A multiinstitutional outcome and prognostic factor analysis of radiosurgery for resectable single brain metastasis

Detection of brain metastasis in potentially operable non-small cell lung cancer: a comparison of CT and MRI

STUDY OBJECTIVE

To compare the usefulness of MRI and CT in the detection of brain metastases during preoperative evaluation and postoperative follow-up.

DESIGN

A prospective and sequential comparison.

PATIENTS AND METHODS

Of 332 patients with potentially operable non-small cell lung cancer who were free of neurologic signs and symptoms, brain CT was performed preoperatively on 155 patients (CT group) and brain MRI on 177 patients (MRI group). Patient characteristics in both groups were comparable. In 279 patients with complete resection of the primary lung tumor, intensive follow-up with CT and MRI was performed in the respective groups. The preoperative detection of brain metastases, postoperative intracranial recurrence rates, and characteristics of detected brain tumors were compared between the two groups. The survival of patients with brain metastases was also compared.

RESULTS

From the first evaluation to 12 months after surgery for primary lung cancer, brain metastases were observed in 11 patients (7.1%) from the CT group and 12 patients (6.8%) from the MRI group. MRI detected brain metastases preoperatively in 6 of the 12 patients (3.4% of the total MRI group), whereas CT detected brain metastases preoperatively in 1 of the 11 patients (0.6% of the total CT group). MRI showed a tendency toward a higher preoperative detection rate of brain metastases than CT (p = 0.069). Furthermore, the mean (+/- SD) maximal diameter of the brain metastases was significantly smaller in the MRI group (12.8+/-9.1 mm) than in the CT group (20.3+/-7.0 mm) (p = 0.041). However, the median survival time and 2-year survival rate after treatment of detected brain metastases, respectively, were 10 months and 27% in the CT group and 17 months and 28% in the MRI group. There was no significant difference between the groups in survival time.

CONCLUSIONS

Preoperative evaluation and intensive follow-up with MRI could facilitate early detection of brain metastases in patients with potentially operable lung cancer. However, further studies on detection and treatment of the metastatic tumors are considered necessary.

Radiosurgery for brain metastases: is whole brain radiotherapy necessary?

PURPOSE

Because whole brain radiotherapy (WBRT) may cause dementia in long-term survivors, selected patients with brain metastases may benefit from initial treatment with radiosurgery (RS) alone reserving WBRT for salvage as needed. We reviewed results of RS +/- WBRT in patients with newly diagnosed brain metastasis to provide background for a prospective trial.

METHODS AND MATERIALS

Patients with single or multiple brain metastases managed initially with RS alone vs. RS + WBRT (62 vs. 43 patients) from 1991 through February 1997 were retrospectively reviewed. The use of upfront WBRT depended on physician preference and referral patterns. Survival, freedom from progression (FFP) endpoints, and brain control allowing for successful salvage therapy were measured from the date of diagnosis of brain metastases. Actuarial curves were estimated using the Kaplan-Meier method. Analyses to adjust for known prognostic factors were performed using the Cox proportional hazards model (CPHM) stratified by primary site.

RESULTS

Survival and local FFP were the same for RS alone vs. RS + WBRT (median survival 11.3 vs. 11.1 months and 1-year local FFP by patient 71% vs. 79%, respectively). Brain FFP (scoring new metastases and/or local failure) was significantly worse for RS alone vs. RS + WBRT (28% vs. 69% at 1 year; CPHM adjustedp = 0.03 and hazard ratio = 0.476). However, brain control allowing for successful salvage of a first failure was not significantly different for RS alone vs. RS + WBRT (62% vs. 73% at 1 year; CPHM adjusted p = 0.56).

CONCLUSIONS

The omission of WBRT in the initial management of patients treated with RS for up to 4 brain metastases does not appear to compromise survival or intracranial control allowing for salvage therapy as indicated. A randomized trial of RS vs. RS + WBRT is needed to assess survival, quality of life, and cost in good-prognosis patients with newly diagnosed brain metastases.

The Mayo Clinic gamma knife experience: indications and initial results

OBJECTIVE

To review the results and expectations of contemporary stereotactic radiosurgery.

MATERIAL AND METHODS

We conducted a retrospective analysis of 1,033 consecutive patients who underwent gamma knife radiosurgery at Mayo Clinic Rochester between January 1990 and January 1998.

RESULTS

The number of patients undergoing radiosurgery increased from 57 in 1990 to 216 in 1997. Of 97 patients with arteriovenous malformations who underwent follow-up angiography 2 years or more after a single radiosurgical procedure, 72 (74%) had complete obliteration of the vascular malformation. Of 209 patients who underwent radiosurgery for benign tumors (schwannomas, meningiomas, or pituitary adenomas) and had radiologic studies after 2 years or more of follow-up, tumor growth control was noted in 200 (96%). Tumor growth was also controlled in 90% of brain metastatic lesions at a median of 7 months after radiosurgery. Of 20 patients with trigeminal neuralgia and follow-up for more than 2 months, 14 (70%) were free of pain after radiosurgery.

