Radiosurgery in Metastatic Brain Cancer

A 3-month survival model after Gamma Knife surgery in patients with brain metastasis from lung cancer with Karnofsky performance status ≤ 70

Gamma Knife surgery (GKS) for brain metastasis (BM) has been generally advocated for patients with a Karnofsky performance status (KPS) scale of ≥ 70. However, some patients with a poor KPS scale of < 70 are recoverable after GKS and show durable survival. A purpose of this study is to devise a 3-month survival prediction model to screen patients with BM with a KPS of ≤ 70 in whom GKS is needed. A retrospective analysis of 67 patients with a KPS scale of 60-70 undergoing GKS for BM of non-small cell lung cancer (NSCLC) from 2016 to 2020 in our institute was performed. Univariate and multivariate logistic regression analyses were performed to investigate factors related to survival for more than 3 months after GKS. The probability (P) prediction model was designed by giving a weight corresponding to the odds ratio of the variables. The overall survival was 9.9 ± 12.7 months (range 0.2-53.2), with a 3-month survival rate of 59.7% (n = 40). In multivariate logistic regression analysis, extracranial disease (ECD) control (p = .033), focal neurological deficit (FND) (p = .014), and cumulative tumor volume (∑ TV) (p = .005) were associated with 3-month survival. The prediction model of 3-month survival (Harrell's C index = 0.767) was devised based on associated factors. In conclusion, GKS for BMs is recommended in selected patients, even if the KPS scale is ≤ 70.

Cerebral hemodynamic and metabolic dysregulation in the postradiation brain

Technological advances in the delivery of radiation and other novel cancer therapies have significantly improved the 5-year survival rates over the last few decades. Although recent developments have helped to better manage the acute effects of radiation, the late effects such as impairment in cognition continue to remain of concern. Accruing data in the literature have implicated derangements in hemodynamic parameters and metabolic activity of the irradiated normal brain as predictive of cognitive impairment. Multiparametric imaging modalities have allowed us to precisely quantify functional and metabolic information, enhancing the anatomic and morphologic data provided by conventional MRI sequences, thereby contributing as noninvasive imaging-based biomarkers of radiation-induced brain injury. In this review, we have elaborated on the mechanisms of radiation-induced brain injury and discussed several novel imaging modalities, including MR spectroscopy, MR perfusion imaging, functional MR, SPECT, and PET that provide pathophysiological and functional insights into the postradiation brain, and its correlation with radiation dose as well as clinical neurocognitive outcomes. Additionally, we explored some innovative imaging modalities, such as quantitative blood oxygenation level-dependent imaging, susceptibility-based oxygenation measurement, and T2-based oxygenation measurement, that hold promise in delineating the potential mechanisms underlying deleterious neurocognitive changes seen in the postradiation setting. We aim that this comprehensive review of a range of imaging modalities will help elucidate the hemodynamic and metabolic injury mechanisms underlying cognitive impairment in the irradiated normal brain in order to optimize treatment regimens and improve the quality of life for these patients.

Successful Treatment of Advanced Gastric Cancer with Brain Metastases through an Abscopal Effect by Radiation and Immune Checkpoint Inhibitor Therapy

The abscopal effect refers to the phenomenon in which local radiotherapy is associated with the regression of metastatic cancer that is distantly located from the irradiated site. Here, we present a case of a patient with advanced gastric cancer and brain metastases who was successfully treated with brain radiotherapy and anti-programmed death-1 (PD-1) therapy-induced abscopal effect. Although anti-PD-1 therapy alone could not prevent disease progression, the metastatic lesions in the brain and also in the abdominal lymph node showed a drastic response after brain radiotherapy and anti-PD-1 therapy. To our knowledge, this is the first reported case of successful treatment of advanced gastric cancer with multiple brain and abdominal lymph node metastases, possibly through anti-PD-1 therapy combined with brain radiotherapy-induced abscopal effect. We suggest that the combination of brain radiotherapy and anti-PD-1 therapy may be considered as a therapeutic option for advanced gastric cancer, especially when there is brain metastasis.

