The influence of surgery and radiation therapy on patients with brain metastases

Optimal management of brain metastases from breast cancer. Issues and considerations

The incidence of brain metastases (BM) in breast cancer patients has increased over the last decade, presumably due to advances in systemic treatment. Today, breast cancer is the second most common cause of BM among all solid malignancies, second only to lung cancer; furthermore, it is the most common cause of leptomeningeal carcinomatosis. The HER2-positive subtype was consistently shown to have a higher risk for BM as compared with HER2-negative disease. More recently, however, it was shown that a similar incidence exists in triple-negative tumours. Local treatment options, radiotherapy and neurosurgical resection, remain the mainstay of therapy for BM. While some studies have suggested a direct effect of conventional chemotherapy on BM, the main beneficial aspect of systemic treatment is rather due to control of non-CNS systemic disease. Importantly, in patients with HER2-positive breast cancer receiving HER2-targeted therapy after local treatment for BM, superior survival outcomes were reported. Leptomeningeal carcinomatosis has a dismal prognosis. Survival with whole brain radiotherapy alone remains short and the potential additional benefit of intrathecal chemotherapy is still disputed. According to case reports, intrathecal administration of trastuzumab appears to be a promising strategy in patients with HER2-positive leptomeningeal carcinomatosis. In conclusion, while the outcome of breast cancer patients with BM has improved especially in the HER2-positive subtype, the prognosis for the majority of patients remains poor. Therefore, development of novel systemic treatment options offering activity within the brain is urgently warranted. Novel insights into the pathobiology of BM formation may offer the possibility for targeted drug prophylaxis of CNS involvement in high-risk patients.

Outcome of whole-brain irradiation for breast cancer patients

PURPOSE

To determine the overall survival (OS) of breast cancer patients treated by Whole Brain Radiation Therapy (WBRT) and possible important prognostic factors for OS.

MATERIAL AND METHODS

The study population comprised 99 patients with brain metastases (BM) treated with WBRT in the period 1988 to 2004 at St. Olavs University Hospital, Trondheim, Norway. Prognostic factors as age, performance status, axillary lymph node involvement and extent of BM were evaluated.

RESULTS

Median survival (range) of the total population from start of irradiation was 5.3 (0.3-157) months. For patients >60 years, 40-60 years and <40 years median survival (range) were 4.5 (0.3-92), 6.8 (0.3-157) and 8.5 (0.8-11) months, respectively (NS, p=0.5), and for Karnofsky performance status (KPS) < or >70, were 3.7 (0.3-92) and 6.8 (1.0-157) months, respectively (NS, p=0.17). One,three, 12 and 24 month survival rate were 90, 64, 29 and 11%, respectively. Grouping patients according to Recursive Partitioning Analyses (RPA) classes, the median survival (range) were 8.0 (1.0-157), 6.5 (1.3-92) and 3.5 (0.3-92) months for RPA class 1, 2 and 3, respectively (NS, p=0.6).

CONCLUSION

KPS and in particular the extent of BM were the most important prognostic factors. Grouping patients into RPA classes may be important when deciding whether breast cancer patients should be aggressively treated for their BM.

Factors influencing the time to development of brain metastases in breast cancer

This retrospective study analyzed risk factors influencing the time to development of brain metastases with the aim to facilitate the definition of a high-risk population among breast cancer patients. One hundred seventy-four breast cancer patients with brain metastases, treated with whole brain radiotherapy, were evaluated. Statistical analysis included hormone receptor status, HER2/neu status, tumour grading, tumour stage, young age at the time of diagnosis, adjuvant systemic treatment, palliative systemic treatment, metastatic sites (if brain metastases were not the first site of recurrence), and immunotherapy with trastuzumab. Time to development of brain metastases was significantly prolonged by systemic palliative treatment (p< or =0.0001) whereas high tumour grading (p< or =0.04) and trastuzumab therapy (p< or =0.04) significantly shortened this time span. Patients with the brain as first metastatic site, age>35 (p< or =0.001) and stage III (p< or =0.018) at the time of diagnosis had a significantly shorter time to development for brain lesions. These factors should be further validated by a prospective trial to identify a high-risk population amongst breast cancer patients and enable the development of screening programs for early detection.

