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

Multiplicity does not significantly affect outcomes in brain metastasis patients treated with surgery

Background

Brain metastasis quantity may be a negative prognostic factor for patients requiring resection of at least one lesion.

Methods

We retrospectively reviewed patients who underwent surgical resection of brain metastases from July 2018 to June 2019 at our institution, and examined outcomes including overall survival (OS), progression free survival (PFS) and rates of local failure (LF). Patients were grouped according to the number of metastases at the time of surgery (single vs multiple).

Results

We identified 130 patients who underwent surgical resection as the initial treatment modality. At the time of surgery, 87 patients had only one lesion (control) and 43 had multiple (>1). Two-year OS for the entire cohort was 46%, with equal rates in both the multiple metastases group and the control group (p=0.335). 2-year PFS was 27%; 21% in the multiple metastases group and 31% in the control group (p=0.766). The rate of LF at 2-years was 32%, with equal rates in both the multiple lesion group and control group (p=0.889). On univariate analysis, multiplicity was not significantly correlated to OS (HR=0.80, 95% CI: 0.51-1.26, p=0.336), PFS (HR=1.06, 95% CI: 0.71-1.59, p=0.766) or LF (HR=1.06, 95% CI: 0.57-1.97, p=0.840). Multivariate analysis revealed preoperative tumor volume of the resected lesion to be the single correlate for OS (p=0.0032) and PFS (p=0.0081).

Conclusions

Having more than one metastasis does not negatively impact outcomes in patients treated with surgery. In carefully selected patients, especially those with large tumors, surgery should be considered regardless of the total number of lesions.

Cerebral metastasis in recurrent squamous cell carcinoma of the vulva: case report and review of the literature

BACKGROUND

Distant metastases from squamous cell cancer of the vulva (VSCC) are encountered rarely and are associated with a poor prognosis. Cerebral metastases have only been described anecdotally.

CASE HISTORY

A 51-year old woman was diagnosed with hepatic metastases due to VSCC. Initial therapy comprised wide local excision of the primary tumor with inguino-femoral lymphadenectomy (LAE) followed by stereotactic radiation of the singular hepatic metastasis while adjuvant chemoradiation of the vulva and lymphatics was declined. 3 years later, she subsequently developed lung and cerebral metastases.

CONCLUSION

The course of metastatic disease in VSCC is poorly understood. Further knowledge of the metastatic patterns in vulvar cancer is required for guidance of future therapeutic interventions.

Results of Whole Brain Radiation Therapy in Patients with Brain Metastases from Colorectal Carcinoma

Aims and background

Carcinoma of the colon-rectum is an infrequent cause of brain metastases, constituting 1-5% of all metastatic lesions to the brain. We reviewed our experience in the treatment of brain metastases from colorectal cancer to define the efficacy of whole brain radiation therapy as a palliative measure in this setting of patients.

Methods

Twenty-three consecutive cases of brain metastasis from colorectal cancer treated between 1999 and 2004 were identified in the files of the Division of Radiotherapy of the A Businco Regional Oncological Hospital, Cagliari. Their records were reviewed for patient and tumor characteristics and categorized according to the RTOG RPA classes.

Results

Fifteen patients (65%) had multiple metastases. Twenty-one patients (91%) showed extracranial metastases. Fourteen patients were classified as RTOG RPA class II and 9 class III. The median radiation dose delivered was 2000 cGy in 5 fractions in one week (range, 20-36 Gy). In 14 of 20 assessable patients (70%), symptomatic improvement was observed. The median follow-up and survival time for all the patients, 12 females and 11 males, was 3 months. In 3 patients only the cause of death was the brain metastasis.

Conclusions

Despite the disappointing survival time, external radiation therapy to the whole brain proved to be an efficacious palliative treatment for patients with multiple or inoperable brain metastasis from colorectal cancer.

Medullary metastasis of a malignant peripheral nerve sheath tumor: A case report

The present study reports a case of medullary metastasis without lung metastasis that occurred as a result of a malignant peripheral nerve sheath tumor (MPNST). An 81-year-old woman presented with a MPNST in the left brachial plexus, arising from the cervical nerve root. The patient underwent carbon ion radiotherapy; however, tumor recurrence was identified in the left shoulder. Subsequently, the patient underwent wide excision. Three weeks subsequent to surgery, imbalance and dysarthria developed suddenly. Dysphagia emerged and left upper limb pain disappeared on the day after symptom development. Magnetic resonance imaging (MRI) revealed that this was due to metastasis to the medulla. Five days subsequent to the onset of dysarthria, the patient succumbed due to respiratory failure. To the best of our knowledge, no previous cases of medullary metastasis arising from a MPNST in the absence of lung metastasis have been reported. MRI is a useful examination tool for the identification of brain metastases; however, the high cost of MRI as a routine examination must be considered due to the rarity of brain metastases. Therefore, methods to detect brain metastasis warrant further investigation.

Contemporary Review of the Management of Brain Metastasis with Radiation

Brain metastases are an important cause of morbidity and mortality, afflicting approximately 200,000 Americans annually. The prognosis for these patients is poor, with median survivals typically measured in months. In this review article, we present the standard treatment approaches with whole brain radiation and as well as novel approaches in the prevention of neurocognitive deficits.

Special treatment issues in non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

This guideline updates the second edition and addresses patients with particular forms of non-small cell lung cancer that require special considerations, including Pancoast tumors, T4 N0,1 M0 tumors, additional nodules in the same lobe (T3), ipsilateral different lobe (T4) or contralateral lung (M1a), synchronous and metachronous second primary lung cancers, solitary brain and adrenal metastases, and chest wall involvement.

METHODS

The nature of these special clinical cases is such that in most cases, meta-analyses or large prospective studies of patients are not available. To ensure that these guidelines were supported by the most current data available, publications appropriate to the topics covered in this article were obtained by performing a literature search of the MEDLINE computerized database. Where possible, we also reference other consensus opinion statements. Recommendations were developed by the writing committee, graded by a standardized method, and reviewed by all members of the Lung Cancer Guidelines panel prior to approval by the Thoracic Oncology NetWork, Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians.