Stereotactic Radiosurgery for Atrioventricular Node Ablation in Swine: A Study on Efficacy and Dosimetric Evaluation of Organs at Risk

Introduction Stereotactic radiosurgery (SRS) delivered to arrhythmogenic foci within the heart is a promising treatment modality. We dosimetrically evaluated the radiation dose to the organs at risk of four swine that were successfully treated with linear-accelerator-based SRS for atrioventricular (AV) node ablation. Materials and methods Single-chamber pacemakers were implanted in four large white breed swine. Cardiac computed tomography simulation scans were performed to localize the AV node and organs at risk. SRS (35-40 Gy) was delivered to the AV node, and the pigs were followed up with pacemaker interrogations. One-sample t-tests were used to evaluate Dmax of great vessels, esophagus, and chest wall as compared to known normal tissue constraints as per RTOG 0631 and AAPM Task Group 101. Results All pigs had disturbances of AV conduction with progressive transition into complete heart block. Macroscopic and microscopic evaluation showed fibrosis in the AV node but did not reveal any changes in non-nodal cardiac tissue or vessels. The mean Dmax±SD (p-value) of the chest wall (14.7±3.3 (0.02)), esophagus (10.7±1.1 (<0.01)) superior vena cava (3.3±4.1 (<0.01)), right pulmonary artery (16.1±6.4 (<0.01)), right pulmonary vein (15.7± 5 (<0.01)), left pulmonary artery (11.1±1.7 (<0.01)) and left pulmonary vein (14.1±2.6 (<0.01)), and the inferior vena cava (33.68±1.6 (0.026)) were significantly below the normal tissue constraint cutoffs. Mean±SD (p-value) of the ascending aorta (19.4±16.1 (0.12)) was not significantly different than normal tissue constraint cutoffs. One swine model treated at 40 Gy had small area of hotspot in the ascending aorta (40.65 (0.4 cc)). Conclusion We have demonstrated in our swine models that SRS using 35-40 Gy can be done without exceeding known human normal tissue constraints to the chest wall, esophagus, and great vessels.

Management evaluation of metastasis in the brain (MEMBRAIN)-a United Kingdom and Ireland prospective, multicenter observational study

BACKGROUND

In recent years an increasing number of patients with cerebral metastasis (CM) have been referred to the neuro-oncology multidisciplinary team (NMDT). Our aim was to obtain a national picture of CM referrals to assess referral volume and quality and factors affecting NMDT decision making.

METHODS

A prospective multicenter cohort study including all adult patients referred to NMDT with 1 or more CM was conducted. Data were collected in neurosurgical units from November 2017 to February 2018. Demographics, primary disease, KPS, imaging, and treatment recommendation were entered into an online database.

RESULTS

A total of 1048 patients were analyzed from 24 neurosurgical units. Median age was 65 years (range, 21-93 years) with a median number of 3 referrals (range, 1-17 referrals) per NMDT. The most common primary malignancies were lung (36.5%, n = 383), breast (18.4%, n = 193), and melanoma (12.0%, n = 126). A total of 51.6% (n = 541) of the referrals were for a solitary metastasis and resulted in specialist intervention being offered in 67.5% (n = 365) of cases. A total of 38.2% (n = 186) of patients being referred with multiple CMs were offered specialist treatment. NMDT decision making was associated with number of CMs, age, KPS, primary disease status, and extent of extracranial disease (univariate logistic regression, P < .001) as well as sentinel location and tumor histology (P < .05). A delay in reaching an NMDT decision was identified in 18.6% (n = 195) of cases.

CONCLUSIONS

This study demonstrates a changing landscape of metastasis management in the United Kingdom and Ireland, including a trend away from adjuvant whole-brain radiotherapy and specialist intervention being offered to a significant proportion of patients with multiple CMs. Poor quality or incomplete referrals cause delay in NMDT decision making.

Combination of anti-PD-1 therapy and stereotactic radiosurgery for a gastric cancer patient with brain metastasis: a case report

Background

Brain metastases from gastric cancer are difficult to treat and their prognosis is poor. Despite various possible treatments, the survival rate of such patients is still unsatisfactory; therefore, new treatment modalities or combinations of therapies need to be explored.

Case presentation

We herein discuss a case of a 38-year-old man initially diagnosed with a gastric cancer brain metastasis. At first, only stereotactic radiosurgery (SRS) was performed, but it was not effective. After the brain and systemic metastases progressed, SRS and anti-PD-1 therapy were administered in combination, and the brain and intra-abdominal metastatic lesions responded satisfactorily.

Conclusion

The combination of anti-PD-1 therapy and SRS could be effective against gastric cancer with brain metastases.