Trastuzumab prolongs overall survival in patients with brain metastases from Her2 positive breast cancer

BACKGROUND

Brain metastases are frequently encountered in Her2 positive advanced breast cancer. It is still not clear, if trastuzumab treatment should be continued following their diagnosis. In this analysis we evaluated if trastuzumab was able to influence time to in-brain progression (TTP) and overall survival (OS). For this reason, we compared patients who continued on trastuzumab with a historical control group.

PATIENTS AND METHODS

Seventeen Her2 positive patients receiving whole brain radiotherapy for brain metastases and continuing on trastuzumab were identified. As historical control group, thirty-six patients treated before 2002 were identified from a breast cancer database. We performed a multivariate analysis (Cox regression) to explore which factors were potentially able to significantly influence TTP and OS.

RESULTS

Median TTP was 6 months, range 1-33+ months. Median OS was 7 months, range 1-38 months. Seventeen patients received trastuzumab after WBRT. Factors associated with prolonged TTP were KPS (p = 0.001), and intensified local treatment (p = 0.004). A trend towards longer TTP was observed in patients treated with trastuzumab (p = 0.068). OS was significantly influenced by KPS (p < 0.001), and continued antibody therapy (p = 0.001).

CONCLUSION

Two parameters were significantly associated with prolonged OS: KPS and trastuzumab. While there was a trend towards prolonged TTP in patients with trastuzumab treatment after WBRT, this did not reach statistical significance. It appears therefore reasonable to suggest continuation of antibody therapy in patients with good performance status despite disease spreading to the brain. Concerning activity of trastuzumab in brain metastases themselves, no final conclusion is possible.

Intensified local treatment and systemic therapy significantly increase survival in patients with brain metastases from advanced breast cancer - a retrospective analysis

BACKGROUND

Brain metastases have evolved from a rare to a frequently encountered event in advanced breast cancer due to advances in palliative systemic treatment.

PATIENTS AND METHODS

All Patients treated at our centre from 1994 to 2004 with WBRT for brain metastases from breast cancer were included. We performed a multivariate analysis (Cox regression) to explore which factors are able to influence significantly cerebral time to progression (TTP) and overall survival (metastatic sites [visceral versus non-visceral], Karnofsky performance score [KPS], age, intensified local treatment [boost irradiation, neuro-surgical resection] further systemic treatment).

RESULTS

Overall 174 patients, median age 51 years, range 27-76 years, were included. Median TTP was 3 months (m), range 1-33+ m. Median overall survival was 7 m, range 1-44 m. Factors significantly influencing TTP were KPS (p = 0.002), intensified local treatment (p < 0.001), and palliative systemic treatment (p = 0.001). Factors significantly influencing survival were intensified local treatment (p = 0.004), metastatic sites (p = 0.008), KPS (p = 0.006), and palliative systemic treatment (p < 0.001).

CONCLUSION

As shown by the significant influence of metastatic sites, some patients die from their advanced systemic tumour situation before they would die from cerebral progression. In other individuals however, intensified local treatment and systemic treatment appear to influence cerebral time to progression and overall survival.

CNS Metastases in Breast Cancer

As systemic therapy of metastatic breast cancer improves, CNS involvement is becoming a more widespread problem. This article summarizes the current knowledge regarding the incidence, clinical presentation, diagnosis, prognosis, and treatment of CNS metastases in patients with breast cancer. When available, studies specific to breast cancer are presented; in studies in which many solid tumors were evaluated together, the proportion of patients with breast cancer is noted. On the basis of data from randomized trials and retrospective series, neurosurgery and stereotactic radiosurgery (SRS) may prolong survival in patients with single brain metastases. The treatment of multiple metastases remains controversial, as does the routine use of whole-brain radiotherapy (WBRT) after either surgery or SRS. Although it is widely assumed that chemotherapy is of limited benefit, data from case series and case reports suggest otherwise. WBRT, neurosurgery, SRS, and medical therapy each have a role in the treatment of CNS metastases; however, neurologic symptoms frequently are not fully reversible, even with appropriate therapy. Studies specifically targeted toward this group of patients are needed.

