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Riecke K, Müller V, Neunhöffer T, Park-Simon TW, Weide R, Polasik A, Schmidt M, Puppe J, Mundhenke C, Lübbe K, Hesse T, Thill M, Wuerstlein R, Denkert C, Decker T, Fehm T, Nekljudova V, Rey J, Loibl S, Laakmann E, Witzel I. Long-term survival of breast cancer patients with brain metastases: subanalysis of the BMBC registry. ESMO Open 2023; 8:101213. [PMID: 37075697 DOI: 10.1016/j.esmoop.2023.101213] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/26/2023] [Accepted: 03/10/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Up to 30% of metastatic breast cancer (BC) patients develop brain metastases (BM). Prognosis of patients with BM is poor and long-term survival is rare. Identification of factors associated with long-term survival is important for improving treatment modalities. PATIENTS AND METHODS A total of 2889 patients of the national registry for BM in BC (BMBC) were available for this analysis. Long-term survival was defined as overall survival (OS) in the upper third of the failure curve resulting in a cut-off of 15 months. A total of 887 patients were categorized as long-term survivors. RESULTS Long-term survivors compared to other patients were younger at BC and BM diagnosis (median 48 versus 54 years and 53 versus 59 years), more often had HER2-positive tumors (59.1% versus 36.3%), less frequently luminal-like (29.1% versus 35.7%) or triple-negative breast cancer (TNBC) (11.9% versus 28.1%), showed better Eastern Cooperative Oncology Group (ECOG) performance status (PS) at the time of BM diagnosis (ECOG 0-1, 76.9% versus 51.0%), higher pathological complete remission rates after neoadjuvant chemotherapy (21.6% versus 13.7%) and lower number of BM (n = 1, BM 40.9% versus 25.4%; n = 2-3, BM 26.5% versus 26.7%; n ≥4, BM 32.6% versus 47.9%) (P < 0.001). Long-term survivors had leptomeningeal metastases (10.4% versus 17.5%) and extracranial metastases (ECM, 73.6% versus 82.5%) less frequently, and asymptomatic BM more often at the time of BM diagnosis (26.5% versus 20.1%), (P < 0.001). Median OS in long-term survivors was about two times higher than the cut-off of 15 months: 30.9 months [interquartile range (IQR) 30.3] overall, 33.9 months (IQR 37.1) in HER2-positive, 26.9 months (IQR 22.0) in luminal-like and 26.5 months (IQR 18.2) in TNBC patients. CONCLUSIONS In our analysis, long-term survival of BC patients with BM was associated with better ECOG PS, younger age, HER2-positive subtype, lower number of BM and less extended visceral metastases. Patients with these clinical features might be more eligible for extended local brain and systemic treatment.
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Affiliation(s)
- K Riecke
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - V Müller
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - T Neunhöffer
- Frauenärzte am Dom, Mainz, Germany; HELIOS Dr. Horst Schmidt Clinic Wiesbaden, Wiesbaden, Germany
| | - T-W Park-Simon
- Hanover Medical School (MHH University), Hanover, Germany
| | - R Weide
- Institute for Health Services Research in Oncology, Koblenz, Germany
| | - A Polasik
- Department of Gynecology and Obstetrics, Ulm University Hospital, Ulm, Germany
| | - M Schmidt
- The University Medical Center Mainz, Mainz, Germany
| | - J Puppe
- Department of Obstetrics & Gynecology, University Hospital of Cologne, Cologne, Germany
| | - C Mundhenke
- Klinikum Bayreuth GmbH/Medizincampus Oberfranken, Bayreuth, Germany; Comprehensive Cancer Center Erlangen-Europäische Metropolregion Nürnberg, Erlangen, Germany
| | - K Lübbe
- Diakovere Henriettenstift, Breast Center, Hannover, Germany
| | - T Hesse
- Agaplesion Diakonieklinikum Rotenburg, Rotenburg, Germany
| | - M Thill
- Department of Gynecology and Gyneacological Oncology, Agaplesion Markus Hospital, Frankfurt, Germany
| | - R Wuerstlein
- Department of Obstetrics and Gynecology, Breast Center and CCC Munich, LMU University Hospital, Munich, Germany
| | - C Denkert
- Institute of Pathology, Philipps University Marburg and University Hospital Marburg (UKGM), Marburg, Germany
| | - T Decker
- Onkology, Haematology Ravensburg, Ravensburg, Germany
| | - T Fehm
- Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | | | - J Rey
- GBG Forschungs GmbH, Neu-Isenburg, Germany
| | - S Loibl
- GBG Forschungs GmbH, Neu-Isenburg, Germany
| | - E Laakmann
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - I Witzel
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Gynecology, University Hospital Zurich, Zürich, Switzerland.
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Ferlini L, Peluso L, Lolli V, Gaspard N, Lefranc F. Prognosis of patients treated in a single neurosurgical reference centre for brain metastasis caused by dormant disseminated cells. Oncol Lett 2021; 21:454. [PMID: 33907564 PMCID: PMC8063273 DOI: 10.3892/ol.2021.12715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 12/30/2020] [Indexed: 11/06/2022] Open
Abstract
Brain metastasis (BM) is a frequent complication of systemic cancer usually associated with poor prognosis. Survival depends on numerous factors, which complicates prognosis and treatment. It has been suggested that BM growing from previously dormant disseminated tumour cells (DTCs) may exhibit a milder phenotype than BM derived from continuously progressing metastatic cells; however, to the best of our knowledge, the prognosis of patients presenting with BM from dormant DTCs is unknown. The present study retrospectively compared survival data, collected from a single neurosurgical centre, between patients presenting with BM from previously dormant DTCs and patients with non-dormant BM. A total of 262 medical records were reviewed. In the univariate Cox regression analysis, the median survival of the dormant BM group was statistically longer than that of the non-dormant group (P=0.048); a trend towards a longer survival persisted after correcting for age, presence of breast cancer and treatment options (P=0.057), which are all factors known to influence outcome. The improved outcome of these patients could be considered in models for prognostication. Moreover, the development of therapies able to eradicate dormant DTCs could provide a new promising strategy to prolong the survival of patients with a favourable prognosis.