RESULTS

In patients with a Pancoast tumor, a multimodality approach appears to be optimal, involving chemoradiotherapy and surgical resection, provided that appropriate staging has been carried out. Carefully selected patients with central T4 tumors that do not have mediastinal node involvement are uncommon, but surgical resection appears to be beneficial as part of their treatment rather than definitive chemoradiotherapy alone. Patients with lung cancer and an additional malignant nodule are difficult to categorize, and the current stage classification rules are ambiguous. Such patients should be evaluated by an experienced multidisciplinary team to determine whether the additional lesion represents a second primary lung cancer or an additional tumor nodule corresponding to the dominant cancer. Highly selected patients with a solitary focus of metastatic disease in the brain or adrenal gland appear to benefit from resection or stereotactic radiosurgery. This is particularly true in patients with a long disease-free interval. Finally, in patients with chest wall involvement, provided that the tumor can be completely resected and N2 nodal disease is absent, primary surgical resection should be considered.

CONCLUSIONS

Carefully selected patients with more uncommon presentations of lung cancer may benefit from an aggressive surgical approach.

Adjuvant whole brain radiation following resection of brain metastases

Brain metastasis is a common complication of systemic cancer and significant cause of suffering in oncology patients. Despite a plethora of available treatment modalities, the prognosis is poor with a median survival time of approximately one year. For patients with controlled systemic disease, good performance status, and a limited number of metastases, treatment typically entails surgical resection or radiosurgery, followed by whole brain radiotherapy (WBRT) to control microscopic disease. WBRT is known to control the progression of cancer in the brain, but it can also have toxic effects, particularly with regard to neurocognition. There is no consensus as to whether the benefit of WBRT outweighs the potential harm. We review the evidence related to the question of whether patients undergoing surgical resection of brain metastases should receive adjuvant WBRT.

Safety and immunogenicity of vaccination with MART-1 (26-35, 27L), gp100 (209-217, 210M), and tyrosinase (368-376, 370D) in adjuvant with PF-3512676 and GM-CSF in metastatic melanoma

The effectivenes of cancer vaccines in inducing CD8(+) T-cell responses remains a challenge, resulting in a need for testing more potent adjuvants. Our objective was to determine the safety and immunogenicity of vaccination against melanoma-related antigens employing MART-1, gp100, and tysosinase paptides combined with the TLR9 agonist PF-3512676 and local granulocyte macrophage-colony stimulating factor in oil emulsion. Using continuous monitoring of safety and a 2-stage design for immunologic efficacy, 20 immune response evaluable patients were targetted. Vaccinations were given subcutaneously on days 1 and 15 per cycle (1cycle=28 d) for up to 13 cycles. Interferon-γ enzyme-linked immunosorbent spot was used as the primary assay measuring the frequency of peripheral antigen-specific CD8(+) T cells at days 50 and 90 compared with baseline (target ≥ 9/20 immunologic responses). Clinical responses were measured by Response Evaluation Criteria In Solid Tumors every 8 weeks. Twenty-two (including 20 immune response evaluable) melanoma patients were enrolled. All had American Joint Committe on Cancer stage IV (5M1a, 6M1b, 11M1c) and most had previously received therapy. Eight had previously treated brain metastases. An average of 3.5 cycles of vaccination per patient was administered. Clinical response data were available for 21 patients. There were 2 partial response and 8 stable disease lasting 2-7 months. One patient with ongoing partial response continued on treatment. At a median follow-up of 7.39 months (range, 3.22-20.47 mo), median progression-free survival was 1.9 months (90% confidence interval, 1.84-3.68) and median overall survival was 13.4 months (90% confidence interval,11.3-∞). No regimen-related grade 3/4/5 toxicities were observed. There were 9/20 patients with positive enzyme-linked immunosorbent spot at day 50 and/or day 90. Our adjuvant regimen combining PF-3512676 and granulocyte macrophage-colony stimulating factor was safe and is worthy of further testing with these or alternative peptides, potentially in combination with antibodies that target immunoregulatory checkpoints.

Neurocognitive function impairment after whole brain radiotherapy for brain metastases: actual assessment

Whole brain radiation therapy (WBRT) is an effective treatment in brain metastases and, when combined with local treatments such as surgery and stereotactic radiosurgery, gives the best brain control. Nonetheless, WBRT is often omitted after local treatment due to its potential late neurocognitive effects. Publications on radiation-induced neurotoxicity have used different assessment methods, time to assessment, and definition of impairment, thus making it difficult to accurately assess the rate and magnitude of the neurocognitive decline that can be expected. In this context, and to help therapeutic decision making, we have conducted this literature review, with the aim of providing an average incidence, magnitude and time to occurrence of radio-induced neurocognitive decline. We reviewed all English language published articles on neurocognitive effects of WBRT for newly diagnosed brain metastases or with a preventive goal in adult patients, with any methodology (MMSE, battery of neurcognitive tests) with which baseline status was provided. We concluded that neurocognitive decline is predominant at 4 months, strongly dependant on brain metastases control, partially solved at later time, graded 1 on a SOMA-LENT scale (only 8% of grade 2 and more), insufficiently assessed in long-term survivors, thus justifying all efforts to reduce it through irradiation modulation.

Gamma knife radiosurgery for brainstem metastasis

OBJECTIVE

Brainstem metastases are rarely operable and generally unresponsive to conventional radiation therapy or chemotherapy. Recently, Gamma Knife Radiosurgery (GKRS) was used as feasible treatment option for brainstem metastasis. The present study evaluated our experience of brainstem metastasis which was treated with GKRS.

METHODS

Between November 1992 and June 2010, 32 patients (23 men and 9 women, mean age 56.1 years, range 39-73) were treated with GKRS for brainstem metastases. There were metastatic lesions in pons in 23, the midbrain in 6, and the medulla oblongata in 3 patients, respectively. The primary tumor site was lung in 21, breast in 3, kidney in 2 and other locations in 6 patients. The mean tumor volume was 1,517 mm(3) (range, 9-6,000), and the mean marginal dose was 15.9 Gy (range, 6-23). Magnetic Resonance Imaging (MRI) was obtained every 2-3 months following GKRS. Follow-up MRI was possible in 24 patients at a mean follow-up duration of 12.0 months (range, 1-45). Kaplan-Meier survival analysis was used to evaluate the prognostic factors.