Radiation therapy in the management of brain metastases from breast cancer

A retrospective analysis of 99 patients treated at Radiumhemmet, Karolinska Hospital 1979-1990 with palliative radiotherapy for brain metastases from breast cancer was performed. A relief of symptoms was obtained in 45% of patients. Median time from diagnosis of breast cancer until CNS metastases was 33 months. Median survival time with CNS metastases after diagnosis was 5 months. Prognostic indicators for survival were studied. Patients operated for a singular brain metastasis and irradiated postoperatively had a mean survival of 21 months while patients with multiple brain metastases and meningeal spread displayed a short median survival. Extracranial disease status influenced prognosis significantly. Radiation dose (CRE) did not correlate with survival.

Dose optimization and indication of Linac radiosurgery for brain metastases

PURPOSE

The authors have examined treatment effects of linear accelerator based radiosurgery for brain metastases. Optimal doses and indications were determined in an attempt to improve the quality of life for terminal cancer patients.

METHODS AND MATERIALS

Ninety-two patients with 162 lesions were treated with Linac radiosurgery for brain metastases between April 1993 and September 1998. To determine prognostic factors, risk factors for recurrence, and appearance of new lesions, univariate and multivariate analyses were performed. To compare the local control between the high-dose (minimum dose > or =25 Gy: prescribed to the 50-80% isodose line) and low-dose (minimum dose <25 Gy) irradiated groups, matched-pairs analysis was performed.

RESULTS

Median survival time was 11 months. In univariate analysis, extracranial tumor activity (p<0.001) and Karnofsky Performance Status (KPS) (p = 0.036) were two significant predictors of survival. In multivariate analysis, the status of an extracranial tumor was the single significant predictor of survival (p = 0.005). Minimum dose was the single most significant predictor of local recurrence in univariate, multivariate, and matched-pairs analyses (p<0.05). As to the appearance of new lesions, activity of extracranial tumors was a significant predictor (p<0.05). Side effects due to radiosurgery were experienced in 4 of 92 cases (4.3%).

CONCLUSIONS

We concluded that brain metastases patients should be irradiated with > or =25 Gy, when extracranial lesions are stable and longer survival is expected. Combined surgery and conventional radiation may have little advantage over radiosurgery alone when metastatic brain tumors are small and extracranial tumors are well controlled. When extracranial tumors are progressive, the rate of appearance of new lesions in other nonirradiated locations becomes higher. In such cases, careful follow-up is required and a combination with whole brain irradiation should be considered.

Focalized external radiotherapy for resected solitary brain metastasis: does the dogma stand?

PURPOSE

To investigate whether whole brain irradiation might be replaced by focalized irradiation after resection of a single brain metastasis in patients where extracranial tumor control is deemed to be obtained.

PATIENTS AND METHODS

Twelve patients were introduced in a phase I/II prospective study of conformal postoperative external irradiation after resection of a solitary brain metastasis. The radiation treatment consisted of 50.4 Gy (1.8 Gy per fraction, five fractions per week). The planning target volume consisted of the tumor bed and a 2 cm safety margin. All treatments were optimized with head immobilization, dedicated tomodensitometry and computer assisted three-dimensional treatment planning.

RESULTS

The median survival was 7.2 months (range 2.4-50.4 months). Eleven of the 12 patients died. Eight of the 12 patients presented intracranial recurrence and seven died as a consequence of intracranial tumor progression.

CONCLUSIONS

Focalized external irradiation cannot serve as a reasonable alternative to whole brain radiotherapy (WBRT) even for patients with apparently one single resected brain metastasis. The dogma of 'one metastasis = multiple metastases' seems to be confirmed.

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.