CONCLUSION

Radiosurgery is a safe and effective management strategy for a wide variety of intracranial disorders. Use of radiosurgical treatment should continue to increase as more data become available on the long-term results of this procedure.

Fractionated stereotactic radiotherapy of small intracranial malignancies

PURPOSE

To retrospectively evaluate the effectiveness of fractionated stereotactic radiotherapy (FSRT) in patients with small intracranial malignancies.

METHODS AND MATERIALS

From July 1991 to March 1997, 80 patients with a total of 121 brain or skull-base tumors were treated with FSRT alone, and were followed for periods ranging from 3 to 62 months (median 9.8). The majority of patients received 42 Gy in 7 fractions over 2.3 weeks, but in July 1993, protocols using smaller fraction doses were introduced for patients whose radiation-field diameters were larger than 3 cm or whose tumors were close to critical normal tissues.

RESULTS

For 64 patients with metastatic brain tumors the overall median survival was 8.3 months and 1-year actuarial survival rate was 33%. Significant prognostic factors were: the presence of extracranial tumors, pre-treatment performance status, and the lung as a primary site. Patients without extracranial tumors prior to FSRT had a median survival of 21.2 months. For seven patients with high-grade glioma, 1-year actuarial local control rate was 75%, with a median survival of 10.3 months. For patients with skull-base tumors the local control was achieved in 6 of 6 patients (100%), with a median survival of 30.7 months. No one suffered from acute complications, but three patients, two of whom had undergone FSRT as the third course of radiotherapy, developed late radiation injuries.

CONCLUSION

Overall high local control and low morbidity rates suggest that FSRT is an effective and safe modality, even for those with a history of prior irradiation. However, patients with risk factors should be treated with smaller fraction doses.

Treatment of human breast cancer in a brain metastatic model by G207, a replication-competent multimutated herpes simplex virus 1

We investigated the therapeutic efficacy of G207, a replication-competent multimutated herpes simplex virus type 1, for the treatment of human malignant mammary tumors metastatic to the brain. In vitro studies demonstrated that G207 efficiently destroyed three of four human malignant breast cancer cell lines. MDA-MB-435 was most susceptible and MDA-MB-231 was least susceptible to G207. In athymic mice harboring subcutaneous or intracerebral MDA-MB-435 cells, intraneoplastic inoculation of G207 caused growth inhibition and/or prolonged survival. In contrast, G207 had minimal effects on MDA-MB-231 subcutaneous tumor growth or survival in the intracerebral tumor model. The efficacy of G207 therapy in vivo correlated well with the susceptibility of the human cancer cells to G207 in vitro. Histological studies indicate that G207 replication is restricted to tumor cells in vivo and does not occur in the surrounding brain tissue. These results suggest that G207 shows particular promise for use as a novel antineoplastic agent for metastatic brain tumors and that in vitro testing may predict which tumors will be most responsive in vivo.

Preliminary experience with frameless stereotactic radiotherapy

PURPOSE

To report initial clinical experience with a novel high-precision stereotactic radiotherapy system.

METHODS AND MATERIALS

Sixty patients ranging in age from 2 to 82 years received a total of 1426 treatments with the University of Florida frameless stereotactic radiotherapy system. Of the total, 39 (65%) were treated with stereotactic radiotherapy (SRT) alone, and 21 (35%) received SRT as a component of radiotherapy. Pathologic diagnoses included meningiomas (15 patients), low-grade astrocytomas (11 patients), germinomas (9 patients), and craniopharyngiomas (5 patients). The technique was used as means of dose escalation in 11 patients (18%) with aggressive tumors. Treatment reproducibility was measured by comparing bite plate positioning registered by infrared light-emitting diodes (IRLEDs) with the stereotactic radiosurgery reference system, and with measurements from each treatment arc for the 1426 daily treatments (5808 positions). We chose 0.3 mm vector translation error and 0.3 degrees rotation about each axis as the maximum tolerated misalignment before treating each arc.

RESULTS

With a mean follow-up of 11 months, 3 patients had recurrence of malignant disease. Acute side effects were minimal. Of 11 patients with low grade astrocytomas, 4 (36%) had cerebral edema and increased enhancement on MR scans in the first year, and 2 required steroids. All had resolution and marked tumor involution on follow-up imaging. Bite plate reproducibility was as follows. Translational errors: anterior-posterior, 0.01 +/- 0.10; lateral, 0.02 +/- 0.07; axial, 0.01 +/- 0.10. Rotational errors (degrees): anterior-posterior, 0.00 +/- 0.03; lateral, 0.00 +/- 0.06; axial, 0.01 +/- 0.04. No patient treatment was delivered beyond the maximum tolerated misalignment. Daily treatment was delivered in approximately 15 min per patient.