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Affiliation(s)
- Lorenzo Ferlini
- Department of Neurology, Erasmus Hospital, Free University of Bruxelles, B-1070 Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Erasmus Hospital, Free University of Bruxelles, B-1070 Brussels, Belgium
| | - Valentina Lolli
- Department of Radiology, Erasmus Hospital, Free University of Bruxelles, B-1070 Brussels, Belgium
| | - Nicolas Gaspard
- Department of Neurology, Erasmus Hospital, Free University of Bruxelles, B-1070 Brussels, Belgium
| | - Florence Lefranc
- Department of Neurosurgery, Erasmus Hospital, Free University of Bruxelles, B-1070 Brussels, Belgium
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3
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Clinicopathologic and Treatment Features of Long-Term Surviving Brain Metastasis Patients. ACTA ACUST UNITED AC 2021; 28:549-559. [PMID: 33477698 PMCID: PMC7903267 DOI: 10.3390/curroncol28010054] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/20/2020] [Accepted: 01/08/2021] [Indexed: 11/18/2022]
Abstract
Background: The purpose of our study was to characterize clinical features among brain metastasis (BM) patients who were long term survivors (LTS). Methods: We reviewed a registry of BM patients referred to our multidisciplinary BM clinic between 2006 and 2014 and identified 97 who lived ≥ 3 years following BM diagnosis. The clinical and treatment characteristics were obtained from a prospectively maintained database, and additional information was obtained through review of electronic medical records and radiologic images. Survival analyses were performed using the Kaplan-Meier method. Results: Median follow up for LTS was 67 months (range 36–181). Median age was 54 years, 65% had single BM, 39% had stable extracranial disease at the time of BM treatment, and brain was the first site of metastasis in 76%. Targetable mutations were present in 39% of patients and 66% received treatment with targeted-, hormonal-, or immuno-therapy. Brain surgery at the time of diagnosis was performed in 40% and stereotactic radiosurgery (SRS) or whole brain radiotherapy (alone or combination) in 52% and 56%, respectively. Following initial BM treatment, 5-year intracranial disease-free survival was 39%, and the cumulative incidence of symptomatic radio-necrosis was 16%. Five and ten-year overall survival was 72% and 26%, respectively. Conclusion: Most LTS were younger than 60 years old and had a single BM. Many received treatment with surgery or targeted, immune, or hormonal therapy.
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Ampil FL, Richards TA. Necessary treatment of brain metastases in poor‐performance status patients: for all, for no one, or for whom? PRECISION RADIATION ONCOLOGY 2020. [DOI: 10.1002/pro6.1102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Federico L. Ampil
- Department of Radiology Division of Radiation Oncology Louisiana State University Health Sciences Center Shreveport Louisiana USA
| | - Troy A. Richards
- Department of Radiology Division of Radiation Oncology Louisiana State University Health Sciences Center Shreveport Louisiana USA
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5
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Schimmel WC, Gehring K, Eekers DB, Hanssens PE, Sitskoorn MM. Cognitive effects of stereotactic radiosurgery in adult patients with brain metastases: A systematic review. Adv Radiat Oncol 2018; 3:568-581. [PMID: 30370357 PMCID: PMC6200877 DOI: 10.1016/j.adro.2018.06.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 03/20/2018] [Accepted: 06/25/2018] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Stereotactic radiation surgery (SRS) is increasingly applied in patients with brain metastases (BM) and is expected to have fewer adverse effects on cognitive functioning than whole brain radiation therapy (WBRT). Patients with BM are often confronted with a relatively short life expectancy, and the prevention or delay of cognitive decline to maintain quality of life is a clinically and highly relevant treatment goal. This review systematically and specifically evaluates the current literature on the cognitive effects of SRS in patients with BM. METHODS AND MATERIALS Published trials on SRS alone or in combination with WBRT, including objective assessment of cognitive functioning, were identified through a systematic search of the PubMed database up to March 2018. RESULTS Of the 241 records screened, 14 studies matched the selection criteria: 2 pilot studies, 7 single-group/observational trials (1 study update), and 5 randomized trials (1 secondary analysis). CONCLUSIONS In general, the results show little to no objective cognitive decline up to 4 months after SRS compared with WBRT. However, most trials suffered from methodologic limitations that hindered reliable conclusions. Most importantly, few studies investigated the specific cognitive effects of SRS alone or versus WBRT. Furthermore, disentangling the cognitive effects of SRS from the effects of the disease itself and from the effects of other treatments remains very difficult. By presenting this comprehensive review, we aim to encourage researchers to probe deeper into this area and to do so in a standardized and methodologically optimal manner. The ultimate objective of this line of research is to inform both doctors and patients more precisely about the cognitive effects they can expect from treatment. This study is expected to improve the quality of decision-making and maximize clinical outcomes for each individual patient.
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Affiliation(s)
- Wietske C.M. Schimmel
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, the Netherlands
| | - Karin Gehring
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, the Netherlands
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Daniëlle B.P. Eekers
- Department of Radiation Oncology, GROW–School for Oncology and Developmental Biology, Maastricht University Medical Centre, the Netherlands
| | - Patrick E.J. Hanssens
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Margriet M. Sitskoorn
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, the Netherlands
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Cacho-Díaz B, Spínola-Maroño H, González-Aguilar A, Arrieta O. Factors associated with long-term survival in central nervous system metastases. J Neurooncol 2018; 140:159-164. [PMID: 30003395 DOI: 10.1007/s11060-018-2946-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 07/05/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Cancer is a leading cause of death worldwide; central nervous system metastases (CNSm) are amongst the most common complications of cancer and are associated with high morbidity and mortality. The aim of the study was to associate clinic and oncologic characteristics with the possibility of survival for ≥ 1 year. MATERIALS AND METHODS A prospective cohort in two referral centers recollected clinical and oncologic data from patients diagnosed with CNSm. Chronic metastases were defined as those patients that survived for ≥ 12 months after the diagnosis of CNSm. RESULTS Of 613 patients with CNSm, 554 had solid tumors as the primary cancer and were included; 405 (73%) were women, the most common primary cancer site were breast, lung and urologic. Chronic CNSm were found in 260 (47%) and were compared to those who did not. After multivariate logistic regression analysis, variables associated with good prognosis (living > 12 months) were: female sex (HR 0.55), single CNSm (HR 0.39), diagnosis of CNSm during initial extension studies or during presentation of cancer (HR 0.43), and occipital location (HR 0.62). CONCLUSIONS Long-term survival in patients with CNSm remains a topic of debate; their bad prognosis could be changing towards improvement. Clinical findings are typically overlooked in CNSm reports and prognostic scales. After our findings, we propose to include them in forthcoming studies to aid prognostic considerations. Factors associated with prolonged survival found in our study include female gender, timing of CNSm diagnosis, occipital lobe location, and single CNSm.
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Affiliation(s)
- Bernardo Cacho-Díaz
- Neuro-oncology Unit, Instituto Nacional de Cancerología, Av. San Fernando 22 Col Sección XVI, ZC 14050, Mexico City, México.
| | - Héctor Spínola-Maroño
- Neuro-oncology Unit, Instituto Nacional de Cancerología, Av. San Fernando 22 Col Sección XVI, ZC 14050, Mexico City, México
| | | | - Oscar Arrieta
- Thoracic Oncology Unit, Instituto Nacional de Cancerología, Mexico City, Mexico
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7
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Non-small cell lung cancer brain metastases and the immune system: From brain metastases development to treatment. Cancer Treat Rev 2018; 68:69-79. [PMID: 29883857 DOI: 10.1016/j.ctrv.2018.05.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 05/30/2018] [Indexed: 12/30/2022]
Abstract
Brain metastases (BM) are diagnosed frequently in non-small cell lung cancer (NSCLC) patients. Despite the high incidence of BM (up to 40% in unselected patients), patients with untreated and/or unstable BM were excluded from pivotal immune checkpoint inhibitors (ICI) NSCLC trials. Percentage of patients with stable and treated BM in these trials ranged from 9.1 to 14.7% and ICI benefit over chemotherapy was not always demonstrated. Only small trials have been completed that demonstrated ICI efficacy in locally untreated, selected BM patients. With 33%, cranial objective response rate (ORR) was comparable to extracranial ORR and responses were often durable. With the promising survival benefits of ICI, in daily practice also unstable and/or untreated BM patients will often receive treatment with ICI and extrapolating clinical trial data to these patients can be challenging. In this review, we will summarize the preclinical rationale and potential concerns for the use of ICI in BM patients. Furthermore, we will summarize BM subgroup data from the pivotal NSCLC trials, retrospective series, the NSCLC BM specific ICI trials and the use of cranial radiation and ICI. Last, we provide an overview of response measurement criteria and future directions.