Five-year Survival After Surgical Removal and Gamma Knife Stereotactic Radiosurgery for a Cerebellar Metastasis from an Esophagogastric Junction Cancer: A Case Report and Literature Review

Brain metastases originating from esophageal or gastric cancer are rare, accounting for 2.1-3.3% of all brain tumors registered in Japan. There are no established therapeutic measures for brain metastases, which accordingly have a poor prognosis. We present here a patient who survived for 5 years after surgery and gamma knife treatment of a cerebellar metastasis from esophagogastric adenocarcinoma. The primary gastric cancer was treated by laparotomy with total gastrectomy, splenectomy, and D2 lymphadenectomy. It was diagnosed as a esophagogastric junction Siewert type II tumor, type 3, tub1-2, pT3 (SS), pN1, and stage IIB on histopathological examination of the surgical specimen. Five months postoperatively, a solitary cerebellar metastasis was identified and surgically removed, followed by 20 Gy administered by gamma knife stereotactic radiosurgery; the patient received no subsequent treatment such as chemotherapy. Five years after the primary surgery, there have been no recurrences and the patient has a good quality of life. There are very few case reports of long-term survival after surgical treatment of cerebellar metastases from esophagogastric junction cancer. We report our experience and review published case reports of surgical treatment of brain metastases from gastric cancer.

A case-matched study of stereotactic radiosurgery for patients with brain metastases: comparing treatment results for those with versus without neurological symptoms

We aimed to reappraise whether post-stereotactic radiosurgery (SRS) results for brain metastases differ between patients with and without neurological symptoms. This was an institutional review board-approved, retrospective cohort study using our prospectively accumulated database including 2825 consecutive BM patients undergoing gamma knife SRS alone during the 15-year period since July 1998. The 2825 patients were divided into two groups; neurologically asymptomatic [group A, 1374 patients (48.6 %)] and neurologically symptomatic [group B, 1451 (51.4 %)]. Because there was considerable bias in pre-SRS clinical factors between groups A and B, a case-matched study was conducted. Ultimately, 1644 patients (822 in each group) were selected. The standard Kaplan–Meier method was used to determine post-SRS survival. Competing risk analysis was applied to estimate cumulative incidences of neurological death, neurological deterioration, local recurrence, re-SRS for new lesions and SRS-induced complications. Post-SRS median survival times (MSTs) did not differ between the two groups; 7.8 months in group A versus 7.4 months in group B patients (HR 1.064, 95 % CI 0.963–1.177, p = 0.22). However, cumulative incidences of neurological death (HR 1.637, 95 % CI 1.174–2.281, p = 0.0036) and neurological deterioration (HR 1.425, 95 % CI 1.073–1.894, p = 0.014) were significantly lower in the group A than in the group B patients. Neurologically asymptomatic patients undergoing SRS for BM had better results than symptomatic patients in terms of both maintenance of good neurological state and prolonged neurological survival. Thus, we conclude that screening computed tomography/magnetic resonance imaging is highly beneficial for managing cancer patients.

Early gastric cancer with suspected brain metastasis arising eight years after curative resection: a case report

Background

Brain metastasis from gastric cancer is fairly uncommon and prognosis is dismal. We report a case of early gastric cancer with brain metastasis arising 8 years after gastrectomy.

Case presentation

A 78-year-old Japanese female presented to our hospital complaining of dizziness, 8 years after undergoing gastrectomy for gastric cancer. Histopathological type of the tumor was well-differentiated adenocarcinoma. Final TNM classification was T1b(sm1)N0M0, and pathological stage was IA. Further examination revealed a metastatic tumor in the cerebellum and multiple liver metastases. The brain metastasis was treated using radiotherapy and steroid. Systemic treatment for liver metastases was performed using the oral fluoropyrimidine drug S-1. Neurological symptoms decreased, enabling the patient to be discharged from hospital. However, chemotherapy was discontinued due to loss of appetite and general fatigue. She died 5 months after the diagnosis of brain metastasis due to progressive disease.

Conclusions

Cases of brain metastasis arising 8 years after gastrectomy for early gastric cancer have rarely reported. Aggressive treatment for brain metastases may be effective for improvement of the damage to neurological function and quality of life.

Long-term outcome of gamma knife radiosurgery for metastatic brain tumors originating from lung cancer

Background:

Gamma knife radiosurgery (GKRS) has emerged as an important treatment option for metastasis brain tumors (MBTs). However, the long-term outcome of GKRS on MBTs originating from lung carcinoma is not well understood. The treatment of MBTs derived from lung cancer with GKRS at our institution is reviewed.