CONCLUSION

Our initial experience with stereotactic radiotherapy using the infrared camera guidance system was good. Patient selection and treatment strategies are evolving rapidly. Treatment accuracy was the best reported, and the treatment approach was practical.

Patient selection criteria for the treatment of brain metastases with stereotactic radiosurgery

In this study we evaluate prognostic factors that predict local-regional control and survival following stereotactic radiosurgery (SRS) in patients with brain metastasis and establish guidelines for patient selection. Our evaluation is based on 73 patients with brain metastasis treated with SRS at the University of Minnesota between March 1991 and November 1995. The ability of stereotactic radiosurgery to improve local control in patients with brain metastases is confirmed in our study in which only 6 of 62 patients failed locally after SRS, with an actuarial local progression-free survival of 80% at 2 years. Variables that predicted worse prognosis were larger tumor size (p = 0.05) for local progression-free survival and multiplicity of metastasis (p = 0.03) and infratentorial location of metastases (p = 0.006) for regional progression-free survival. Absence of extracranial disease, KPS > or = 70, and single intracranial metastasis were significant predictors of longer survival. Patients who fulfill all three criteria will survive longer after SRS (MS = 17.7 months) and will most likely benefit from the increase local control in the brain achieved by SRS. Survival in patients who do not meet any of these criteria is very poor (MS = 1.5 months), and these patients are less likely to benefit from this treatment. Careful selection of patients for SRS is warranted.

Stereotactic radiosurgery for cerebral metastatic melanoma: factors affecting local disease control and survival

PURPOSE

The development of a brain metastasis represents an ominous event for patients with malignant melanoma. We evaluated results after stereotactic radiosurgery (SR) for patients with metastastic melanoma to identify patient outcomes and factors for survival.

METHODS

The authors reviewed the management results of 60 consecutive patients with melanoma metastases, with a total of 118 melanoma brain metastases, undergoing SR during a 9-year interval. Of these, 51 also had whole-brain radiation therapy (WBRT). A total of 118 tumors of mean volume of 2.95 ml (range, 0.1-25.5 ml) were treated by SR with a mean margin dose of 16.4 Gy (range, 10 to 20 Gy). Univariate and multivariate analyses were used to determine significant prognostic factors affecting survival in 60 patients.

RESULTS

Median survival was 7 months after SR in all 60 patients and 10 months from brain tumor diagnosis (mean follow-up period, 9.3 months). Lack of active systemic disease and a solitary metastasis were associated with improved survival in multivariate analysis (median, 15 months). The imaging-defined local control rate of evaluable tumors (n = 72) was 90% (disappearance = 11%, shrinkage = 44%, and stable = 35%). Local recurrence developed in 7 patients and remote brain disease developed in 14 patients. WBRT combined with radiosurgery did not improve survival nor local tumor control. New brain metastases developed less often when WBRT was added to SR (23% vs. 44%), but this difference was not significant. Only 4 patients (7%) died from progression of a radiosurgery-managed tumor. No patient developed a delayed radiation-related complication, but 3 patients developed delayed intratumoral hemorrhage at the radiosurgery site, 2 of whom had new symptoms.

CONCLUSIONS

Stereotactic radiosurgery for melanoma brain metastasis is effective and is associated with few complications. The use of radiosurgery alone is an appropriate management strategy for many patients with solitary tumors.

Stereotactic radiosurgery for brain metastasis from renal cell carcinoma

BACKGROUND

The authors evaluated results after stereotactic radiosurgery (SR) for brain metastases from renal cell carcinoma (RCC) and identified factors associated with improved survival and tumor control.

METHODS

The authors reviewed the management results from a total of 52 RCC brain metastases in 35 consecutive patients who underwent stereotactic radiosurgery (SR) during a 9-year interval. Twenty-eight patients also underwent whole brain radiation therapy (WBRT). The mean tumor volume was 2.4 mL (range, 0.1-14.1 mL). The mean dose delivered to the tumor margin was 17 gray (Gy) (range, 13-20 Gy). Univariate and multivariate testing was performed to determine significant prognostic factors.

RESULTS

The median survival was 11 months after SR and 14 months after brain tumor diagnosis. Only 2 patients (8%) died of progression of the irradiated tumor. Age < 55 years, lack of active systemic disease, and use of chemotherapy and/or immunotherapy after SR were significant favorable prognostic factors in multivariate testing. Post-SR imaging was evaluated in 26 patients (39 tumors). The local control rate from the 39 treated tumors imaged was 90% (tumor disappearance, 21%; tumor regression, 44%; and stable disease, 26%). Local recurrence developed in 3 patients (4 lesions) and remote brain disease in 12 patients. No patient developed a new focal neurologic deficit due to SR. Patients were classified into two groups: SR with and SR without WBRT. The addition of WBRT to SR did not improve survival. Distant failure occurred similarly in both groups (46% vs. 50%). WBRT combined with SR may contribute to local control, but did not prevent the development of new remote tumors.