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8
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Survival of Patients With Multiple Intracranial Metastases Treated With Stereotactic Radiosurgery. Am J Clin Oncol 2018; 41:425-431. [DOI: 10.1097/coc.0000000000000299] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Kotecha R, Damico N, Miller JA, Suh JH, Murphy ES, Reddy CA, Barnett GH, Vogelbaum MA, Angelov L, Mohammadi AM, Chao ST. Three or More Courses of Stereotactic Radiosurgery for Patients with Multiply Recurrent Brain Metastases. Neurosurgery 2018; 80:871-879. [PMID: 28327948 DOI: 10.1093/neuros/nyw147] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 12/14/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Although patients with brain metastasis are treated with primary stereotactic radiosurgery (SRS), the use of salvage therapies and their consequence remains understudied. OBJECTIVE To study the intracranial recurrence patterns and salvage therapies for patients who underwent multiple SRS courses. METHODS A retrospective review was performed of 59 patients with brain metastases who underwent ≥3 SRS courses for new lesions. Cox regression analyzed factors predictive for overall survival. RESULTS The median age at diagnosis was 52 years. Over time, patients underwent a median of 3 courses of SRS (range: 3-8) to a total of 765 different brain metastases. The 6-month risk of distant intracranial recurrence after the first SRS treatment was 64% (95% confidence interval: 52%-77%). Overall survival was 40% (95% confidence interval: 28%-53%) at 24 months. Only 24 patients (41%) had a decline in their Karnofsky Performance Status ≤70 at last office visit. Quality of life was preserved among 77% of patients at 12 months, with 45% experiencing clinically significant improvement during clinical follow-up. Radiation necrosis developed in 10 patients (17%). On multivariate analysis, gender (males, Hazard Ratio [HR]: 2.0, P < .05), Karnofsky Performance Status ≤80 (HR 3.2, P < .001), extracranial metastases (HR: 3.6, P < .001), and a distant intracranial recurrence ≤3 months from initial to repeat SRS (HR: 3.8, P < .001) were associated with a poorer survival. CONCLUSION In selected patients, performing ≥3 SRS courses controls intracranial disease. Patients may need salvage SRS for distant intracranial relapse, but focal retreatments are associated with modest toxicity, do not appear to negatively affect a patient's performance status, and help preserve quality of life.
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Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicholas Damico
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jacob A Miller
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Erin S Murphy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gene H Barnett
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Vogelbaum
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lilyana Angelov
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alireza M Mohammadi
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samuel T Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
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10
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Kotecha R, Vogel S, Suh JH, Barnett GH, Murphy ES, Reddy CA, Parsons M, Vogelbaum MA, Angelov L, Mohammadi AM, Stevens GHJ, Peereboom DM, Ahluwalia MS, Chao ST. A cure is possible: a study of 10-year survivors of brain metastases. J Neurooncol 2016; 129:545-555. [DOI: 10.1007/s11060-016-2208-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 07/06/2016] [Indexed: 11/29/2022]
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11
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Cho KR, Lee MH, Kong DS, Seol HJ, Nam DH, Sun JM, Ahn JS, Ahn MJ, Park K, Kim ST, Lim DH, Lee JI. Outcome of gamma knife radiosurgery for metastatic brain tumors derived from non-small cell lung cancer. J Neurooncol 2015; 125:331-8. [PMID: 26373297 DOI: 10.1007/s11060-015-1915-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 08/29/2015] [Indexed: 11/24/2022]
Abstract
The purpose of this study was to analyze outcomes in patients treated with gamma knife radiosurgery (GKS) for brain metastases from non-small cell lung cancer (NSCLC). We retrospectively reviewed the medical records of 817 patients who underwent GKS for brain metastases from NSCLC between January 2002 and December 2012. A total of 1363 GKS procedures were performed for 2970 lesions. The median overall survival time from the initial GKS was 13 months and the salvage treatment-free survival from the first GKS was 6.5 months. Younger age (≤65 years), female sex, better RPA class, higher DS-GPA score, adenocarcinoma, synchronous onset, and lower integrated value of the "numbers and cumulative volume of tumors" were associated with better outcomes. Among the 601 patients with an available follow up image, the pattern of the first progression after initial GKS was the development of new lesions in 356 patients (59.2 %), regrowth of treated lesions in 106 patients (17.6 %), and leptomeningeal seeding (LMS) in 51 patients (8.5 %). Among the deceased, the last MRI performed prior to death was evaluated in 409 patients and showed progression in 263 patients (64.3 %), despite multiple salvage treatments. LMS was identified in 63 patients (15.4 %); a rate much higher than the incidence at first progression. Intracranial tumor burden, defined as the integrated value of the "number of the lesions and cumulative tumor volume", is a new prognostic factor of greater significance than tumor volume or number alone when analyzed as separate factors. Although the cause of death was not progression of brain lesions in the majority of patients, the brain lesions tended to have been persistently progressive in most patients, despite repeated salvage treatment. LMS is an important pattern of treatment failure, in addition to local progression or development of new lesions, particularly in the terminal phase of the disease.
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Affiliation(s)
- Kyung Rae Cho
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam Gu, Seoul, 135-710, Korea
| | - Min Ho Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam Gu, Seoul, 135-710, Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam Gu, Seoul, 135-710, Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam Gu, Seoul, 135-710, Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam Gu, Seoul, 135-710, Korea
| | - Jong-Mu Sun
- Division of Hematology Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Seok Ahn
- Division of Hematology Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myung-Ju Ahn
- Division of Hematology Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keunchil Park
- Division of Hematology Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Tae Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do Hun Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam Gu, Seoul, 135-710, Korea.