Methods:

We performed a retrospective review (2000-2013) of 173 patients with MBTs from lung cancer who received GKRS. Out of 173 patients, 38 patients had recurrent tumors after microsurgical resection and whole brain radiotherapy (WBT).

Results:

GKRS in MBTs metastasized from lung carcinoma showed significant variations in tumor growth control (decreased in 79 [45.7%] patients, arrested growth in 54 [31.2%] patients, and increased tumor size in 40 [23.1%] patients). The median survival in the study population was 14 months. Overall survival after 3 years was 25%, whereas progression-free survival after 3 years was 45%. The predictive factors for improving survival in the patients with MBTs were recursive partitioning analysis (RPA) class I (P = 0.005), absence of hydrocephalus (P = 0.001), Karnofsky performance scale (KPS) >70 (P = 0.007), age ≤65 (P = 0.041), tumor size ≤3 cm (P = 0.023), controlled primary tumor (P = 0.049), and single number of MBTS (P = 0.044).

Conclusion:

Long-term follow-up revealed that GKRS offers a high rate of tumor control and good overall survival period in both new and recurrent patients with MBTs originating from lung carcinoma. Thus, GKRS is an effective treatment option for new patients with MBTs from lung cancer, as well as an adjuvant therapy in patients with recurrent MBTs derived from lung cancer.

Long term outcome of Gamma Knife radiosurgery for metastatic brain tumors

Gamma Knife radiosurgery (GKRS; Elekta AB, Stockholm, Sweden) has emerged as an important treatment option for metastatic brain tumors (MBT). However, the long term outcome of GKRS on MBT is not well understood. We reviewed the treatment of MBT with GKRS at our institution. We performed a retrospective review (2000-2013) of 298 patients with MBT who received GKRS. The study population was monitored clinically and radiographically after GKRS treatment. Survival benefits and predictive factors of the outcome were analyzed using the Kaplan-Meier test and Cox regression model, respectively. GKRS in MBT showed significant variation in tumor growth control (decreased in 135 [45%] patients, arrested growth in 91 [37%] patients and increased tumor size in 72 [24%] patients). The median survival in the study population was 17 months. Overall and progression free survival after 3 years were 25% and 45%, respectively. The predictive factors for improving survival in the patients with MBT were recursive partitioning analysis class I (p<0.0001), absence of hydrocephalus (p<0.0001), Karnofsky Performance Status (KPS) >80 (p=0.007) and absence of recurrent MBT (p=0.01). Forty (12%), 15 (4.3%) and two (0.6%) patients required GKRS, resection and whole brain radiation, respectively, after initial GKRS due to tumor progression and worsening of signs and symptoms. Our findings revealed that GKRS offers a high rate of tumor control and good survival benefits in both new and recurrent patients with MBT. Thus, GKRS is an effective treatment option for new patients with MBT, as well as an adjuvant therapy in patients with recurrent MBT.

Delayed surgical resections of brain metastases after gamma knife radiosurgery

Although brain metastases are one of the most frequently diagnosed sequelae of systemic malignancy, their optimal management still is not well defined. In that respect, the different diagnostic and therapeutic approaches of BMs patients is an issue for serious discussions. The treatment options include surgical excision, WBRT, radiosurgery, chemotherapy, immunotherapy, etc. Nowadays, the aforementioned treatment modalities are usually combined in different treatment schemes. More than one option is used for the same patient and combining these treatment modalities gives better results than when separately use them. The value of surgical excision of progressing brain metastases treated with gamma knife surgery (GKS) is not well investigated.With the present study, we aim to investigate the value of surgical excision of symptomatic brain lesions that have been previously treated with GKS.

Radiosurgery for brain metastases from unknown primary cancers

PURPOSE

We evaluated the role of Gamma Knife stereotactic radiosurgery in the multidisciplinary management of brain metastases from an undiagnosed primary cancer.

METHODS AND MATERIALS

Twenty-nine patients who had solitary or multiple brain metastases without a detectable primary site underwent stereotactic radiosurgery between January 1990 and March 2007 at the University of Pittsburgh. The median patient age was 61.7 years (range, 37.9-78.7 years). The median target volume was 1.0 cc (range, 0.02-23.6 cc), and the median margin radiosurgical dose was 16 Gy (range, 20-70 Gy).

RESULTS

After radiosurgery, the local tumor control rate was 88.5%. Twenty four patients died and 5 patients were living at the time of this analysis. The overall median survival was 12 months. Actuarial survival rates from stereotactic radiosurgery at 1 and 2 years were 57.2% and 36.8%, respectively. Factors associated with poor progression-free survival included large tumor volume (3 cc or more) and brainstem tumor location.