CONCLUSIONS

SR for brain metastasis from RCC results in brain disease control in the majority of patients and was associated with few complications. Early detection of brain metastases and treatment with SR provides extended quality survival.

[Radiosurgery of single brain metastasis without combined total cerebral irradiation. Results of a consecutive series of 12 cases]

PURPOSE

To evaluate the usefulness of radiosurgery without whole brain irradiation for a solitary brain metastasis.

PATIENTS AND METHODS

Between December 1994 and November 1996, 12 patients were treated for a single brain metastasis by radiosurgery alone. Median age was 53, and 10 patients had a Karnofsky performance status above 70. Half the patients had active extracranial disease at the time of radiosurgery. Stereotactic radiosurgery delivered a single dose of 20 Gy (specified at the isocenter with a 70% isodose reference curve). Evaluation of results was performed according to local control, survival, evolution of performance status, as well as evolution of neurologic symptoms.

RESULTS

No patient had immediate toxicity. One month later, ten patients showed improvement in their neurologic impairments, and none had progression of the cerebral lesion according to CT scan evaluation (diminution for seven patients, and stabilization for five). Local control rate was 58%, and median time to failure was 4 months. The overall median survival time was 10 months. Three patients were alive, with good performance status, and six died following cerebral progression.

CONCLUSION

These poor results in terms of local control are in favor of supplementary whole brain irradiation, except for particular cases.

[Could the evaluation of the cost of complications be a worthwhile means to improve radiotherapy?]

At the present time, the current improvement of technical and dosimetric aspects of radiation oncology has to be evaluated in terms of potential benefit for the patient and the society. For this last point of view, specially designed economic analyses must be performed in order to justify the number of resources involved by these technical improvements. If the question is how the current technical procedures could reduce the risk of undesirable side-effects, the response cannot be immediately drawn from the literature. This paper emphasizes the possibility to evaluate the role of side-effects as endpoints of economic analyses when using special models in medical decision making such as Markov's. Only few oncologic situations are reliable to properly analyze the relationship between sophisticated radiation techniques and the incidence of post-radiation complications. These situations should be selected when prospective economic analyses are planned in the field of radiation therapy.

[Importance of radiotherapy in stereotactic conditions (radiosurgery) in brain metastasis: experience and results of the Hôpital Pitié-Salpêtrière Group]

PURPOSE

Retrospective analysis of the influence of clinical and technical factors on local control and survival after radiosurgery for brain metastasis.

PATIENTS AND METHODS

From January 1994 to December 1996, 42 patients presenting with 71 metastases underwent radiosurgery for brain metastasis. The median age was 56 years and the median Karnofsky index 80. Primary sites included: lung (20 patients), kidney (seven), breast (five), colon (two), melanoma (three), osteosarcoma (one) and it was unknown for three patients. Seventeen patients had extracranial metastasis. Twenty-four patients were treated at recurrence which occurred after whole brain irradiation (12 patients), surgical excision (four) or after both treatments (eight). Thirty-six sessions of radiosurgery have been realized for one metastasis and 13 for two, three or four lesions. The median metastasis diameter was 21 mm and the median volume 1.7 cm3. The median peripheral dose to the lesion was 14 Gy, and the median dose at the isocenter 20 Gy.

RESULTS

Sixty-five metastases were evaluable for response analysis. The overall local control rate was 82% and the 1-year actuarial rate was 72%. In univariate analysis, theoretical radioresistance (P = 0.001), diameter less than 3 cm (P = 0.039) and initial treatment with radiosurgery (P = 0.041) were significantly associated with increased local control. Only the first two factors remained significant in multivariate analysis. No prognostic factor of overall survival was identified. The median survival was 12 months. Six patients had a symptomatic oedema (RTOG grade 2), only one of which requiring a surgical excision.

CONCLUSION

In conclusion, 14 Gy delivered at the periphery of metastasis seems to be a sufficient dose to control most brain metastases, with a minimal toxicity. Better results were obtained for lesions initially treated with radiosurgery, theoretically radioresistant and with a diameter less than 3 cm.

Is it time to reevaluate our approach to the treatment of brain metastases in patients with non-small cell lung cancer?

Brain metastases from non-small cell lung cancer develop in approximately one-third of patients. If not treated, neurological deterioration occurs quickly. Treatment with whole brain irradiation is advisable to palliate symptoms but despite this treatment, survival remains poor at 3-6 months. Recently, aggressive approaches with surgical resection and stereotactic radiosurgery have dramatically improved the control of brain metastases resulting in a meaningful survival advantage for a subset of eligible patients. New evidence also suggests a possible role for chemotherapy in the treatment of brain metastases. With several options now available to treat brain metastases proper patient selection is needed. This article will stratify patients with brain metastases and discuss the treatment modalities for each category.