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12
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Gerszten PC. Spine Metastases: From Radiotherapy, Surgery, to Radiosurgery. Neurosurgery 2014; 61 Suppl 1:16-25. [DOI: 10.1227/neu.0000000000000375] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Peter C. Gerszten
- Departments of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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13
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Kuremsky JG, Urbanic JJ, Petty WJ, Lovato JF, Bourland JD, Tatter SB, Ellis TL, McMullen KP, Shaw EG, Chan MD. Tumor histology predicts patterns of failure and survival in patients with brain metastases from lung cancer treated with gamma knife radiosurgery. Neurosurgery 2014; 73:641-7; discussion 647. [PMID: 23842552 DOI: 10.1227/neu.0000000000000072] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We review our experience with lung cancer patients with newly diagnosed brain metastases treated with Gamma Knife radiosurgery (GKRS). OBJECTIVE To determine whether tumor histology predicts patient outcomes. METHODS Between July 1, 2000, and December 31, 2010, 271 patients with brain metastases from primary lung cancer were treated with GKRS at our institution. Included in our study were 44 squamous cell carcinoma (SCC), 31 small cell carcinoma (SCLC), and 138 adenocarcinoma (ACA) patients; 47 patients with insufficient pathology to determine subtype were excluded. No non-small cell lung cancer (NSCLC) patients received whole-brain radiation therapy (WBRT) before their GKRS, and SCLC patients were allowed to have prophylactic cranial irradiation, but no previously known brain metastases. A median of 2 lesions were treated per patient with median marginal dose of 20 Gy. RESULTS Median survival was 10.2 months for ACA, 5.9 months for SCLC, and 5.3 months for SCC patients (P = .008). The 1-year local control rates were 86%, 86%, and 54% for ACA, SCC, and SCLC, respectively (P = .027). The 1-year distant failure rates were 35%, 63%, and 65% for ACA, SCC, and SCLC, respectively (P = .057). The likelihood of dying of neurological death was 29%, 36%, and 55% for ACA, SCC, and SCLC, respectively (P = .027). The median time to WBRT was 11 months for SCC and 24 months for ACA patients (P = .04). Multivariate analysis confirmed SCLC histology as a significant predictor of worsened local control (hazard ratio [HR]: 6.46, P = .025) and distant failure (HR: 3.32, P = .0027). For NSCLC histologies, SCC predicted for earlier time to salvage WBRT (HR: 2.552, P = .01) and worsened overall survival (HR: 1.77, P < .0121). CONCLUSION Histological subtype of lung cancer appears to predict outcomes. Future trials and prognostic indices should take these histology-specific patterns into account.
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Affiliation(s)
- J Griff Kuremsky
- Departments of ‡Radiation Oncology; §Internal Medicine, Hematology, and Oncology; ¶Neurosurgery, and ‖Public Health Sciences, Wake Forest University, Winston-Salem, North Carolina; †Deceased
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Identifying better surgical candidates among recursive partitioning analysis class 2 patients who underwent surgery for intracranial metastases. World Neurosurg 2013; 82:e267-75. [PMID: 24076052 DOI: 10.1016/j.wneu.2013.08.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Revised: 05/24/2013] [Accepted: 08/15/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The management of patients with brain metastases is typically dependent on their prognosis. Recursive partitioning analysis (RPA) is the most commonly used method for prognosticating survival, but has limitations for patients in the intermediate class. The aims of this study were to ascertain preoperative risk factors associated with survival, develop a preoperative prognostic grading system, and evaluate the utility of this system in predicting survival for RPA class 2 patients. METHODS Adult patient who underwent intracranial metastatic tumor surgery at an academic tertiary care institution from 1997 to 2011 were retrospectively reviewed. Multivariate proportional hazards regression analysis was used to identify preoperative factors associated with survival. The identified associations were then used to develop a grading system. Survival as a function of time was plotted using the Kaplan-Meier method, and survival rates were compared using log-rank analyses. RESULTS A total of 421 (59%) of 708 patients were RPA class 2. The preoperative factors found to be associated with poorer survival were: male gender (P < 0.0001), motor deficit (P = 0.0007), cognitive deficit (P = 0.0004), nonsolitary metastases (P = 0.002), and tumor size >2 cm (P = 0.003). Patients having 0-1, 2, and 3-5 of these variables were assigned a preoperative grade of A, B, and C, respectively. Patients with a preoperative grade of A, B, and C had a median survival of 17.0, 10.3, and 7.3 months, respectively. These grades had distinct survival times (P < 0.05). CONCLUSIONS The present study devised a preoperative grading system that may provide prognostic information for RPA class 2 patients, which may also guide medical and surgical therapies before any intervention is pursued.
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Robbins JR, Ryu S, Kalkanis S, Cogan C, Rock J, Movsas B, Kim JH, Rosenblum M. Radiosurgery to the surgical cavity as adjuvant therapy for resected brain metastasis. Neurosurgery 2013; 71:937-43. [PMID: 22806080 DOI: 10.1227/neu.0b013e31826909f2] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The standard treatment of resected brain metastasis is whole-brain radiotherapy (WBRT). To avoid the potential toxicity of WBRT and to improve local control, we have used radiosurgery alone to the surgical cavity. OBJECTIVE To demonstrate the rates of local control, new intracranial metastasis, and overall survival using this treatment scheme without WBRT. METHODS Eighty-five consecutive patients with brain metastasis were treated with surgical resection of at least 1 lesion followed by radiosurgery alone to the surgical cavity and any unresected lesions from August 2000 to March 2011. Sixty-eight percent had gross total resections. After surgery, radiosurgery was delivered to the surgical cavity with a 2- to 3-mm margin. The median marginal radiosurgery dose was 16 Gy, and median target volume was 13.96 cm. Follow-up imaging and clinical examination were obtained every 2 to 3 months. RESULTS Median follow-up time was 11.2 months. Overall local control was 81.2%. The 6-month, 1-year, and 2-year rates of local control were 88.7%, 81.4%, and 75.7%, respectively. Forty-seven patients (55%) developed new intracranial metastases at a median time of 5.6 months. For the entire population, the rate of new metastases was 32.1%, 58.1%, and 62.9% at 6 months, 1 year, and 2 years, respectively. Median overall survival time was 12.1 months. From initial treatment until death or last follow-up, only 30 patients (35%) received WBRT as salvage treatment. CONCLUSION Radiosurgery to the surgical cavity without WBRT achieved excellent local control of resected brain metastasis. Close imaging follow-up allows early intervention for any new metastasis.
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Affiliation(s)
- Jared R Robbins
- Department of Radiation Oncology, Henry Ford Hospital, Detroit, Michigan 48202, USA
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16
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Picarelli H, Oliveira MDL, Bor-Seng-Shu E, Ribas ESC, Santos AM, Teixeira MJ. Intraoperative ultrasonography for presumed brain metastases: a case series study. ARQUIVOS DE NEURO-PSIQUIATRIA 2013; 70:793-8. [PMID: 23060106 DOI: 10.1590/s0004-282x2012001000008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 06/15/2012] [Indexed: 11/22/2022]
Abstract
UNLABELLED Brain metastases (BM) are one of the most common intracranial tumors and surgical treatment can improve both the functional outcomes and patient survival, particularly when systemic disease is controlled. Image-guided BM resection using intraoperative exams, such as intraoperative ultrasound (IOUS), can lead to better surgical results. METHODS To evaluate the use of IOUS for BM resection, 20 consecutive patients were operated using IOUS to locate tumors, identify their anatomical relationships and surgical cavity after resection. Technical difficulties, complications, recurrence and survival rates were noted. RESULTS IOUS proved effective for locating, determining borders and defining the anatomical relationships of BM, as well as to identify incomplete tumor resection. No complications related to IOUS were seen. CONCLUSION IOUS is a practical supporting method for the resection of BM, but further studies comparing this method with other intraoperative exams are needed to evaluate its actual contribution and reliability.
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Affiliation(s)
- Helder Picarelli
- Division of Neurological Surgery, Instituto do Câncer do Estado de São Paulo Octavio Frias de Oliveira, São Paulo SP, Brazil.