RESULTS

Follow-up MRI showed tumor disappearance in 6, tumor shrinkage in 14, no change in tumor size in 1, and tumor growth in 3 patients, which translated into a local tumor control rate of 87.5% (21 of 24 tumors). The mean progression free survival was 12.2 months (range, 2-45) after GKRS. Nine patients were alive at the completion of the study, and the overall mean survival time after GKRS was 7.7 months (range, 1-22). One patient with metastatic melanoma experienced intratumoral hemorrhage during the follow-up period. Survival was found to be associated with score of more than 70 on Karnofsky performance status and low recursive partitioning analysis class (class 1 or 2), in terms of favorable prognostic factors.

CONCLUSION

GKRS was found to be safe and effective for management of brainstem metastasis. The integral clinical status of patient seems to be important in determining the overall survival time.

Adjuvant whole-brain radiotherapy versus observation after radiosurgery or surgical resection of one to three cerebral metastases: results of the EORTC 22952-26001 study

PURPOSE

This European Organisation for Research and Treatment of Cancer phase III trial assesses whether adjuvant whole-brain radiotherapy (WBRT) increases the duration of functional independence after surgery or radiosurgery of brain metastases.

PATIENTS AND METHODS

Patients with one to three brain metastases of solid tumors (small-cell lung cancer excluded) with stable systemic disease or asymptomatic primary tumors and WHO performance status (PS) of 0 to 2 were treated with complete surgery or radiosurgery and randomly assigned to adjuvant WBRT (30 Gy in 10 fractions) or observation (OBS). The primary end point was time to WHO PS deterioration to more than 2.

RESULTS

Of 359 patients, 199 underwent radiosurgery, and 160 underwent surgery. In the radiosurgery group, 100 patients were allocated to OBS, and 99 were allocated to WBRT. After surgery, 79 patients were allocated to OBS, and 81 were allocated to adjuvant WBRT. The median time to WHO PS more than 2 was 10.0 months (95% CI, 8.1 to 11.7 months) after OBS and 9.5 months (95% CI, 7.8 to 11.9 months) after WBRT (P = .71). Overall survival was similar in the WBRT and OBS arms (median, 10.9 v 10.7 months, respectively; P = .89). WBRT reduced the 2-year relapse rate both at initial sites (surgery: 59% to 27%, P < .001; radiosurgery: 31% to 19%, P = .040) and at new sites (surgery: 42% to 23%, P = .008; radiosurgery: 48% to 33%, P = .023). Salvage therapies were used more frequently after OBS than after WBRT. Intracranial progression caused death in 78 (44%) of 179 patients in the OBS arm and in 50 (28%) of 180 patients in the WBRT arm.

CONCLUSION

After radiosurgery or surgery of a limited number of brain metastases, adjuvant WBRT reduces intracranial relapses and neurologic deaths but fails to improve the duration of functional independence and overall survival.

Focal radiation therapy of brain metastases after complete surgical resection

Brain metastases are a frequent occurrence in cancer patients and result in significant morbidity and mortality. The three main treatments for brain metastases include surgery, radiation, and/or chemotherapy, alone or in combination. After resection alone, local recurrence rates are high. Whole brain radiation therapy can decrease the probability of recurrence; however, this has some disadvantages. Focal radiation therapy (FRT) may provide many of the same benefits without some of these disadvantages. In this study, we retrospectively analyzed patients with single brain metastases treated with FRT after surgery. Doses ranged from 14 Gy as single dose stereotactic radiosurgery (SRS) to 54 Gy in 27 2-Gy fractions as conformal fractionated radiotherapy. Four of the seven patients had a same-site recurrence, with an average time to recurrence of 115.5 d. Median dose in the patients that had same-site recurrence was 42 Gy. One of these patients is currently living. Two patients did not have recurrence, and one patient had a recurrence at a different site within the brain. The low rate of out-of-field recurrences during the patients life indicates focal radiation may be a reasonable therapeutic alternative. Given the number of patients with same-site recurrences, wide field margins around the tumor volume or higher radiation doses than those typically used in palliative regimens may be useful in post-excisional FRT. Additionally, we found that a longer delay in the initiation of FRT after initial diagnosis may result in a decreased time to same-site recurrence. However, further studies are warranted given the small number of patients in this study.

Presentation and outcome in cancer patients with extensive spread to the brain

BACKGROUND

Controversy exists around the preferred management of patients with brain metastases and limited survival expectation, e.g. because of extensive brain involvement. Few studies have focused on this particular group of patients.

FINDINGS

A group of 24 patients with a large number of brain metastases, defined as 10 or more on computed tomography scans, who were managed with palliative whole-brain radiotherapy (WBRT), typically 30 Gy in 10 fractions, were analyzed. The median number of lesions was 14. The patient characteristics were comparable to those of studies in the general population with brain metastases, except for the fact that all patients had active sites of extracranial disease. Clinical benefit, imaging response and overall survival were lower than expected. Median survival, for example was 2 months. Trends towards better survival were found in patients with brain metastases detected at first cancer diagnosis (synchronous manifestation, treatment naïve) and those with better prognostic features according to the graded prognostic assessment (GPA) score.

CONCLUSIONS

The benefit of WBRT did not meet the expectations, suggesting that consideration should be given to best supportive care including corticosteroid administration, especially if a patient belongs to the lowest GPA class.

Factors affecting the outcome after treatment for metastatic melanoma to the brain

BACKGROUND

Because of the difficulties inherent to the treatment of metastatic melanoma to the brain including high rates of disease progression and local treatment failure, we attempted to determine the prognostic factors that impacted the outcome of these patients, and reviewed patient outcome based on primary treatment with either surgical resection or SRS.