Treatment and outcome of brain metastasis as first site of distant metastasis from breast cancer

Twenty-eight consecutive patients with breast cancer were analyzed who presented with a single brain metastasis as first site of distant metastasis. The response to surgery with postoperative radiation therapy (RT) (9 patients) and to non-surgical therapy as first-line treatment was 100% and 89% respectively with a significant difference in median recurrence-free intervals of 23 months and of 5 months respectively (p = 0.033). Retreatment of a local relapse by surgery (+/-RT, +/-chemotherapy) or by non-surgical treatment resulted in a response in 6 of the 7 operated patients and in 5 of the 6 non-operated patients with a median duration of response of 7 months (range 2-20 months) and of 3 months (range 2-4 months) respectively. The overall median survival of the 28 patients with a single brain metastasis was 16 months (range 2-39 months). The median survival in the primarily operated patients was 23 months, in the primarily not-operated group 10 months, and in the never-operated group 9 months. In comparison, the response to non-surgical treatment in 20 consecutive patients who presented with multiple brain metastases as first site of distant metastasis was 55% with a median recurrence free interval of 4 months. The median survival in this group was 4 months, which was significantly shorter than survival of patients with single brain metastasis (p = 0.0036). These results suggest that breast cancer patients with a single brain metastasis as first presentation of relapse constitute a specific subgroup with a favorable response to treatment and a long survival especially if they can be treated by surgery with postoperative RT.

Brain relapses in chemotherapy-treated small cell lung cancer: a retrospective review of two time-dose regimens of therapeutic brain irradiation

The incidence of brain metastases secondary to small cell lung cancer (SCLC) is about 35% and the treatment strategy of brain irradiation with respect to dose and fractionation is controversial. In order to evaluate treatment outcome of brain irradiation in SCLC patients with brain relapse, we retrospectively evaluated all patients treated with brain irradiation in the eastern part of Denmark from 1988 to 1992 (PCI patients excluded). During this 5-year period, 101 evaluable patients were included (44 females, 57 males) (median age 61 years; range, 39-75 years). Forty-four patients, of whom 43 were in extracerebral complete remission (CR), received extended course (EC) brain irradiation (> 45 Gy, treatment schedule > 4 weeks). Fifty-seven patients received short course (SC) brain irradiation (< 30 Gy, treatment schedule < 1 week). Among the SC treated patients, 14 were in CR, 20 had partial remission or stable disease and 23 had progressive extracerebral disease. The median survival (from diagnosis of brain metastases) in the group receiving irradiation with EC (44 patients) was 160 days (range, 74-2021 days), while the 57 patients treated with SC had a median survival of 88 days (range, 20-948 days) (P = 0.00001, Log-Rank analysis). In a subgroup of 14 patients in extracerebral CR, receiving SC irradiation, the median survival was 83 days (range, 15-948 days). When the latter patients were compared to the 43 patients in CR in the group treated with EC, a statistically significant difference was shown (P = 0.034, Log-Rank analysis). Using Cox-hazard regression analysis with backward elimination, liver metastases and poor performance status were adverse prognostic signs, although the only significant parameters of survival were gender (female vs. male, relative risk of dying 1 and 1.52, P = 0.05) and schedule of brain irradiation (extended course vs. short course, relative risk of dying, 0.36 and 1, P < 0.001). Extended course irradiation of brain relapse secondary to SCLC seems in general to be of limited value, although a significant prolonged survival at approximately 7 weeks, was obtained. The prolongation of survival does not seem worthwhile considering the length of treatment time (5-6 weeks) compared to SC treatment (1 week). However, the data do not permit evaluation of the quality of life of the patients. This retrospective evaluation suggests the need for randomized trials with carefully planned quality-of-life assessments.

Central nervous system metastasis in breast cancer

BACKGROUND AND PURPOSE

Central nervous system (CNS) metastasis occurs in at least 30% of patients with breast cancer. Standard treatment is the same as in other solid tumors, though clinical behavior, and sensitivity to radiation therapy (RT) and to chemotherapy may differ considerably. Most of these patients die within a few months, but a substantial subgroup may survive a year or more. The last decade has given rise to new diagnostic methods, new surgical and radiotherapeutic techniques, and the clinical evidence of a chemotherapy permissive blood-brain barrier in CNS metastases. The literature was reviewed to assess the clinical impact of early diagnosis, recognition of prognostic factors, and of the recently developed therapeutic approaches.