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Abstract
The use of surgery in the treatment of brain metastases is controversial. Patients who present certain clinical characteristics may experience prolonged survival with resection compared with radiation therapy. Thus, for patients with a single metastatic lesion in the setting of well-controlled systemic cancer, surgery is highly indicated. Stereotactic radiosurgery (SRS) alone can provide a similar survival advantage, but when used as postoperative adjuvant therapy, patients experience extended survival times. Furthermore, surgery remains the only treatment option for patients with life-threatening neurological symptoms, who require immediate tumor debulking. Treatment of brain metastases requires a careful clinical assessment of individual patients, as different prognostic factors may indicate various modes or combinations of therapy. Since surgery is an effective method for achieving tumor management in particular cases, it remains an important consideration in the treatment algorithm for brain metastases.
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Affiliation(s)
- Kurt Andrew Yaeger
- Department of Neurosurgery, Georgetown University School of Medicine, Washington DC 20007, USA
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Affiliation(s)
- Toral R Patel
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06520, USA
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Abstract
Multiple options for retreatment are available, which include whole-brain radiation therapy, stereotactic radiosurgery, surgery, chemotherapy, and supportive care. Size, number, timing, location, histology, performance status, and extracranial disease status all need to be carefully considered when choosing a treatment modality. There are no randomized trials examining the retreatment of brain metastases. Repeat whole-brain radiation has been examined in a single-institution experience, showing the potential for clinical responses in selected patients. Local control rates as high as 91% using stereotactic radiosurgery for relapses after whole-brain radiation are reported. Surgery can be indicated in progressive and/or hemorrhagic lesions causing mass effect. The role of chemotherapy in the recurrent setting is limited but some agents may have activity on the basis of experiences on a smaller scale. Supportive care continues to be an important option, especially in those with a poor prognosis. Follow-up for brain metastases patients is discussed, examining the modality, frequency of imaging, and imaging options in differentiating treatment effect from recurrence. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of the current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Chao ST, Koyfman SA, Woody N, Angelov L, Soeder SL, Reddy CA, Rybicki LA, Djemil T, Suh JH. Recursive Partitioning Analysis Index Is Predictive for Overall Survival in Patients Undergoing Spine Stereotactic Body Radiation Therapy for Spinal Metastases. Int J Radiat Oncol Biol Phys 2012; 82:1738-43. [DOI: 10.1016/j.ijrobp.2011.02.019] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Revised: 01/28/2011] [Accepted: 02/02/2011] [Indexed: 10/18/2022]
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Sun T, Warrington NM, Rubin JB. Why does Jack, and not Jill, break his crown? Sex disparity in brain tumors. Biol Sex Differ 2012; 3:3. [PMID: 22277186 PMCID: PMC3293746 DOI: 10.1186/2042-6410-3-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Accepted: 01/25/2012] [Indexed: 02/06/2023] Open
Abstract
It is often reported that brain tumors occur more frequently in males, and that males suffer a worse outcome from brain tumors than females. If correct, these observations suggest that sex plays a fundamental role in brain tumor biology. The following review of the literature regarding primary and metastatic brain tumors, reveals that brain tumors do occur more frequently in males compared to females regardless of age, tumor histology, or region of the world. Sexually dimorphic mechanisms that might control tumor cell biology, as well as immune and brain microenvironmental responses to cancer, are explored as the basis for this sex disparity. Elucidating the mechanisms by which sex chromosomes and sex hormones impact on brain tumorigenesis and progression will advance our understanding of basic cancer biology and is likely to be essential for optimizing the care of brain tumor patients.
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Affiliation(s)
- Tao Sun
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Washington University School of Medicine, CB 8208, 660 South Euclid Ave, St Louis, MO 63110, USA.
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Hashimoto K, Narita Y, Miyakita Y, Ohno M, Sumi M, Mayahara H, Kayama T, Shibui S. Comparison of Clinical Outcomes of Surgery Followed by Local Brain Radiotherapy and Surgery Followed by Whole Brain Radiotherapy in Patients With Single Brain Metastasis: Single-Center Retrospective Analysis. Int J Radiat Oncol Biol Phys 2011; 81:e475-80. [DOI: 10.1016/j.ijrobp.2011.02.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Revised: 01/28/2011] [Accepted: 02/02/2011] [Indexed: 10/18/2022]
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The role of surgery, radiosurgery and whole brain radiation therapy in the management of patients with metastatic brain tumors. Int J Surg Oncol 2011; 2012:952345. [PMID: 22312545 PMCID: PMC3263703 DOI: 10.1155/2012/952345] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2011] [Accepted: 10/03/2011] [Indexed: 01/30/2023] Open
Abstract
Brain tumors constitute the most common intracranial tumor. Management of brain metastases has become increasingly complex as patients with brain metastases are living longer and more treatment options develop. The goal of this paper is to review the role of stereotactic radiosurgery (SRS), whole brain radiation therapy (WBRT), and surgery, in isolation and in combination, in the contemporary treatment of brain metastases. Surgery and SRS both offer management options that may help to optimize therapy in selected patients. WBRT is another option but can lead to late toxicity and suboptimal local control in longer term survivors. Improved prognostic indices will be critical for selecting the best therapies. Further prospective trials are necessary to continue to elucidate factors that will help triage patients to the proper brain-directed therapy for their cancer.
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Georgiadis P, Kostopoulos S, Cavouras D, Glotsos D, Kalatzis I, Sifaki K, Malamas M, Solomou E, Nikiforidis G. Quantitative combination of volumetric MR imaging and MR spectroscopy data for the discrimination of meningiomas from metastatic brain tumors by means of pattern recognition. Magn Reson Imaging 2011; 29:525-35. [PMID: 21315534 DOI: 10.1016/j.mri.2010.11.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Revised: 09/21/2010] [Accepted: 11/28/2010] [Indexed: 10/18/2022]
Abstract
The analysis of information derived from magnetic resonance imaging (MRI) and spectroscopy (MRS) has been identified as an important indicator for discriminating among different brain pathologies. The purpose of this study was to investigate the efficiency of the combination of textural MRI features and MRS metabolite ratios by means of a pattern recognition system in the task of discriminating between meningiomas and metastatic brain tumors. The data set consisted of 40 brain MR image series and their corresponding spectral data obtained from patients with verified tumors. The pattern recognition system was designed employing the support vector machines classifier with radial basis function kernel; the system was evaluated using an external cross validation process to render results indicative of the generalization performance to "unknown" cases. The combination of MR textural and spectroscopic features resulted in 92.15% overall accuracy in discriminating meningiomas from metastatic brain tumors. The fusion of the information derived from MRI and MRS data might be helpful in providing clinicians a useful second opinion tool for accurate characterization of brain tumors.
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Affiliation(s)
- Pantelis Georgiadis
- Medical Image Processing and Analysis (MIPA) Group, Laboratory of Medical Physics, Faculty of Medicine, University of Patras, GR-26503 Rio, Greece.