METHODS

A retrospective review identified 37 patients treated for metastatic melanoma between July 2002 and April 2007. Information was obtained documenting systemic disease, preoperative symptoms, tumor size and location, disease recurrence, primary and secondary treatments, and survival time.

RESULTS

Two patients were alive as of March 2008. The median survival time for patients primarily treated with surgical resection was 9.7 months compared to 7.9 months for patients initially treated with SRS. Solitary brain metastases and the absence of both preoperative hemorrhage and lung metastases served as prognostic factors increasing survival in both groups. Four patients undergoing primary treatment with SRS required subsequent surgical intervention secondary to radiation necrosis (3 patients) or local recurrence (1 patient). All 4 had lesions greater than 1.5 cm. For surgical patients, planned postoperative treatment with either radiosurgery or radiation therapy increased survival time to 12.3 months vs 7.3 months.

CONCLUSIONS

Patients with positive prognostic factors including solitary brain lesions, absence of hemorrhage preoperatively, and absence of lung disease are viable candidates for aggressive, surgical intervention followed by adjuvant therapy with radiosurgery or conventional radiation therapy. Other patients should be considered for more conservative treatment with radiosurgery or other palliative treatments.

Microsurgery plus whole brain irradiation versus Gamma Knife surgery alone for treatment of single metastases to the brain: a randomized controlled multicentre phase III trial

BACKGROUND

Is Gamma Knife surgery alone as effective as surgery plus whole brain irradiation (WBRT) for patients with a single, small-sized brain metastasis?

METHODS

Patients aged between 18 and 80 years harboring a single, resectable metastasis < or =3 cm in diameter, a Karnofsky performance score (KPS) > or =70, and a stable systemic disease were randomly assigned to microsurgery plus WBRT or Gamma Knife surgery alone. The primary end point was length of survival, secondary end points were recurrence of tumor in the brain, health related quality of life, and treatment related toxicity.

RESULTS

Due to poor patient accrual, the study was stopped prematurely. The final analysis was based on 33 patients in the surgery and 31 patients in the radiosurgery group. Treatment results did not differ in terms of survival (P = 0.8), neurological death rates (P = 0.3), and freedom from local recurrence (P = 0.06). Patients of the radiosurgery group experienced more often distant recurrences (P = 0.04); after adjustment for the effects of salvage radiosurgery this difference was lost (P = 0.4). Radiosurgery was associated with a shorter hospital stay, less frequent and shorter timed steroid application (P < or = 0.001), and lower frequency of grade 1/2 toxicities (according to the RTOG/EORTC CNS toxicity criteria, P < or = 0.01). Improved scores for role functioning and quality of life were seen 6 weeks after radiosurgery (P < 0.05); this difference was lost 6 months after treatment.

CONCLUSIONS

In patients harboring a single, small-sized metastasis, Gamma Knife surgery alone is less invasive; local tumor control seems to be as high as after surgery plus WBRT. Distant tumor control, however, is significantly less frequently achieved (after radiosurgery alone). The role of radiosurgical salvage therapy (alternatively to WBRT) for distant tumor control deserves further prospective evaluation.

Special Treatment Issues in Lung Cancer

BACKGROUND

This chapter of the guidelines addresses patients who have particular forms of non-small cell lung cancer that require special considerations. This includes patients with Pancoast tumors, T4N0,1M0 tumors, satellite nodules in the same lobe, synchronous and metachronous multiple primary lung cancers (MPLCs), solitary brain and adrenal metastases, and chest wall involvement.

METHODS

The nature of these special clinical cases is such that in most cases, metaanalyses or large prospective studies of patients are not available. For ensuring that these guidelines were supported by the most current data available, publications that were appropriate to the topics covered in this chapter were obtained by performance of a literature search of the MEDLINE computerized database. When possible, we also referenced other consensus opinion statements. Recommendations were developed by the writing committee, graded by a standardized method (see "Methodology for Lung Cancer Evidence Review and Guideline Development" chapter), and reviewed by all members of the lung cancer panel before approval by the Thoracic Oncology NetWork, Health and Science Policy Committee, and the Board of Regents of the American College of Chest Physicians.

RESULTS

In patients with a Pancoast tumor, a multimodality approach seems to be optimal, involving chemoradiotherapy and surgical resection, provided appropriate staging has been conducted. Patients with central T4 tumors that do not have mediastinal node involvement are uncommon. Such patients, however, seem to benefit from resection as part of the treatment as opposed to chemoradiotherapy alone when carefully staged and selected. Patients with a satellite lesion in the same lobe as the primary tumor have a good prognosis and require no modification of the approach to evaluation and treatment than what would be dictated by the primary tumor alone. However, it is difficult to know how best to treat patients with a focus of the same type of cancer in a different lobe. Although MPLCs do occur, the survival results after resection for either a synchronous presentation or a metachronous presentation with an interval of < 4 years between tumors are variable and generally poor, suggesting that many of these patients may have had a pulmonary metastasis rather than a second primary lung cancer. A thorough and careful evaluation of these patients is warranted to try to differentiate between patients with a metastasis and a second primary lung cancer, although criteria to distinguish them have not been defined. Selected patients with a solitary focus of metastatic disease in the brain or adrenal gland seem to benefit substantially from resection. This is particularly true in patients with a long disease-free interval. Finally, in patients with chest wall involvement, as long as tumors can be completely resected and there is absence of N2 nodal involvement, primary surgical treatment should be considered.

CONCLUSIONS

Carefully selected patients may benefit from an aggressive surgical approach.

The elderly with synchronous non-small cell lung cancer and solitary brain metastasis: does palliative thoracic radiotherapy have a useful role?

We evaluated the prognosis associated with advanced age by comparing the clinical features of individuals 65 years of age and older to those of younger patients with single metastasis to the brain alone (SMBA) and simultaneous non-small cell lung cancer (NSCLC), and the potential role of palliative thoracic radiotherapy in this cohort of patients. Our 23-year experience included 72 consecutive (22 elderly and 50 non-elderly) people. Older patients predominantly presented with N0-N1 stage disease and coexisting illness. Univariate analysis showed that younger age (p=0.04) and operative removal of SMBA (p=0.01) were predictive of better survival. However, with multivariate analysis, resection of SMBA remained the sole predictor of prognosis. The application of NSCLC radiotherapy for palliation did not favorably alter outcome. In conclusion, elderly patients with simultaneous NSCLC and SMBA seem to fare less well than their younger counterparts. Moreover, the concurrent application of radiotherapy for palliation of the lung neoplasm was not prognostically advantageous.