MATERIAL AND METHODS

Review of the literature on CNS involvement in breast cancer focusing on clinical studies on early diagnosis, new modes of treatment, and factors influencing outcome.

RESULTS

Although randomized studies are still awaited, systemic chemotherapy seems a valuable alternative for RT of brain metastases in selected cases. In meningeal carcinomatosis, long survival may be independent of intraventricular chemotherapy. Neurotoxicity of intensive intraventricular treatment is considerable. In epidural metastasis, early diagnosis with prompt start of treatment remains the crucial factor for outcome. Radiation therapy is the mainstay of treatment of epidural metastasis, but new surgical techniques and even systemic chemotherapy should be considered in selected cases.

CONCLUSIONS

Recognition of prognostic factors combined with appropriate use of various recently developed therapeutic possibilities will improve the clinical outcome including better local tumor control and less treatment-induced neurotoxicity in a considerable number of patients with CNS metastasis from breast cancer.

Treatment of brain metastases from bladder cancer

The records of 28 patients with transitional cell cancer who had brain metastases were retrospectively reviewed. Data from 19 patients were considered suitable for analysis and were included in this study. One patient was treated with surgery alone, 10 with radiation alone and 7 with radiation and surgery, while 1 received no treatment. Mean and median survival times, respectively, were 57 and 42 months from the initial diagnosis, and 11 and 4 months from diagnosis of central nervous system metastases. Patients treated with surgery and radiation demonstrated a mean survival time of 19 months compared to 6 months for patients treated with radiation alone (p = 0.03). There were 2 long-term survivors in the combined modality group at 50 and at 12 months. Enthusiasm for combined modality treatment should be tempered by the fact that selection bias favored the combined modality group; 13 patients with single lesions demonstrated a mean survival of 14 months compared to 3 months for 6 patients with multiple lesions (p = 0.009) and only patients with solitary lesions underwent surgical resection. Brain metastases have an ominous prognosis in patients with bladder cancer primaries. Considering the sum of the retrospective and prospective reports, we recommend that patients with solitary brain lesions and good performance status be aggressively managed with surgical resection and postoperative radiation therapy.

Resection for solitary brain metastasis. Role of adjuvant radiation and prognostic variables in 229 patients

The authors reviewed 229 consecutive patients treated intramurally by resection of solitary cerebral metastasis. Patients were classified into four groups on the basis of whether a gross total resection or subtotal resection was performed and whether systemic disease was present or absent at the time of craniotomy. Group 1 had gross total resection and no systemic disease; Group 2 had subtotal resection and no systemic disease; Group 3 had subtotal resection and systemic disease; and Group 4 had gross total resection and systemic disease. All four groups were further subdivided into Subgroup A (adjuvant whole-brain radiation therapy) or Subgroup B (no adjuvant radiation). Data were collected regarding multiple patient and tumor variables for multivariate analysis. Survival data for the 46 patients in Group 1A (median 1.3 years, 2-year survival rate 41%, 5-year survival rate 21%) were markedly better than those for the 75 in Group 1B (median 0.7 year, 2-year survival rate 19%, 5-year survival rate 4%). The 20 patients in Group 2A also had superior survival data (median 1.1 years, 2-year survival rate 30%, 3-year survival rate 30%) when compared with the eight patients in Group 2B (median 3 months, 1-year survival rate 0%). However, the 16 and 22 patients in Groups 3A and 4A, respectively, had no discernible differences compared to the seven and 35 patients in their Group 3B and 4B counterparts. Multivariate analyses were performed to assess the association of survival with multiple patient, disease, and treatment variables. Poor neurological status and systemic disease were significantly associated with inferior survival, while longer (greater than 36 months) intervals between primary diagnosis and craniotomy were significantly associated with improved survival. After adjusting for the effects of other patient, disease, and treatment characteristics, adjuvant whole-brain radiotherapy was significantly associated with improved survival times. These data support the continued use of craniotomy followed by adjuvant whole-brain radiation therapy for treatment of solitary brain metastasis. However, this aggressive therapy appears relatively contraindicated in the face of either systemic disease or substantial neurological deficit.