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Implications of Identifying Additional Cerebral Metastases during Gamma Knife Radiosurgery. Int J Surg Oncol 2011; 2012:748284. [PMID: 22312543 PMCID: PMC3265271 DOI: 10.1155/2012/748284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 06/13/2011] [Indexed: 11/18/2022] Open
Abstract
Introduction. Gamma Knife radiosurgery (GK-SRS) is commonly used to treat cerebral metastases. Although additional intracranial metastases are often found on the day of GK-SRS, the significance of finding them is unknown. Methods. A retrospective review of 133 patients undergoing GK-SRS for cerebral metastases was performed. The change in number of metastases detected between initial referral magnetic resonance imaging (MRI) and subsequent treatment MRI was quantified. Multivariate and Kaplan-Meier analyses were employed to examine the significance of identifying additional lesions. Results. Additional lesions were identified in 41% of patients. An increasing number of metastases on referral MRI (P = 0.001) and the presence of progressive systemic disease (P = 0.003) were predictive of identifying additional metastases. Median survival was 6.9 months for patients with additional metastases, compared to 12.1 months for patients without additional metastases (hazard ratio 1.56, P = 0.021). Conclusions. Identifying additional metastases on the day of GK-SRS may add important prognostic information.
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Validation of the new Graded Prognostic Assessment scale for brain metastases: a multicenter prospective study. Radiat Oncol 2011; 6:23. [PMID: 21366924 PMCID: PMC3058011 DOI: 10.1186/1748-717x-6-23] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 03/02/2011] [Indexed: 12/04/2022] Open
Abstract
Background Prognostic indexes are useful to guide tailored treatment strategies for cancer patients with brain metastasis (BM). We evaluated the new Graded Prognostic Assessment (GPA) scale in a prospective validation study to compare it with two published prognostic indexes. Methods A total of 285 newly diagnosed BM (n = 85 with synchronous BM) patients, accrued prospectively between 2000 and 2009, were included in this analysis. Mean age was 62 ± 12.0 years. The median KPS and number of BM was 70 (range, 20-100) and 3 (range, 1-50), respectively. The majority of primary tumours were lung (53%), or breast (17%) cancers. Treatment was administered to 255 (89.5%) patients. Only a minority of patients could be classified prospectively in a favourable prognostic class: GPA 3.5-4: 3.9%; recursive partitioning analysis (RPA) 1, 8.4% and Basic Score for BM (BSBM) 3, 9.1%. Mean follow-up (FU) time was 5.2 ± 4.7 months. Results During the period of FU, 225 (78.9%) patients died. The 6 months- and 1 year-OS was 36.9% and 17.6%, respectively. On multivariate analysis, performance status (P < 0.001), BSBM (P < 0.001), Center (P = 0.007), RPA (P = 0.02) and GPA (P = 0.03) were statistically significant for OS. The survival prediction performances' of all indexes were identical. Noteworthy, the significant OS difference observed within 3 months of diagnosis between the BSBM, RPA and GPA classes/groups was not observed after this cut-off time point. Harrell's concordance indexes C were 0.58, 0.61 and 0.58 for the GPA, BSBM and RPA, respectively. Conclusions Our data suggest that the new GPA index is a valid prognostic index. In this prospective study, the prediction performance was as good as the BSBM or RPA systems. These published indexes may however have limited long term prognostication capability.
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Characteristics of long-term survivors of brain metastases from lung cancer. Rep Pract Oncol Radiother 2011; 16:49-53. [PMID: 24376956 DOI: 10.1016/j.rpor.2011.01.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 01/05/2011] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND AIM Long-term survival of lung cancer patients with brain metastases (BM) is very rare. Our aim is to report the characteristics of patients who survived for at least three years after a BM diagnosis. MATERIALS AND METHODS Nineteen lung cancer patients who had survived ≥3 years after a BM diagnosis were identified in our database. Seven (37%) had undergone whole-brain radiotherapy (WBRT) only, five (26%) BM surgery + WBRT, three (16%) BM surgery + WBRT + BM radiosurgery, and four (21%) no WBRT (one, surgery; one, radiosurgery; two, BM surgery + radiosurgery). Their characteristics were compared with historical data for 322 lung cancer patients with BM (control group, CG), who had received WBRT between 1986 and 1997. RESULTS Median survival from BM in long survivors group was 73 months (in CG - 4 months). Characteristics comparison: median age 55 vs. 58 (CG), p = 0.16; female sex 68% vs. 28% (CG), p = 0.003; RTOG/RPA class 1 - 75% vs. 13% (CG), p = 0.00001; adenocarcinoma histology 84% vs. 24% (CG), p < 0.00001; control of primary tumor 95% vs. 27% (CG), p < 0.00001; extracranial metastases 0 vs. 26% (CG), p = 0.01; single BM 63% vs. 9% (CG), p = 0.00001; surgery of BM 53% vs. 14% (CG), p = 0.00001. CONCLUSIONS Beside prognostic factors already recognized as favorable in patients with BM, the adenocarcinoma histology and female sex were prevalent in long-term survivors of BM from lung cancer.
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Chi A, Komaki R. Treatment of brain metastasis from lung cancer. Cancers (Basel) 2010; 2:2100-37. [PMID: 24281220 PMCID: PMC3840463 DOI: 10.3390/cancers2042100] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2010] [Revised: 11/11/2010] [Accepted: 12/02/2010] [Indexed: 12/25/2022] Open
Abstract
Brain metastases are not only the most common intracranial neoplasm in adults but also very prevalent in patients with lung cancer. Patients have been grouped into different classes based on the presence of prognostic factors such as control of the primary tumor, functional performance status, age, and number of brain metastases. Patients with good prognosis may benefit from more aggressive treatment because of the potential for prolonged survival for some of them. In this review, we will comprehensively discuss the therapeutic options for treating brain metastases, which arise mostly from a lung cancer primary. In particular, we will focus on the patient selection for combined modality treatment of brain metastases, such as surgical resection or stereotactic radiosurgery (SRS) combined with whole brain irradiation; the use of radiosensitizers; and the neurocognitive deficits after whole brain irradiation with or without SRS. The benefit of prophylactic cranial irradiation (PCI) and its potentially associated neuro-toxicity for both small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) are also discussed, along with the combined treatment of intrathoracic primary disease and solitary brain metastasis. The roles of SRS to the surgical bed, fractionated stereotactic radiotherapy, WBRT with an integrated boost to the gross brain metastases, as well as combining WBRT with epidermal growth factor receptor (EGFR) inhibitors, are explored as well.
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Affiliation(s)
- Alexander Chi
- Department of Radiation Oncology, University of Arizona, 1501 N Campbell Ave., Tucson, AZ 85724, USA; E-Mail:
| | - Ritsuko Komaki
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
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Dai XJ, Jiang WJ, Wang WM, Zhao SJ. Drug or vaccine?: selecting the appropriate treatment for malignant glioma patients. Drugs 2010; 70:1477-86. [PMID: 20687616 DOI: 10.2165/11538040-000000000-00000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Malignant gliomas are the most common and aggressive form of brain tumour. Current combinations of aggressive surgical resection, radiation therapy and chemotherapy regimens do not significantly improve long-term patient survival for these cancers. Therefore, investigative therapies including tumour vaccines have targeted this devastating condition. This article reviews evidence and data on chemotherapy and immunotherapy for a personalized medicine approach in order to enable physicians to select the appropriate treatment for glioma patients. Dendritic cell- and peptide-based therapy for gliomas seems to be safe and without major adverse effects. Gene-modified vaccines have also shown promise in the treatment of malignant gliomas. The concept of 'personalized medicine' is currently important in oncology treatment development. Using a personalized medicine approach, it may be necessary to evaluate the molecular genetic abnormalities in individual patient tumours, and such findings should be the mainstay of immunotherapeutic strategies designed for the individual patient.