Patterns of relapse and late toxicity after resection and whole-brain radiotherapy for solitary brain metastases

BACKGROUND

This retrospective analysis was performed in order to evaluate the pattern of relapse and the risk of late toxicity for solitary brain metastases treated with surgery and whole-brain radiotherapy and to correlate the results with those from radiosurgical trials.

PATIENTS AND METHODS

From a total of 66 patients, 52 received 10 x 3 Gy and 10 were treated with 20 x 2 Gy whole-brain radiotherapy after resection of their brain metastases.

RESULTS

The actuarial probability of relapse was 27% and 55% after 1 and 2 year(s), respectively. The local relapse rate (at the original site of resected brain metastases) was rather high for melanoma, non-breast adenocarcinoma, and squamous-cell carcinoma. No local relapse occurred in breast cancer and small-cell carcinoma. Failure elsewhere in the brain seemed to be influenced by extracranial disease activity. Size of brain metastases and total dose showed no correlation with relapse rate. Occurrence of brain relapse was not associated with a reduced survival time, because 10/15 patients who developed a relapse received salvage therapy. Of the patients, 11 had symptoms of late radiation toxicity (the actuarial probability was 42% after 2 years).

CONCLUSIONS

Most results of surgical and radiosurgical studies are comparable to ours. Several randomized trials investigate surgical resection versus radiosurgery, as well as the effects of additional whole-brain radiotherapy in order to define the treatment of choice. Some data support the adjuvant application of 10 x 3 Gy over 2 weeks as a reasonable compromise when local control, toxicity, and treatment time have to be considered.

[Radiosurgery of brain metastasis]

Radiosurgery has recently provided an alternative to conventional therapy for the treatment of brain metastases. This non-invasive technique delivers a single large fraction of ionizing radiation to a well-defined small intracranial target as brain metastases. After a computerized tomography (CT) with stereotactic frame in place for tumor localization, a dosimetric study was performed. The sharp dose gradient of radiation reduces the dose to the surrounding normal structures at a minimal level (> 10%). The prescribed dose at the periphery of the lesion varies from 8 to 27 Gy with a combined whole brain irradiation and from 20 to 35 Gy without any irradiation. Radiosurgery has been reported to be highly efficacious with a local control rate of 86% (not increased size without local recurrence). Brain metastases from melanoma and renal carcinoma are usually resistant to conventional irradiation and are highly sensitive with this technique. The morbidity is very low with a symptomatic edema rate of 5-10% at 2 years, resolved with corticosteroids. A radiation necrosis has been reported in less than 5% of cases. The patients with a good performance status, without any extracranial metastasis and with a solitary brain metastases have presented the best survival rate. New brain metastases have occurred in 20 to 30% of the cases during the follow-up. Eleven to 25% of patients died from their intracranial disease and the others from the extracranial evolution of the cancer. The median survival was still poor, ranging from 8 to 12 months. Radiosurgery is a good choice for surgically inaccessible and recurrent tumors. It represents an alternative to the neurosurgery with or without whole brain irradiation, taking into account different prognostic factors and morbidity rate. The local control and the survival rates without neurologic symptom should be considered the major endpoints of different ongoing randomized studies for evaluating the role of the radiosurgery.

Management of Cerebral Metastases: The Role of Surgery

BACKGROUND: Metastatic brain tumors represent the most common neurological complication in patients with systemic cancer. They are predominantly cerebrally located and constitute a significant source of morbidity and mortality. The overall incidence of brain metastases exceeds that of all other intracranial tumors, and as improved systemic cancer treatments have extended patients' lives, this number is rising. METHODS: The role of surgery in the management of cerebral metastases is reviewed by considering patient selection criteria, surgical approaches to metastases, intraoperative adjuncts, whole-brain irradiation as a postoperative adjuvant, resection of multiple vs single metastases, and the relative roles of stereotactic radiosurgery and conventional surgery. RESULTS: Surgical resection of single or multiple metastases can be effective management for patients with otherwise good prognoses, providing all the known metastases can be removed without producing significant neurologic deficit. Radiosurgery, an alternate approach, can be used for smaller or inaccessible tumors. CONCLUSIONS: The presence of multiple brain metastases does not automatically contraindicate surgery because in properly selected patients, resection of multiple metastases can extend survival and enhance the quality of life. An awareness of how the modalities of open craniotomy, whole-brain radiotherapy, and stereotactic radiosurgery best complement each other will result in the best outcomes.