Targeted Therapy for Brain Metastases: Improving the Therapeutic Ratio

Brain metastasis is the most common intracranial malignancy in adults. Improvements in modern imaging techniques are detecting previously occult brain metastases, and more effective therapies are extending the survival of patients with invasive cancer who have historically died from extracranial disease before developing brain metastasis. This combination of factors along with increased life expectancy has led to the increased diagnosis of brain metastases. Conventional treatment has been whole brain radiotherapy, which can improve symptoms, but potentially results in neurocognitive deficits. Several strategies to improve the therapeutic ratio are currently under investigation to either enhance the radiation effect, thereby preventing tumor recurrence or progression as well as reducing collateral treatment-related brain injury. In this review article, we discuss new directions in the management of brain metastases, including the role of chemical modifiers, novel systemic agents, and the management and prevention of neurocognitive deficits.

Whole-brain radiotherapy in the management of brain metastasis

Brain metastases are an important cause of morbidity and mortality, afflicting nearly 170,000 Americans annually. The prognosis for these patients is poor, with median survival times measured in months. In this review article, we present the standard treatment approach of whole-brain radiotherapy and discuss new directions, including the role of chemical modifiers and the management and prevention of neurocognitive deficits.

Long-term survivors after gamma knife radiosurgery for brain metastases

BACKGROUND

Stereotactic radiosurgery, with or without whole-brain radiation therapy, has become a valued management choice for patients with brain metastases, although their median survival remains limited. In patients who receive successful extracranial cancer care, patients who have controlled intracranial disease are living longer. The authors evaluated all brain metastasis in patients who lived for > or = 4 years after radiosurgery to determine clinical and treatment patterns potentially responsible for their outcome.

METHODS

Six hundred seventy-seven patients with brain metastases underwent 781 radiosurgery procedures between 1988 and 2000. Data from the entire series were reviewed; and, if patients had > or = 4 years of survival, then they were evaluated for information on brain and extracranial treatment, symptoms, imaging responses, need for further care, and management morbidity. These long-term survivors were compared with a cohort who lived for < 3 months after radiosurgery (n = 100 patients).

RESULTS

Forty-four patients (6.5%) survived for > 4 years after radiosurgery (mean, 69 mos with 16 patients still alive). The mean age at radiosurgery was 53 years (maximum age, 72 yrs), and the median Karnofsky performance score (KPS) was 90. The lung (n = 15 patients), breast (n = 9 patients), kidney (n = 7 patients), and skin (melanoma; n = 6 patients) were the most frequent primary sites. Two or more organ sites outside the brain were involved in 18 patients (41%), the primary tumor plus lymph nodes were involved in 10 patients (23%), only the primary tumor was involved in 9 patients (20%), and only brain disease was involved in 7 patients (16%), indicating that extended survival was possible even in patients with multiorgan disease. Serial imaging of 133 tumors showed that 99 tumors were smaller (74%), 22 tumors were unchanged (17%), and 12 tumors were larger (9%). Four patients had a permanent neurologic deficit after brain tumor management, and six patients underwent a resection after radiosurgery. Compared with the patients who had limited survival (< 3 mos), long-term survivors had a higher initial KPS (P = 0.01), fewer brain metastases (P = 0.04), and less extracranial disease (P < 0.00005).

CONCLUSIONS

Although the expected survival of patients with brain metastases may be limited, selected patients with effective intracranial and extracranial care for malignant disease can have prolonged, good-quality survival. The extent of extracranial disease at the time of radiosurgery was predictive of outcome, but this does not necessarily mean that patients cannot live for years if treatment is effective.

Brainstem Metastases: Management Using Gamma Knife Radiosurgery

OBJECTIVE:

Brainstem metastasis is an uncommon complication of systemic cancer, generally considered to have a highly unfavorable prognosis. Surgical risks are high and standard radiation or chemotherapy have little effect. The purpose of this study is to evaluate our experience using Gamma Knife radiosurgery (GKRS) for the management of brainstem metastasis.

METHODS:

Between July 1992 and March 2001, we treated 28 patients with brainstem metastasis using GKRS. Lesions were located in the pons in 17 patients, midbrain in nine, and medulla oblongata in two. At time of the radiosurgery, eight patients presented with another supratentorial metastasis. The most frequent primary tumor site was the lung (13 cases) followed by the melanoma in four cases, the kidney in two, and other locations in six. Only six patients underwent fractionated whole-brain radiation therapy. Mean marginal radiation dose for GKRS was 19.6 Gy (range, 11–30). Mean maximum diameter was 17.2 mm (range, 10–30).

RESULTS:

No GKRS-related morbidity was observed. Local tumor control was achieved in 92% of patients. Twenty-six patients have died. Death was related to the progression of the brainstem lesion in two cases. Mean and median survival after GKRS were 10.2 and 12 months, respectively. Follow-up periods in the two surviving patients were 12 and 13 months.

CONCLUSION:

The results of this small series demonstrate that GKRS can be a valuable modality for safe and effective management of brain stem metastasis. Owing to the high risk of surgical resection and low efficacy of medical treatment, radiosurgery can be proposed upfront.

Role of Stereotactic Radiosurgery in the Treatment of Brain Metastases

Stereotactic radiosurgery (SRS) is a highly conformal form of radiation therapy designed to deliver a high dose in a single treatment to the target volume while sparing adjacent normal tissues. Its role in the treatment of brain metastases continues to be defined, but the recently reported RTOG 95-08 trial demonstrated a survival benefit with the addition of SRS to whole-brain radiation therapy in select patients with a single brain metastasis, as well as a local control and palliative benefit in select patients with 1 to 3 brain metastases. The authors review the role of SRS in the treatment of brain metastases and discuss the use of SRS with or without whole-brain radiation therapy, optimal dose of SRS, SRS delivery methods, and selection of appropriate patients for SRS.