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Affiliation(s)
- Xue-jun Dai
- Department of Neurosurgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong, People's Republic of China
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30
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Suh JH, Videtic GMM, Aref AM, Germano I, Goldsmith BJ, Imperato JP, Marcus KJ, McDermott MW, McDonald MW, Patchell RA, Robins HI, Rogers CL, Wolfson AH, Wippold FJ, Gaspar LE. ACR Appropriateness Criteria: single brain metastasis. Curr Probl Cancer 2010; 34:162-74. [PMID: 20541055 DOI: 10.1016/j.currproblcancer.2010.04.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Single brain metastasis represents a common neurologic complication of cancer. Given the number of treatment options that are available for patients with brain metastasis and the strong opinions that are associated with each option, appropriate treatment for these patients has become controversial. Prognostic factors such as recursive partitioning analysis and graded prognostic assessment can help guide treatment decisions. Surgery, whole brain radiation therapy (WBRT), stereotactic radiosurgery or combination of these treatments can be considered based on a number of factors. Despite Class I evidence suggestive of best therapy, the treatment recommendation is quite varied among physicians as demonstrated by the American College of Radiology's Appropriateness Panel on single brain metastasis. Given the potential concerns of the neurocognitive effects of WBRT, the use of SRS alone or SRS to a resection cavity has gained support. Since aggressive local therapy is beneficial for survival, local control and quality of life, the use of these various treatment modalities needs to be carefully investigated given the growing number of long-term survivors. Enrollment of patients onto clinical trials is important to advance our understanding of brain metastasis.
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Hassaneen W, Suki D, Salaskar AL, Wildrick DM, Lang FF, Fuller GN, Sawaya R. Surgical management of lateral-ventricle metastases: report of 29 cases in a single-institution experience. J Neurosurg 2010; 112:1046-55. [PMID: 19663549 DOI: 10.3171/2009.7.jns09571] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The aim of this study was to review the outcome of patients undergoing surgery for treatment of lateral-ventricle metastases. METHODS Imaging information and chart reviews of operative reports were used to conduct a retrospective analysis in 29 patients who underwent resection of lateral-ventricle metastases at the authors' institution between 1993 and 2007. Clinical and neurosurgical outcomes and recurrence rates were studied. RESULTS The mean patient age was 56 years (range 20-69 years); 66% of patients were male. Single intraventricular metastases occurred in 69% of patients, and 55% of them had systemic metastases. The 30-day postoperative mortality rate was 7%. There was intracerebral tumor recurrence in 41% of patients, with 1 patient undergoing a second operation for this. The median postoperative survival duration for 28 patients (excluding 1 patient with preoperative leptomeningeal disease) was 11.7 months; the 3- and 5-year survival rates were 17 and 11%, respectively. Univariate analysis identified factors significantly influencing survival, including the preoperative Karnofsky Performance Scale (KPS) score (p = 0.02), the number of cerebral metastases (p = 0.02), the presence of primary renal cell carcinoma (RCC) (p = 0.02), and the resection method (en bloc vs piecemeal; p = 0.05). The presence of extracranial metastases did not significantly influence survival. Multivariate analysis showed that the preoperative KPS score (p = 0.002), the presence of primary RCC (p = 0.039), and the resection method (en bloc vs piecemeal; p = 0.008) correlated significantly with survival time. CONCLUSIONS Surgery is an important component in the management of intraventricular metastases. To the authors' knowledge, this is the first study focusing totally on resection of lateral-ventricle metastases. The authors found that patients with primary RCC, those with a favorable preoperative KPS score, and those who underwent en bloc resection had a better outcome than others.
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Affiliation(s)
- Wael Hassaneen
- Department of Neurosurgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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Aoyama H. Radiation therapy for brain metastases in breast cancer patients. Breast Cancer 2010; 18:244-51. [PMID: 20458564 DOI: 10.1007/s12282-010-0207-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Accepted: 04/01/2010] [Indexed: 12/26/2022]
Abstract
Most randomized comparison trials (RCTs) investigating treatments for brain metastases (BM) have included BM from any origin; as a result, more than half (52.4-77.0%) of the BM in these trials originated from the lungs (mostly non-small-cell lung cancer, NSCLC), with the breasts being the origin in only 6.8-19.0% of cases. In addition, patients with poor systemic status (KPS < 70) were not included in these trials. Hence, before we can apply RCT-based information to the daily clinical treatment of BM from breast cancers, it will be crucial to differentiate the characteristics of BM originating from NSCLC and BM originating from breast cancer. Although stereotactic radiosurgery (SRS) is widely used in Japan, level-1 evidence suggests that the benefit of using SRS in addition to whole-brain radiation therapy (WBRT) has been proven only for patients with a single BM. Treatment with SRS alone, which is widely used in Japan, seems attractive because it could avoid the risk of long-term adverse effects of WBRT. However, level-1 evidence suggests that the omission of WBRT results in a high frequency of brain tumor recurrence (BTR). In an RCT between SRS-alone and SRS + WBRT conducted in Japan, we found that patients who had a single BM and no extracranial metastases had a low risk of developing BTR after initial brain management (low-risk group) compared with those who had 2 or more BM and extracranial metastases (high-risk group). In order to meet the criteria of "low-risk" BTR, patients also should have good systemic status (KPS ≧ 70). Epidemiologic data suggest that the prognosis is twice as likely to be poor in patients with BM from breast cancer (RPA III = KPS < 70) than in patients with BM from NSCLC (40 vs. 20%); in addition, the probability of brain-only metastases in patients with breast cancer is less than half that in patients with NSCLC (20-25 vs. 60-75%). Considering these findings, we should be aware that most patients with BM from breast cancer are not good candidates for SRS alone, and, therefore, the role of WBRT is still important in the era of modern radiation techniques.
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Affiliation(s)
- Hidefumi Aoyama
- Division of Radiation Oncology, Department of Radiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Chuo-ku, Niigata, 9518510, Japan.
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Karlsson B, Hanssens P, Wolff R, Söderman M, Lindquist C, Beute G. Thirty years' experience with Gamma Knife surgery for metastases to the brain. J Neurosurg 2009; 111:449-57. [PMID: 19199505 DOI: 10.3171/2008.10.jns08214] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The aim of this study was to analyze factors influencing survival time and patterns of distant recurrences after Gamma Knife surgery (GKS) for metastases to the brain.
Methods
Information was available for 1855 of 1921 patients who underwent GKS for single or multiple cerebral metastases at 4 different institutions during different time periods between 1975 and 2007. The total number of Gamma Knife treatments administered was 2448, an average of 1.32 treatments per patient. The median survival time was analyzed, related to patient and treatment parameters, and compared with published data following conventional fractionated whole-brain irradiation.