CONCLUSIONS

Radiosurgery is an effective and safe minimally invasive option for patients with brain metastases from an unknown primary site.

Relationship between volume, dose and local control in stereotactic radiosurgery of brain metastasis

The aim of this study is to analyse the efficacy of linear accelerator stereotactic radiosurgery (SRS) on prognostic factors, local control rate and survival in patients with brain metastasis. Patients with either a single metastasis or up to 4 multiple brain metastases with a maximum tumour diameter of 40 mm for each tumour and a Karnofsky Performance Status (KPS) > or = 70 were eligible for SRS. SRS was applied to 150 lesions in 86 consecutive patients with a median age of 60 years (median 1 and mean 1.7 lesions per patient, mean KPS 86). Median overall survival was 6.2 months after SRS and 9.7 months from diagnosis of brain metastasis. Multivariate analysis revealed that a KPS of 90 or more (p = 0.009) and female sex (p = 0.003) were associated with a longer survival. Radiation dose < or = 15 Gy (p = 0.017) and KPS < 90 (p = 0.013) were independent predictors of a shorter time to local failure. Five patients showed evidence of radionecrosis with a median survival of 14.8 months. Addition of WBRT neither led to improvement of survival nor to improvement of local control. Improved local control following SRS for brain metastases was associated with KPS > or =90, a radiation dose > 15 Gy and a PTV < 13 cc. The potential of hypofractionated stereotactic radiotherapy (SRT) for brain metastases of larger volume warrants further study.

Outcomes and cost-effectiveness of gamma knife radiosurgery and whole brain radiotherapy for multiple metastatic brain tumors

We aimed to analyze the outcomes and cost-effectiveness of gamma knife radiosurgery (GKRS) and whole brain radiotherapy (WBRT) for multiple metastatic brain tumors. Over a period of 5 years, 156 patients with multiple metastatic brain tumors were enrolled and freely assigned by the referring doctors to either gamma knife radiosurgery (GKRS, Group A, n=56), or to whole brain radiotherapy (WBRT, Group B, n=100). The follow-up time was set at 1200 days (3.3 years) post-treatment. The number of tumors, patient age, extent of systemic disease and Karnofsky performance scale (KPS) score, were recorded and recursive partitioning analysis used. The outcomes analyzed were: mortality, survival time, neurological complications, post-treatment KPS score, quality-adjusted life years (QALY), and cost-effectiveness. A paired t-test was used for statistical analysis. Mortality rates for patients receiving GKRS and WBRT were 81.1% and 93.0%, respectively (p=0.05). The mortality rate was lower for GKRS (74.4%) than for WBRT (97.1%) in patients with initial KPS70 (p=0.02). The mortality rate was also significantly lower for GKRS (78.9%) than WBRT (95.5%) in patients with 2-5 tumors (p<0.05). Post-treatment KPS score (mean+/-standard deviation [s.d.] was higher for patients receiving GKRS (73.8+/-13.2) than for those receiving WBRT (45.5+/-26.0), p<0.01. The median survival time for GKRS and WBRT was 9.5 months and 8.3 months, respectively, p=0.72. The mean (+/- s.d.) QALY was 0.76+/-0.23 for GKRS and 0.59+/-0.18 for WBRT, respectively (p<0.05). The cost-effectiveness per unit of QALY was better for the GKRS treatment (US$10,381/QALY) than in the WBRT treatment (US$17,622/QALY), p<0.05. The cost-effectiveness per KPS score was also higher for the GKRS treatment (US$139/KPS score) than for WBRT (US$229/KPS score), p<0.01. Thus, the mortality rate for multiple metastatic brain tumors treated by GKRS is significantly better with a good initial KPS score and when the tumor number is 2-5. GKRS results in a better post-treatment KPS score, QALY, and higher cost-effectiveness than WBRT for treating multiple metastatic brain tumors.

Gamma knife radiosurgery for metastatic brain tumors from thyroid cancer

OBJECTIVE

We report our experience using gamma knife radiosurgery (GKR) for brain metastasis from thyroid cancer, which is extremely rare.