Radiosurgery for the treatment of brain metastases

Surgical resection and whole brain radiotherapy (WBRT) have been the mainstays of the treatment of cerebral metastases. This approach results in a median survival of about 10 months. Several recent publications and our own experience suggest that a similar median survival can be achieved with stereotactic radiosurgery using either the Leksell Gamma Knife or the linear accelerator radiosurgical techniques. In addition, radiosurgery can effectively treat metastatic tumors in surgically inaccessible sites, e.g., the brainstem. Radiosurgery can also effectively treat multiple intracranial metastases in widely separated areas of the brain. In fact, we have shown that patients with multiple metastases have similar lengths and qualities of survival as do patients with single metastases treated with stereotactic radiosurgery. The most important predictor of success in radiosurgical treatment of cerebral metastases is the neurological status of the patient, usually expressed as the Karnofsky Performance Status (KPS). The histological type of primary cancer is not an outcome predictor. Even so-called "radioresistant" tumors (e.g., melanoma, renal cell) respond favorable to radiosurgery. A great benefit of radiosurgery is the virtual lack of perioperative complications and the minimal interference with quality of life compared either to surgery or to fractionated whole brain radiotherapy. Long-term complications of radiosurgery are infrequent and primarily relate to failure of local tumor control (10%) and radiation-induced edema or necrosis. The later usually can be controlled with corticosteroids, but occasionally, craniotomy may be required to treat life-threatening mass effects. We believe that radiosurgery is the treatment of choice for most cerebral metastases. Only large lesions (> 3.5-4 cm diameter) and those which require immediate decompression to treat life-threatening mass effects require surgical treatment. Radiosurgery also may be used to treat residual disease after surgical resection. We have shown that WBRT does not increase the efficacy of radiosurgery in the treatment of cerebral metastases, and, therefore, we prefer to avoid both the short- and long-term morbidity of that treatment, if possible.

The prognostic factors of lung cancer patients with brain metastases treated with radiotherapy

PURPOSE

To analyze the prognostic factors of lung cancer with brain metastases (BM) and evaluate the role of cranial irradiation on survival.

METHODS AND MATERIALS

From 1987 to 1994, 159 lung cancer patients with CT scan documented BM were reviewed. All of them underwent cranial irradiation (median radiation dose: 30 Gy). Chemotherapy and surgery of BM were performed in 21 and 10 cases, respectively.

RESULTS

Overall median survival was 3.5 months and one year survival rate was 10.69%. Univariate analysis showed that the significant factors were performance status, age, total radiation dose to brain, BM as the first metastasis, neurosurgery, symptoms of urine/stool incontinence, and synchronous BM. Multivariate analysis indicated that (1) performance status (p = 0.0002), (2) total radiation dose (p = 0.0032), (3) BM as the first metastasis (p = 0.0449), (4) neurosurgery (p = 0.0233), (5) symptoms of urine/stool incontinence (p = 0.0002), and (6) the presence of a midline shift on cranial CT scans (p = 0.0063) were significant prognostic factors.

CONCLUSION

The prognosis of BM in lung cancer patients is extremely poor. Radiotherapy appears as an effective means of palliation with 75% overall symptomatic response rate. Higher radiation dose (> or = 30 Gy) and neurosurgery are associated with longer survival. Good performance status, BM as the first metastasis, absence of sphincter dysfunction, and midline shift on CT scans are favorable prognostic predictors. The role of midline shift is very interesting and needs to be explored further.

Radiotherapy for pediatric brain tumors

Brain tumors in children are a diverse group of diseases that require multidisciplinary and subspecialty expertise. Radiation therapy is an established treatment cornerstone for these pediatric tumors. Basic concepts of radiation biology and physics provide a framework for understanding the ongoing evolution in radiation delivery techniques and current treatment paradigms. Standard techniques of pediatric central nervous system radiotherapy are included in this review, as well as newer techniques including conformal therapy, stereotactic radiosurgery, and fractionated stereotactic radiotherapy. Examples are provided to illustrate differences in treatment approaches. The appropriate application of each technique is discussed, and then outcomes and treatment sequelae are compared.

Stereotactic radiosurgery for patients with nonsmall cell lung carcinoma metastatic to the brain

BACKGROUND

A retrospective study of patients undergoing stereotactic radiosurgery for one to four brain metastases from nonsmall lung cell carcinoma (NSCLC) was performed to document outcomes and risks.

METHODS

Seventy-seven patients underwent radiosurgery during a 7-year interval; 71 also underwent whole brain radiation therapy. Univariate and multivariate analyses were used to determine significant prognostic factors affecting survival.

RESULTS

The overall median survival was 10 months after radiosurgery, and 15 months from the diagnosis of brain metastases. Five factors significantly affected survival: extent of systemic disease, presence of a neurologic deficit, size of the intracranial tumor, initial imaging appearance of intratumoral necrosis, and initial resection of the primary tumor of the chest. Median survival time was 26 months in a subgroup of patients with no extracranial metastases, no neurologic deficits, and a small tumor without necrosis. The authors evaluated 91 tumors with imaging. Local tumor control was achieved in 77 lesions (85%) and tumoral radiation necrosis developed in 4 lesions (4.4%). Nineteen new metastatic tumors developed during the observation interval.

