyberKnife Real-Time Image-Guided Radiosurgery System for spinal lesion treatment involving a single-fraction radiosurgical technique.

Methods

This frameless image-guided radiosurgery system uses the coupling of an orthogonal pair of x-ray cameras to a dynamically manipulated robot-mounted linear accelerator possessing six degrees of freedom, which guides the therapy beam to the target without the use of frame-based fixation. Cervical lesions were located and tracked relative to osseous skull landmarks; lower spinal lesions were tracked relative to percutaneously placed gold fiducial bone markers. Fifty-six spinal lesions in 46 consecutive patients were treated using single-fraction radiosurgery (26 cervical, 15 thoracic, and 11 lumbar, and four sacral). There were 11 benign and 45 metastatic lesions.

Tumor volume ranged from 0.3 to 168 ml (mean 26.7 ml). Thirty-one lesions had previously received external-beam radiotherapy with maximum spinal cord doses. Dose plans were calculated based on computerized tomography scans acquired using 1.25-mm slices. Tumor dose was maintained at 12 to 18 Gy to the 80% isodose line; spinal cord lesions receiving greater than 8 Gy ranged from 0 to 1.3 ml (mean 0.3 ml). All patients tolerated the procedure in an outpatient setting. No acute radiation-induced toxicity or new neurological deficits occurred during the follow-up period. Axial and radicular pain improved in all patients who were symptomatic prior to treatment.

Conclusions

Spinal stereotactic radiosurgery involving a frameless image-guided system was found to be feasible and safe. The major potential benefits of radiosurgical ablation of spinal lesions are short treatment time in an outpatient setting with rapid recovery and symptomatic response. This procedure offers a successful alternative therapeutic modality for the treatment of a variety of spinal lesions not amenable to open surgical techniques; the intervention can be performed in medically untreatable patients, lesions located in previously irradiated sites, or as an adjunct to surgery.

Stereotactic Radiosurgery for Patients with “Radioresistant” Brain Metastases

OBJECTIVE

Our aim was to evaluate the efficacy of stereotactic radiosurgery (SRS) for the treatment of patients with brain metastases that have been determined to be “radioresistant” on the basis of histological examination.

METHODS

We reviewed the medical records of 41 consecutive patients who presented with 83 brain metastases from radioresistant primaries and subsequently underwent SRS. All patients were followed until death or for a median of 31 months after SRS. Tumor histologies included renal cell carcinoma (16 patients), melanoma (23 patients), and sarcoma (2 patients). Eighteen patients (44%) had a solitary metastasis, and 23 patients (56%) had multiple metastases.

RESULTS

The median overall survival time was 14.2 months after SRS. On the basis of univariate analysis, systemic disease status (P = 0.006) and Radiation Therapy Oncology Group recursive partitioning analysis (RPA) class (P = 0.005) were associated with survival. The median survival time was 23.5 months for patients in RPA Class I status and 10.5 months for patients in RPA Class II or III status. There was a trend (P = 0.12) toward improved median survival for patients with renal cell carcinoma (17.8 mo) as compared with patients with melanoma (9.7 mo). Multivariate analysis showed RPA class (P = 0.038) and histological diagnosis of primary tumor (P &lt; 0.001) to be independent predictors for overall survival. In the 35 patients who underwent follow-up imaging, 9 (12%) of 73 tumors recurred locally. In 54% of the patients, distant brain failure (DBF) developed. Whole brain radiotherapy (WBRT) improved local control and decreased DBF, according to the univariate and multivariate analyses. Patients who received adjuvant WBRT in addition to SRS had 6-month actuarial local control of 100% as compared with 85% among those who did not receive WBRT (P = 0.018). Patients who received adjuvant WBRT with SRS had a 6-month actuarial DBF rate of 17%, as compared with a rate of 64% among patients who had SRS alone (P = 0.0027).

CONCLUSION

Well-selected patients with brain metastases from radioresistant primary tumors who undergo SRS survive longer than historical controls. RPA Class I status and primary renal cell carcinoma predict longer survival. Adjuvant WBRT improves local control and decreases DBF but does not affect overall survival. Further studies are needed to determine which patients should receive WBRT.

Treatment of brain metastases in patients with non-small cell lung cancer (NSCLC) by stereotactic linac-based radiosurgery: prognostic factors

A restrospective study of patients with brain metastases from non-small cell lung cancer (NSCLC) is performed to identify patients who benefit from radiosurgery and to determine prognostic factors for survival. Eighty-six consecutive patients with a total of 110 brain metastases from NSCLC were treated with linac-based radiosurgery. Six patients with eight brain metastases who received radiosurgery as a focal boost to whole brain radiotherapy where excluded. Median age at treatment was 60 years. Median dose was 20 Gy/80%-isodose. A chi(2)-test was used to identify potential prognostic factors for local control of brain metastases and survival of the patients. Median follow-up was 6 months (range 1 1/2-77 months) with 17/80 patients still alive. Median actuarial survival was significantly longer (P<0.004) in patients with metachronous onset of brain metastases in comparison to synchronous onset (8.3 vs. 3.3 months). Survival was significantly increased after radiosurgery in the absence of extracranial tumor progression (P<0.03). Eleven patients (14%) developed new brain metastases after radiosurgery after a latency of median 5 months. Actuarial local control rate was 96% after 3 months. Local control was significantly increased with a prescribed dose > or=18 Gy/80%-isodose (P<0.01). We conclude that especially patients with poor prognostic factors and a limited number of brain metastases may be palliatively treated with radiosurgery alone. This approach allows to effectively control CNS manifestation of the disease and can be integrated into chemotherapeutic protocols.