Gamma knife surgery for brain metastases in patients harboring four or more lesions: survival and prognostic factors

Object. This study was performed to evaluate the role of gamma knife surgery (GKS) in patients with a large number (four or more) of metastatic brain lesions.

Methods. The authors retrospectively reviewed the outcome in 130 patients who underwent GKS for metastatic lesions. Eighty-four patients presented with one to three lesions (Group A) and 46 presented with four or more lesions (Group B). The overall median survival time after GKS was 35 weeks. The median survival time in Group A (48 weeks) was significantly longer (p = 0.005) than the survival time in Group B (26 weeks). The recursive partitioning analysis (RPA) class was the only significant prognostic factor identified in multivariate analysis. The median survival for patients in RPA Classes I, II, and III was 72, 48, and 19 weeks, respectively, in Group A and 36 and 13 weeks for Classes II and III in Group B. The number of lesions, tumor volume, whole brain radiotherapy, primary tumor site, age, and sex did not affect survival significantly.

Conclusions. It is suggested that GKS provides an increase in survival time even in patients with a large number (four or more) of metastatic lesions. Concerning the selection of patients for GKS, RPA class should be considered as the most important factor and multiplicity of the lesions alone should not be a reason for withholding GKS.

Analysis of long-term outcomes and prognostic factors in patients with non—small cell lung cancer brain metastases treated by gamma knife radiosurgery

Object.The authors conducted a study to evaluate the long-term outcomes and prognostic factors for survival in a large series of patients treated by gamma knife surgery (GKS) for non—small cell lung cancer (NSCLC) brain metastases.

Methods.The study is based on the retrospective analysis of clinical and radiological records obtained during a 10-year period (1993–2003), concerning 836 lesions in 504 patients. The lesions were primary in 86% and recurrent 14% of the cases; they were solitary in 31%, single in 29%, and multiple in 40%. The mean follow-up period was 16 months (range 4–113 months). The most common histological types were adenocarcinoma (51%) and squamous cell carcinoma (27%). Dose planning parameters were as follows: mean target volume 6.2 cm3(range 0.06–22.5 cm3); mean prescription dose 21.4 Gy (range 15.5–28 Gy); and mean number of isocenters 6.7 (range one–18). Progression-free and actuarial survival curves were calculated using the Kaplan—Meier method. The main factors affecting survival were determined by unimultivariate analysis (log-rank test and Cox proportional hazard models).

Analysis of long-term outcomes seemed to confirm that GKS is a primary therapeutic option in these patients. The 1-year local tumor control rate was 94%. The overall median survival was 14.5 months, with extremely rewarding quality of life indices. The recursive partitioning analysis classification was the dominant prognostic factor.

Conclusions.Gamma knife surgery is a useful treatment for brain metastases from NSCLC.

Gamma knife surgery for brain metastases in patients harboring four or more lesions: survival and prognostic factors

Object.This study was performed to evaluate the role of gamma knife surgery (GKS) in patients with a large number (four or more) of metastatic brain lesions.

Methods.The authors retrospectively reviewed the outcome in 130 patients who underwent GKS for metastatic lesions. Eighty-four patients presented with one to three lesions (Group A) and 46 presented with four or more lesions (Group B). The overall median survival time after GKS was 35 weeks. The median survival time in Group A (48 weeks) was significantly longer (p = 0.005) than the survival time in Group B (26 weeks). The recursive partitioning analysis (RPA) class was the only significant prognostic factor identified in multivariate analysis. The median survival for patients in RPA Classes I, II, and III was 72, 48, and 19 weeks, respectively, in Group A and 36 and 13 weeks for Classes II and III in Group B. The number of lesions, tumor volume, whole brain radiotherapy, primary tumor site, age, and sex did not affect survival significantly.

Conclusions.It is suggested that GKS provides an increase in survival time even in patients with a large number (four or more) of metastatic lesions. Concerning the selection of patients for GKS, RPA class should be considered as the most important factor and multiplicity of the lesions alone should not be a reason for withholding GKS.

Cognitive sequelae of brain radiation in adults

Radiotherapy (RT) is a proven curative and palliative therapeutic tool in the treatment of a wide variety of primary and metastatic brain tumors in adults. Recent advances in multimodality therapy have led to improvement in survival for many cancer patients. As survival has improved, more attention has been directed toward long-term treatment-related morbidity. Specifically, the effect of RT on the long-term cognitive performance of these patients is a major concern. This article reviews the neurocognitive effects of cranial RT on adult patients with brain tumors. Analyses of neurocognitive function are confounded by factors such as surgery, chemotherapy, tumor characteristics, tumor progression, concurrent medical illnesses, neurologic comorbidity, and medications that can contribute to neurocognitive deficits. Risk of deficits after cranial RT is associated with high RT dose, large fraction size, larger field size, and extremes of age at time of treatment. Using modern techniques with moderate total doses (50 to 54 Gy), conformal RT, conventional fractionation, and advanced planning imaging and software, the risks of neurocognitive deficits are quite small and greatly overshadowed by deficits caused by the tumor itself. Further studies need to be undertaken to elucidate the degree and cause of cognitive decline in adult patients undergoing multimodality therapy for cranial tumors.

Recursive Partitioning Analysis Classifications I and II

PURPOSE

Radiation Therapy Oncology Group (RTOG) recursive partitioning analysis (RPA) prognostic classes I and II for patients with brain metastases is derived from a database made up primarily of patients with unresected and multiple metastases. An analysis of a previously published randomized trial was performed to determine the applicability of these RPA prognostic classes in the setting of resection of single metastases to the brain.

PATIENTS AND METHODS

Ninety-five patients with single metastases to the brain that were treated with complete surgical resection entered this study. Patients were randomly assigned to treatment with postoperative whole brain radiotherapy (WBRT) (n = 49 patients) or no further brain treatment (n = 46 patients). All patients entered on this study had a Karnofsky performance status of > or =70. Therefore, although the RTOG RPA has 3 classes, only patients with RPA classes I (n = 26) or II (n = 69) were eligible for this study analysis.