The objective response of brain metastases on radiotherapy. A prospective study using computer tomography

A prospective study was performed to establish the objective response of brain metastases after radiotherapy. Twenty-five patients with a total of 53 metastatic lesions were evaluated approximately 6 weeks after completing the treatment (30 Gy/2,5 weeks). Clinical response was seen more often than objective response, due probably to concomitant use of corticosteroids and to most patients having multiple metastases. Clinical response, although important for the patient, does not well reflect the objective response. In 48% of the cases there was agreement between the clinical and the radiodiagnostic findings. The tumor size was an important prognostic factor for prediction of complete response. The majority of patients who achieved complete remission of at least one of the metastatic lesions, did not show recurrence of the neurological symptoms.

The role of radiotherapy in palliative care

Radiotherapy is an indispensable modality in the palliation of cancer. All palliative care programs should be acquainted with its indications and have a close working relationship with a radiation oncology department. The technical aspects of the subject may be intimidating to many staff and patients, and departments need to improve their outreach and education. The main indications are: pain relief (particularly bone pain), control of hemorrhage, fungation and ulceration, dyspnea, blockage of hollow viscera, and the shrinkage of any tumors causing problems by virtue of space occupancy. In addition, it has an important role in the palliation of three oncological emergencies: superior vena caval obstruction, spinal cord compression, and raised intracranial pressure due to cerebral metastases. More pragmatic fractionation schedules are being developed that are compatible with good results in terms of palliative end points, giving shorter courses with fewer hospital attendances for patient and family comfort and convenience. More clinical research and evaluation of palliative radiotherapy are required.

A randomized phase III protocol for the evaluation of misonidazole combined with radiation in the treatment of patients with brain metastases (RTOG-7916)

From 1979 through July 1983, 859 patients were enrolled in a Phase III RTOG Protocol (7916) evaluating the role of Misonidazole combined with radiation in the treatment of brain metastasis. Patients were randomized to one of four treatment arms (3.0 Gy x 10 fractions with or without 1 g/m2 of Misonidazole [total 10 g/m2] versus 5.0 Gy x 6 fractions with or without 2 g/m2 of Misonidazole) [total 12 g/m2]. Among the 779 analyzable cases, 63% had a lung primary and 12% had breast. Of the histologic types, 43% were adenocarcinoma and 24% were squamous cell. Seventy-eight percent had a Karnofsky of greater than 70. Of the 779 cases, 773 are dead (99%). Median survival is 3.9 months, with 60% alive at 3 months, 35% at 6 months, and 15% at 1 year. Survival was evaluated by treatment arm, Misonidazole status, and fractionation scheme; none showed any statistical significance. Favorable prognostic factors were assessed (age less than 60, Karnofsky of 70-100, controlled primary and brain metastasis only) in each treatment arm and no difference was found. Brain metastasis was cause of death in 1/3, and 19-33% of patients were retreated. Because up to 1/3 of the patients in this study died secondary to uncontrolled brain metastasis, improvement in local control remains an important goal. Until proven otherwise, the treatment of choice for the majority of patients still remains a conventional palliative course of 3.0 Gy x 10 fractions.

A randomized trial of surgery in the treatment of single metastases to the brain

To assess the efficacy of surgical resection of brain metastases from extracranial primary cancer, we randomly assigned patients with a single brain metastasis to either surgical removal of the brain tumor followed by radiotherapy (surgical group) or needle biopsy and radiotherapy (radiation group). Forty-eight patients (25 in the surgical group and 23 in the radiation group) formed the study group; 6 other patients (11 percent) were excluded from the study because on biopsy their lesions proved to be either second primary tumors or inflammatory or infectious processes. Recurrence at the site of the original metastasis was less frequent in the surgical group than in the radiation group (5 of 25 [20 percent] vs. 12 of 23 [52 percent]; P less than 0.02). The overall length of survival was significantly longer in the surgical group (median, 40 weeks vs. 15 weeks in the radiation group; P less than 0.01), and the patients treated with surgery remained functionally independent longer (median, 38 weeks vs. 8 weeks in the radiation group; P less than 0.005). We conclude that patients with cancer and a single metastasis to the brain who receive treatment with surgical resection plus radiotherapy live longer, have fewer recurrences of cancer in the brain, and have a better quality of life than similar patients treated with radiotherapy alone.