METHODS

Between 1995 and 2007, 9 patients with 26 metastatic brain tumor(s) from thyroid cancer underwent GKR. The mean patient age was 58 years (range: 10-78). Seven patients had metastases from papillary thyroid cancer, and two from medullary thyroid cancer. Five patients had solitary tumors, and four patients had multiple metastases. Three patients who had multiple metastases also underwent whole brain radiation therapy (WBRT). The mean tumor volume was 2.4 cc (range: 0.03-14.0). A median margin dose of 18.0 Gy (range: 12-20) was delivered to the tumor margin.

RESULTS

Tumor control was obtained in 25 out of 26 tumors (96%). The median progression-free period after GKR was 12 months (range: 4-53). The overall median survival after GKR was 33 months (range: 5-54). There were no procedure-related complications and six patients are still living 5-54 months after GKR.

CONCLUSIONS

Radiosurgery is an effective and minimally invasive strategy for management of brain metastases form thyroid cancer.

Can standard magnetic resonance imaging reliably distinguish recurrent tumor from radiation necrosis after radiosurgery for brain metastases? A radiographic-pathological study

OBJECTIVE

Stereotactic radiosurgery is a commonly used treatment method in the management of metastatic brain tumors. When lesions enlarge after radiosurgery, it may represent tumor regrowth, radiation necrosis, or both. The purpose of this study was to determine whether standard magnetic resonance imaging (MRI) sequences could reliably distinguish between these pathological possibilities.

METHODS

A total of 619 patients, reported in a previous study, were treated with radiosurgery for metastatic brain tumors. Of those patients, 59 underwent subsequent craniotomy for symptomatic lesion enlargement. Of those 59 patients, 32 had complete preoperative MRI studies as well as surgical pathology reports. The following MRI features were analyzed in this subset of patients: arteriovenous shunting, gyriform lesion or edema distribution, perilesional edema, cyst formation, and pattern of enhancement. A novel radiographic feature, called the lesion quotient, which is the ratio of the nodule as seen on T2 imaging to the total enhancing area on T1 imaging, was also analyzed.

RESULTS

Sensitivity, specificity, and predictive values were computed for each radiographic characteristic. Lesions containing only radiation necrosis never displayed gyriform lesion/edema distribution, marginal enhancement, or solid enhancement. All lesions exhibited perilesional edema. A lesion quotient of 0.6 or greater was seen in all cases of recurrent tumor, a lesion quotient greater than 0.3 was seen in 19 of 20 cases of combination pathology, and a lesion quotient of 0.3 or less was seen in 4 of 5 cases of radiation necrosis. The lesion quotient correlated with the percentage of tumor identified on pathological specimens.

CONCLUSION

The lesion quotient appears to reliably identify pure radiation necrosis on standard sequence MRI. Other examined radiographic features, including arteriovenous shunting, gyriform lesion/edema distribution, enhancement pattern, and cyst formation, achieved 80% or greater predictive value but had either low sensitivity or low specificity.

Risk of cerebral metastases and neurological death after pathological complete response to neoadjuvant therapy for locally advanced nonsmall-cell lung cancer: clinical implications for the subsequent management of the brain

BACKGROUND

The incidence and pattern of brain metastases was analyzed among patients who achieved a pathological complete response (pCR) after neoadjuvant chemotherapy or chemoradiotherapy for locally advanced nonsmall-cell lung cancer (NSCLC).

METHODS

Between 1990 and 2004, 211 patients were treated with neoadjuvant therapy before surgical resection for stage III NSCLC. The clinical course of 51 patients who demonstrated a pCR were reviewed. The neoadjuvant regimen consisted of either chemotherapy (29 patients) or chemoradiotherapy (22 patients). Histology was 45% adenocarcinoma, 41% squamous cell, and 14% large cell carcinoma. No patient received prophylactic cranial irradiation (PCI).

RESULTS

Overall survival at 1, 3, and 5 years was 82%, 63%, and 42%, respectively. The most common site of initial recurrence was the brain. Twenty-two (43%) patients developed brain metastasis as the site of first failure, which represented 71% of all isolated recurrences. Ultimately, 28 (55%) patients developed brain metastases at some point during their clinical course. The 5-year estimates of brain metastasis-free survival for patients with squamous and nonsquamous cancers were 57% and 34%, respectively (P = .02). Median survival from the time of brain metastasis was 10 and 5 months for those with isolated and nonisolated recurrences, respectively.

CONCLUSION

Patients with a pCR after multimodality therapy for locally advanced NSCLC are at excessively high risk for the subsequent development of brain metastases. Implications for management strategies including PCI and stereotactic radiosurgery (SRS) are discussed.