RESULTS

For RPA class I, the median survival was 10.9 months versus 9.8 months for class II patients (P = 0.45). Multivariate analysis showed that only postoperative WBRT, independent of RPA class I or II, lessened the risk of brain tumor recurrence (P < 0.0001).

CONCLUSION

This analysis of a randomized trial evaluating postoperative WBRT in the treatment of single metastases to the brain showed no difference in survival between RPA class I or II patients. In addition, the use of postoperative WBRT after complete surgical resection of single brain metastases results in substantially better control of disease in the brain independent of RPA classes I or II.

Survival in relation to radiotherapeutic modality for brain metastasis: whole brain irradiation vs. gamma knife radiosurgery

The purpose of this report is to evaluate and compare the survival of patients with brain metastasis (BRM) treated by whole brain irradiation (WBI) using linear energy accelerator (LINAC) and by stereotactic radiosurgery using gamma knife. This study consists of a series of 67 patients with BRM treated with WBI between 1998 and 1999 and 53 patients with BRM treated with gamma knife radiosurgery (GKRS) between 2000 and 2001. A retrospective study of the data was performed and the overall survival between these 2 groups was analyzed. The comparability of these 2 groups was tested by chi2 and t test values. Log-rank test was used in the survival comparison. The 1-year survival rate was 26.3% and 22.6%, and corresponding mean survival was 7.8 months and 6.7 months for WBI and GKRS groups, respectively. There was no statistically significant difference between these 2 groups' survival. It was evident from imaging defined lesions that with GKRS the lesions were reduced, stabilized, or disappeared in 89% of cases. Survival of patients with BRM treated with WBI or GKRS was similar in these series. The present study suggests that good tumor response by GKRS does not translate in longer patient survival.

Radiosurgery for treatment of brain metastases: Estimation of patient eligibility using three stratification systems

PURPOSE

To compare three patient stratification systems predicting survival: recursive partitioning analysis (RPA), score index for radiosurgery in brain metastases (SIR), and a proposed basic score for brain metastases (BS-BM).

METHODS AND MATERIALS

We analyzed the outcome of 110 patients treated with Leksell Gamma Knife radiosurgery between December 1999 and January 2003. The BS-BM was calculated by evaluating three main prognostic factors: Karnofsky performance status, primary tumor control, and presence of extracranial metastases.

RESULTS

The median survival was 27.6 months for RPA Class I, 10.7 months for RPA Class II, and 2.8 months for RPA Class III (p <0.0001). Using the SIR, the median survival was 27.7, 10.8, 4.6, and 2.4 months for a score of 8-10, 5-7, 4, and 0-3, respectively (p <0.0001). The median survival was undefined in patients with a BS-BM of 3 (55% at 32 months) and was 13.1 months for a BS-BM of 2, 3.3 months for a BS-BM of 1, and 1.9 months for a BS-BM of 0 (p <0.0001). The backward elimination model in multivariate Cox analysis identified SIR and BS-BM as the only two variables significantly associated with survival (p = 0.031 and p = 0.043, respectively).

CONCLUSION

SIR and BS-BM were the most accurate for estimating survival. They were specific enough to identify patients with short survival (SIR 0-3 and BS-BM 0). Because of it simplicity, BS-BM is easier to use.

Management of brain metastases in patients with melanoma

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

The role of gamma knife radiosurgery in the treatment of primary and metastatic brain tumors

With the widespread diffusion of stereotactic radiosurgical procedures, GKR treatments have gained considerable momentum as a major therapeutic option for patients harboring primary or metastatic brain tumors. Present results in high grade gliomas indicate a potential palliative role of this technique. The overall low radiosensitivity of these oncotypes and their infiltrative nature-with the resulting problems in properly defining the tumor target-are still a major obstacle to further development of the approach. In this regard, useful contributions are expected from advances in molecular neurobiology and functional neuroimaging as shown by preliminary investigations with MR spectroscopy. Surgery maintains a dominant role in the therapeutic armamentarium for low grade gliomas. However, in unfavorable cases (unresectable tumors, recurrences), GKR seems to be an effective alternative to conventional radiochemotherapy. In grade 2 astrocytomas and specifically in grade 1 pilocytic forms, short-to-mid-term reported studies have documented encouraging 70 to 93% local tumor control rates, with minimal cerebral toxicity. Finally, during the last decade, GKR has become a primary treatment choice for patients harboring small-to-medium-size brain metastases, with reasonable life expectancy and no impending intracranial hypertension. Focal tumor responses are consistently elevated, even in the most radioresistant oncotypes (melanoma, renal carcinoma); median and actuarial survival rates are far better than with conventional radiation treatments and are comparable to those observed in accurately selected surgical-radiation series.

Waterjet resection of brain metastases - first clinical results with 10 patients

The waterjet technique enables precise tissue dissection without thermal damage and with preservation of vessels in general surgery. In neurosurgery, these qualities could help to avoid damage of intact brain parenchyma in tumour resections. The present study reports our first results with this technique in brain metastases. Ten patients with intracranial metastases underwent surgery with the aid of the waterjet. Resection was performed in combination with conventional neurosurgical methods. The follow-up consisted of neurological examination and MRI studies. Intraoperatively, the device was easy to handle. No complications due to the device were observed. Vessels were preserved at pressures below 20 bars. Six of the tumours consisted of soft tissue which was poorly demarcated from the surrounding brain. In these tumours, the waterjet was very helpful. It enabled tumour debulking by aspiration and - more important - precise separation of tumour and brain parenchyma. The remaining four cases were rather hard and well demarcated metastases. In these only separation of the tumour from the surrounding brain was achieved. In conclusion, the waterjet can be applied in surgery of brain metastases without complications. The device appears particularly suitable for soft, poorly demarcated metastases. Further clinical studies with this device are required.