CONCLUSIONS

Stereotactic radiosurgery for NSCLC brain metastases is effective and is associated with few complications. The early detection of brain metastases and treatment with radiosurgery combined with radiation therapy provide the opportunity for extended high quality survival.

Surgical treatment of 70 patients with brain metastases from breast carcinoma

BACKGROUND

Brain metastases are diagnosed in 15% of patients with metastatic breast carcinoma. Most patients are treated with whole-brain radiotherapy (WBRT) and/or chemotherapy. The information on surgical results is sparse.

METHODS

Among 709 patients with tumors metastatic to the brain who underwent craniotomy at Memorial Hospital, New York, New York, between January 1974 and December 1993, 70 (10%) had a primary breast carcinoma. Their treatment outcomes were analyzed retrospectively.

RESULTS

The median age at diagnosis of primary breast carcinoma and brain metastasis was 46 and 50 years, respectively. All but two patients had metachronous diagnoses of breast carcinoma and brain metastasis. The median interval between both diagnoses in this subgroup was 28 months. In all 70 patients, the overall median survival was 54 months after diagnosis of the primary breast tumor and 16.2 months after diagnosis of the brain tumor. Only 5 patients (7%) were alive at last follow-up. The overall median survival after brain surgery was 14 months. Four patients died within 30 days of craniotomy. Twelve patients had a solitary cerebellar metastasis and 16 had multiple metastases; their median survival was 10.9 months and 14.8 months, respectively. There was no statistical difference in survival for patients who had single or multiple lesions. The median survival of 22 patients with positive hormonal receptor (estrogen receptor [ER] or progesterone receptor [PR]) was significantly longer than the median survival of 20 patients with negative ER/PR (21.9 vs. 12.5 months, P < 0.05). For 35 patients (50%) who had brain lesions > or =4 cm, the median survival was 11 months, compared with 16.3 months for patients with smaller lesions (P = 0.16, not significant [NS]). Patients age < or =50 years versus >50 years had survival of 17.3 and 11.1 months, respectively (P = NS). Neurologic deficit prior to craniotomy shortened survival for 24 patients to 11.5 months, compared with 17.4 months for patients without deficit (P = NS). Fifteen patients experienced failure with WBRT prior to undergoing craniotomy, and their median survival was shorter than for those who underwent craniotomy as the initial treatment (6.3 vs. 15.8 months, P < 0.03). However, their survival after diagnosis of brain metastasis was not significantly different (19.2 vs. 16.1). Forty-seven patients received WBRT postoperatively, and 9 patients did not receive adjuvant radiation therapy. Subsequent relapse in the brain was diagnosed in 27 patients, and 8 of them underwent reresection. One-year, 2-year, 3-year, and 5-year survival rates were 53%, 25.7%, 18.6%, and 7%, respectively. In multivariate analysis, the adjuvant WBRT after craniotomy and the absence of meningeal carcinomatosis were the only significant predictive variables for longer survival.

CONCLUSIONS

In a subset of selected patients, craniotomy followed by WBRT can positively impact survival.

A Case Report of Long-term Survival after Radiotherapy for a Solitary Brain Metastasis from Breast Cancer

This is the report of a patient with a solitary brain metastasis from breast cancer who survived more than 8 years after the first brain metastasis. The brain metastasis was treated with partial removal followed by 30 Gy/15 fructions of whole brain irradiation plus 20 Gy/10 fructions of local boost irradiation for 5weeks. Brain metastases from breast cancer are usually a sign of rapid systemic tumor progression and long-term survivors are extremely rare. However, this case demonstrated the possibility of long-term survival in rare cases of brain metastases from breast cancer. This suggests a need for aggressive therapy in patients with a solitary brain metastasis.

A cost-effectiveness and cost-utility analysis of radiosurgery vs. resection for single-brain metastases

PURPOSE

The median survival of well-selected patients with single-brain metastases treated with whole-brain irradiation and resection or radiosurgery is comparable, although a randomized trial of these two modalities has not been performed. In this era of cost containment, it is imperative that health-care professionals make fiscally prudent decisions. The present environment necessitates a critical appraisal of apparently equi-efficacious therapeutic modalities, and it is within this context that we present a comparison of the actual costs of resection and radiosurgery for brain metastases.