Palliative radio-chemotherapy with ifosfamide and BCNU for breast cancer patients with cerebral metastases. A 5-year experience

Between January 1983 and April 1989, 61 patients with brain metastases of primary breast cancer were treated in the Robert Janker Clinic. To optimize the overall response rates, a simultaneous combination of radiation and chemotherapy was used. The patients median age was 49 (range, 30-67) years and the median performance score, 1 (0-2). The average interval between the diagnosis of the primary tumour and the brain metastases was 38 (range, 3-144) months. A total of 82% of the patients had multiple cerebral metastases. All patients had been pretreated with primary surgery; 79%, with radiation; 74%, with chemotherapy; and 64%, with hormones. Radiotherapy was given using a cobalt 60 machine. The whole brain was irradiated in daily fractions of 1.5 Gy, up to a total dose of 45 Gy. Using a split-course technique, this dose was given in three courses simultaneously with the chemotherapy. The chemotherapeutic regimen consisted of ifosfamide given daily for 5 days at 2 g/m2 and the nitrosourea derivative carmustine (BCNU) given at 30 mg/m2 on 3 days. The toxicity of the treatment was moderate; no haemotological or gastro-intestinal complications occurred. Complete and mostly irreversible alopecia occurred in all cases. All patients received a cranial computerized tomographic (CT) scan prior to and after treatment. According to the criteria of the International Union Against Cancer (UICC), there was a complete remission (CR) in 20% of the patients and a partial remission (PR) in 45%; 20% had a minor remission (MR) and 7% showed no change (NC) in the tumour. Another 7% of the patients experienced a progression of their metastases (PD). The median survival was 8 months for all patients and 12 months for those showing a CR.

Adjuvant radiation therapy after surgical resection of solitary brain metastasis: association with pattern of failure and survival

We reviewed patients treated by resection of solitary cerebral metastasis at the Mayo Clinic from January 1, 1972, to December 1, 1982. Eighty-five patients rendered clinically disease-free and who received intramural follow-up after craniotomy were studied. Adjuvant whole-brain radiation therapy (WBRT) was delivered to 34, and 51 were observed after craniotomy. Pattern-of-failure analysis showed a much smaller incidence of subsequent brain relapse in the adjuvant WBRT group than in the observation group (21% versus 85%, respectively). Multivariate analysis utilizing 17 patient, tumor, and treatment characteristics showed adjuvant WBRT to have the strongest association with brain control (p less than 0.0001). The only other variable which was significant (p less than 0.01) was multilobe involvement of the metastatic lesion, which was associated with a greater likelihood of brain failure. Systemic failures were more frequent (61% versus 37%), and the proportion of patients remaining disease-free (29% versus 4%) was higher in the adjuvant group. Those patients who received adjuvant WBRT to a dose of 39 Gy or greater manifested an 11% rate of subsequent brain failure versus a 31% rate when less than 39 Gy was delivered. The median survival was longer for the adjuvant WBRT group (21 months versus 11.5 months). Multivariate analysis indicated that adjuvant WBRT was one of several variables (including female gender, long disease-free survival, and good neurologic function prior to craniotomy) significantly associated with improved survival. This study suggests that adjuvant cranial irradiation may help prevent clinical recurrence of resected metastatic intracranial disease and that improved control of intracranial disease may be associated with an improved survival in patients without clinical evidence of systemic disease at the time of craniotomy.

Brain metastases from carcinoma of breast: a review of 90 cases

The case records of 90 patients developing brain metastases from carcinoma of the breast have been reviewed. Brain metastases developed more commonly in those patients who had Stage III disease at first diagnosis of breast cancer and in those who were pre- or perimenopausal at that time. Patients given whole-brain irradiation for brain metastases lived longer, from the date of central nervous system involvement, than those not given radiotherapy.