A review of stereotactic radiosurgery in the management of brain metastases

This review addresses the epidemiology, historical reports, current issues, data and controversies involved in the management of brain metastases. The literature regarding surgery, whole brain radiation therapy, stereotactic radiosurgery or some combination of those treatments is discussed as well as issues of cost-effectiveness. Ongoing prospective randomized trials will further elucidate the optimal management for patients with brain metastases. Until those data are available, clinicians are encouraged to apply the existing data reviewed here in conjunction with best clinical judgment. A brief clinical guide is as follows. Patients with a solitary metastasis in an operable location and symptomatic mass effect should undergo surgery. Patients with poor performance status (KPS < 70) or more than three brain metastases should receive WBRT alone. Patients with 1-3 brain metastases and KPS >or= 70, should receive WBRT + SRS. If the patient refuses WBRT or needs salvage after WBRT, then SRS alone is appropriate. Clinicians should not be too dogmatic and should always apply the best clinical judgment.

Lung cancer. Special treatment issues

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

Dural cerebellopontine angle metastasis from malignant parotid oncocytoma

Malignant oncocytoma of the parotid gland is a quite rare tumor, with only 40 cases with unequivocal histological diagnosis reported in the literature. No cases with intracranial metastasis have been described. The authors report a very unusual case of malignant parotid gland oncocytoma with a large dural extracerebellar metastasis occurring in the contiguous cerebellopontine angle six months after surgery for the primary tumor. Only a partial removal of the dural metastasis was possible because of the cranial nerve and vessel encasement within the mass. Surgery and irradiation resulted in one-year survival. Interestingly, no destruction and infiltration of the petrous and temporal bones were found both at radiological and surgical exploration. We may suggest that metastatic spread from the parotid region to the cerebellopontine angle occurred through the mastoid cells or by haematogenous diffusion through the meningeal branches to the posterior fossa dura from the occipital or ascending pharyngeal arteries.

Properly selected patients with multiple brain metastases may benefit from aggressive treatment of their intracranial disease

To determine whether properly selected patients with multiple brain metastases benefit from aggressive treatment of their intracranial disease, we reviewed 52 patients having stereotactic radiosurgery (SRS), tumor resection, or both between April 1997 and March 2000. Tumor histology included lung (n = 18, 35%), breast (n = 11, 21%), renal (n = 6, 12%), melanoma (n = 6, 12%), and other (n = 11, 21%). The median patient age was 58 years, the median Karnofsky performance status (KPS) was 90, and the median number of tumors was three. Twenty patients (39%) had progressed after prior radiation therapy. Treatment included multiple craniotomies and tumor resection (n = 5, 10%), radiosurgery (n = 31, 60%), or resection and radiosurgery (n= 16, 30%). Median survival was 15.5 months. The one- and two-year actuarial survivals were 63% and 27%, respectively. Multivariate analysis found radiation therapy oncology group recursive partitioning analysis (RTOG RPA) Class (1 vs. 2/3) correlated with improved survival (Relative risk = 2.60, 95% CI 1.13-5.97, p = 0.03). Class 1 patients (KPS > or = 70, age < 65 years, and controlled primary with no extracranial metastases) survived a median of 19 months whereas Class 3 patients (KPS < 70) survived 8 months. Class 2 patients (all other patients) survived a median of 13 months. Thirty-five patients (67%) had intracranial progression at a median of 8.0 months. Intracranial progression was local (n = 6), distant (n = 23), or local and distant (n = 6); 26 patients with intracranial progression underwent additional brain tumor treatments. Multivariate analysis found patients with radiosensitive tumors (lung, breast, other) had fewer intracranial recurrences compared to patients with radio-resistant tumors (melanoma, renal, sarcoma) (Relative risk = 2.43, 95% CI 1.13-5.10, p = 0.02). The length of survival in our series is quite comparable to historical reports on the management of brain metastasis patients, and supports aggressive intervention for RTOG RPA Class 1 patients and Class 2 patients with controlled primary disease who have a limited number of brain metastases.

The treatment of brain metastases from malignant melanoma

Metastasis to the CNS develops in nearly half of patients with advanced melanoma; in 15% to 20% of these patients, the CNS is the first site of relapse. While systemic therapy for metastatic melanoma produces objective responses in 15% to 50% of patients, the available drugs do not penetrate well into the CNS, and these patients rarely benefit from systemic therapy. Although brain metastasis may be treated with surgery and/or stereotactic radiosurgery (SRS) when disease is limited to approximately one to three lesions, treatment for patients with large or multiple metastases is limited to whole brain irradiation (WBRT). While formal response and survival analyses of the impact of WBRT in melanoma have not been reported, the estimated median survival time for unselected patients with CNS metastases is only 2 to 4 months, with 1-year survival rates of less than 13%. In a selected population of patients with limited CNS involvement, surgical resection alone or in combination with WBRT appears to prolong median survival. More recently, SRS has been shown to be an effective local treatment for selected patients with brain metastases. In several retrospective reports of patients with melanoma CNS metastases, treatment with surgical resection alone or in combination with WBRT has been demonstrated to prolong median survival. More recently, SRS has been shown to be an effective local treatment for selected patients with brain metastases. In several retrospective reports, patients with CNS metastases from melanoma treated with a combination of WBRT plus SRS or SRS alone had median survivals and rates of control in the CNS superior to published reports for traditional WBRT. Most of these patients died from progressive extracranial disease with locally controlled CNS disease. Investigation of the contribution of newer systemic agents to the control of melanoma metastatic to the CNS has been based on the identification of drugs that have antitumor activity and the ability to cross the blood-brain barrier. Fotemustine is a nitrosourea that produced similar activity in CNS metastasis as in systemic disease, with a response rate of about 25%. Temozolomide (TMZ) is an oral alkylating agent that acts via the same mechanism as dacarbazine (DTIC), the most active single agent in melanoma. TMZ, which is highly active in brain tumors, has also been associated with activity in systemic and CNS metastases in melanoma patients, also in the 25% range. Efforts are underway to assess the additive benefit of TMZ and other drugs to WBRT or focused radiotherapy in this disease.

Stereotactic Radiosurgery for Patients with “Radioresistant” Brain Metastases

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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