METHODS AND MATERIALS

Survival and quality of life outcome data for radiation alone or with surgery were obtained from two randomized trials, and radiosurgical results were obtained from a multiinstitutional analysis that specifically evaluated patients meeting surgical criteria. Only linear accelerator radiosurgery data were considered. Cost analysis was performed from a societal view point, and the following parameters were evaluated: actual cost, cost ratios, cost effectiveness, incremental cost effectiveness, cost utility, incremental cost utility, and national cost burden. The computerized billing records for all patients undergoing resection or radiosurgery for single-brain metastases from January 1989 to July 1994 were reviewed. A total of 46 resections and 135 radiosurgery procedures were performed. During the same time period, 454 patients underwent whole-brain radiation alone. An analysis of the entire bill was performed for each procedure, and each itemized cost was assigned a proportionate figure. The relative cost ratios of resection and radiosurgery were compared using the Wilcoxon rank sum test. Cost effectiveness of each modality, defined as the cost per year of median survival, was evaluated. Incremental cost effectiveness, defined as the additional cost per year of incremental gain in median survival, compared to the next least expensive modality, was also determined. To calculate the societal or national impact of these practices, the proportion of patients potentially eligible for aggressive management was estimated and the financial impact was determined using various utilization ratios for radiosurgery and surgery.

RESULTS

Both resection and radiosurgery yielded superior survival and functional independence, compared to whole brain radiotherapy alone, with minor differences in outcome between the two modalities; resection resulted in a 1.8-fold increase in cost, compared to radiosurgery. The latter modality yielded superior cost outcomes on all measures, even when a sensitivity analysis of up to 50% was performed. A reversal estimate indicated that in order for surgery to yield equal cost effectiveness, its cost would have to decrease by 48% or median survival would have to improve by 108%. The average cost per week of survival was $310 for radiotherapy, $524 for resection plus radiation, and $270 for radiosurgery plus radiation.

CONCLUSIONS

For selected patients, aggressive strategies such as resection or radiosurgery are warranted, as they result in improved median survival and functional independence. Radiosurgery appears to be the more cost-effective procedure.

Hyperfractionated and accelerated radiation therapy in central nervous system tumors (malignant gliomas, pediatric tumors, and brain metastases)

The authors review the main contributions of the international literature concerning the role of hyperfractionation (HF), accelerated fractionation (AF), and accelerated hyperfractionation (AHF) of the dose in radiation therapy (RT) of central nervous system tumors. Basic rationales, clinical results, acute/late toxicity, and current prospectives are summarized in three sections focusing on malignant gliomas, pediatric brainstem tumors, and brain metastases. In supratentorial malignant gliomas the superiority of AHF (0.89 Gy x 3 fractions/day; total dose 61.4 Gy) over conventional fractionation ((CF) total dose 58 Gy) was demonstrated by a randomized trial. However, the gain in median survival time was less than 6 months. No other randomized trials support the preferential choice of non-CF schedules outside clinical trials. Ongoing trials are exploring the role of AHF in combination with chemotherapy, hypoxic cell and radiosensitizing agents. As for pediatric brainstem tumors, there are no data to support the routine use of HF that should be preferably used in an investigative setting. As late sequelae have been reported in the few long-term survivors, patients should be carefully selected. Regarding brain metastases AF RT and AHF RT, with their faster treatment course, may represent a convenient alternative to CF RT for the palliation of brain metastases. In carefully selected patients with solitary brain metastases non-CF RT may be part of aggressive treatment approaches.

Stereotactic radiosurgery for the treatment of brain metastases. Results of a single institution series

BACKGROUND

Stereotactic radiosurgery is being used with increasing frequency for the treatment of brain metastases. Optimal patient selection and treatment factors continue to be defined. This study provides outcome data from a single institutional experience with radiosurgery and identifies parameters that may be useful for the proper selection and treatment of patients.

METHODS

Eighty-four patients underwent stereotactic radiosurgery for brain metastases between September 1989 and November 1995. Seventy-nine patients (93%) were treated at recurrence after previous whole brain radiotherapy. Patients had between 1 and 6 lesions treated with a median minimum tumor dose of 1600 centigrays (cGy). Thirty-eight patients (45%) had active extracranial disease at the time of radiosurgery.

RESULTS

Median survival for the entire group was 43 weeks from the date of radiosurgery and 71 weeks from the original diagnosis of brain metastases. Patients with 1 or 2 metastases had significantly improved survival compared with patients with > or = 3 metastases (P = 0.02), and patients without active extracranial tumor survived longer than those with extracranial disease (P = 0.03). Median time to failure for 145 evaluable lesions was 35 weeks. Local control was significantly improved for radiosurgery doses of > 1800 cGy, and for melanoma histology.

CONCLUSIONS

These results are comparable to reports of patients treated with resection and significantly superior to results observed after whole brain radiotherapy. The authors conclude that stereotactic radiosurgery is an effective, low risk treatment for extending the survival of patients with recurrent brain metastasis. Although survival is best for patients with < or = two lesions and no active extracranial disease, selected patients with > two lesions or active extracranial tumor may benefit as well.