Results
Twenty-five patients survived for longer than 10 years after GKS, and 23 are still alive. Age and primary tumor control were strongly related to survival time. Patients with single metastases had a longer survival than those with multiple metastases, but there was no difference in survival between patients with single and multiple metastases who had controlled primary disease. There were no significant differences in median survival time between patients with 2, 3–4, 5–8, or > 8 metastases. The 5-year survival rate was 6% for the whole patient population, and 9% for patients with controlled primary disease. New hematogenous spread was a more significant problem than micrometastases in patients with longer survival.
Conclusions
Patient age and primary tumor control are more important factors in predicting median survival time than number of metastases to the brain. Long-term survivors are more common than previously assumed.
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Affiliation(s)
- Bengt Karlsson
- 1Department of Neurosurgery, West Virginia University, Morgantown, West Virginia
| | - Patrick Hanssens
- 2Gamma Knife Center, St. Elisabeth Ziekenhuis, Tilburg, The Netherlands
| | - Robert Wolff
- 3Gamma Knife Zentrum, Frankfurt am Main, Germany
| | - Michael Söderman
- 4Department of Neuroradiology, Karolinska Hospital, Stockholm, Sweden; and
| | | | - Guus Beute
- 2Gamma Knife Center, St. Elisabeth Ziekenhuis, Tilburg, The Netherlands
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Sarin H. Recent progress towards development of effective systemic chemotherapy for the treatment of malignant brain tumors. J Transl Med 2009; 7:77. [PMID: 19723323 PMCID: PMC2743638 DOI: 10.1186/1479-5876-7-77] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Accepted: 09/01/2009] [Indexed: 12/15/2022] Open
Abstract
Systemic chemotherapy has been relatively ineffective in the treatment of malignant brain tumors even though systemic chemotherapy drugs are small molecules that can readily extravasate across the porous blood-brain tumor barrier of malignant brain tumor microvasculature. Small molecule systemic chemotherapy drugs maintain peak blood concentrations for only minutes, and therefore, do not accumulate to therapeutic concentrations within individual brain tumor cells. The physiologic upper limit of pore size in the blood-brain tumor barrier of malignant brain tumor microvasculature is approximately 12 nanometers. Spherical nanoparticles ranging between 7 nm and 10 nm in diameter maintain peak blood concentrations for several hours and are sufficiently smaller than the 12 nm physiologic upper limit of pore size in the blood-brain tumor barrier to accumulate to therapeutic concentrations within individual brain tumor cells. Therefore, nanoparticles bearing chemotherapy that are within the 7 to 10 nm size range can be used to deliver therapeutic concentrations of small molecule chemotherapy drugs across the blood-brain tumor barrier into individual brain tumor cells. The initial therapeutic efficacy of the Gd-G5-doxorubicin dendrimer, an imageable nanoparticle bearing chemotherapy within the 7 to 10 nm size range, has been demonstrated in the orthotopic RG-2 rodent malignant glioma model. Herein I discuss this novel strategy to improve the effectiveness of systemic chemotherapy for the treatment of malignant brain tumors and the therapeutic implications thereof.
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Affiliation(s)
- Hemant Sarin
- National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, Maryland, USA.
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Kim SH, Weil RJ, Chao ST, Toms SA, Angelov L, Vogelbaum MA, Suh JH, Barnett GH. Stereotactic radiosurgical treatment of brain metastases in older patients. Cancer 2008; 113:834-40. [PMID: 18536026 DOI: 10.1002/cncr.23625] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND This study was designed to evaluate the therapeutic effect of stereotactic radiosurgery (SRS) in patients aged > or =75 years who presented with brain metastasis. METHODS The authors analyzed the data from 44 consecutive patients treated with SRS for > or =1 brain metastasis. The median age at the time of treatment for brain metastases was 79.3 years (range, 75 years-86 years), and the median Karnofsky performance status was 80 (range, 50-100). At the time of SRS, 31 patients were treated for a single metastasis, and the remaining 13 patients were treated for > or =2 lesions (n = 74 lesions). The median tumor volume was 1.2 cm(3) (range, 0.007 cm(3)-22.5 cm(3)). The median maximal and marginal doses were 36 grays (Gy) (range, 18.8 Gy-48.2 Gy) and 20 Gy (range, 10 Gy-24 Gy), respectively. RESULTS Median survival was 7.3 +/- 1.65 months (range, 1.6 months-38.9 months) from the time of diagnosis of brain metastasis. Median survival of the patients with a single brain metastasis (10.1 +/- 1.92 months) was longer than that of the patients with > or =2 metastases (6.6 +/- 1.28 months) (P <.02). A single lesion was found to be an independent favorable prognostic factor (P +/- = +/- .017; odds ratio, 2.385 [95% confidence interval, 1.167-4.874]) in univariate and multivariate analysis. Patients with nonsmall cell lung cancer fared worse than patients with other tumor types (survival of 6.5 +/- 0.70 months vs 10.1 +/- 2.33 months [P<.05]). CONCLUSIONS SRS for patients aged > or =75 years with brain metastases is an effective and safe treatment modality that appears to improve survival, with outcomes that compare favorably with those reported for younger patients in an appropriately selected population.
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Affiliation(s)
- Se-Hyuk Kim
- The Brain Tumor and Neuro-Oncology Center, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Kim SH, Chao ST, Toms SA, Vogelbaum MA, Barnett GH, Suh JH, Weil RJ. Stereotactic radiosurgical treatment of parenchymal brain metastases from prostate adenocarcinoma. ACTA ACUST UNITED AC 2008; 69:641-6; discussion 646. [PMID: 18262258 DOI: 10.1016/j.surneu.2007.05.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2007] [Accepted: 05/16/2007] [Indexed: 01/11/2023]
Abstract
BACKGROUND Prostate cancer metastatic to the brain is uncommon and has been associated historically with a poor prognosis. It has been suggested that SRS may be an effective treatment. METHODS We analyzed a prospective, institutional review board-approved database of patients treated with SRS and identified 5 patients with prostate cancer metastasis. Clinical, pathologic, radiographic, treatment, and outcome information regarding the primary/systemic disease status, and brain metastases were collected. RESULTS Mean age at the time of treatment for CNS parenchymal metastasis was 72.0 +/- 8.3 years and lesions developed 82.0 +/- 65.1 months after the initial tumor was identified. Four patients had a single lesion and 1 had 4; 3 patients were treated with SRS alone, 1 with WBRT and SRS, and 1 with surgery, then WBRT and SRS. All were symptomatic. Stereotactic radiosurgery controlled the brain metastases in all 5 patients, with functional improvement and with a typical increase of 1 grade in the Karnofsky performance score. Mean survival was at least 10.0 +/- 6.7 months (range, 6-22+ months). Two patients died of conditions unrelated to prostate cancer and 2 of systemic disease progression; 1is alive and asymptomatic. There were no local SRS failures and no new CNS lesions. CONCLUSIONS Stereotactic radiosurgery for prostate cancer metastatic to the brain, alone or in combination with brain radiation therapy and surgery, is a safe, effective treatment that improves neurologic symptoms and function and may prolong survival.
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Affiliation(s)
- Se-Hyuk Kim
- The Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH 44195, USA
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