Solitary brain metastases treated with the Leksell gamma knife: prognostic factors for patients

Association between Sarcopenia and Survival in Patients Undergoing Gamma Knife Surgery for Brain Metastasis from Breast Cancer: A Retrospective Single-centre Cohort Study

AIMS

Many recent studies related to cancer surgery have reported that sarcopenia influences mortality in surgical patients. However, few comprehensive studies have examined the associations between sarcopenia and short- and long-term surgical outcomes of metastatic cancer, especially breast cancer with brain metastasis. In the present study, we investigated the association between sarcopenia and mortality in patients who underwent gamma knife radiosurgery (GKRS) for brain metastasis with breast cancer.

MATERIALS AND METHODS

This retrospective study analysed 157 patients who underwent GKRS for brain metastasis with breast cancer between January 2014 and December 2018. A Cox regression analysis was carried out to evaluate the association between sarcopenia and mortality at 90 days, 180 days, 1 year, 3 years and the overall period.

RESULTS

In the Cox regression analysis, sarcopenia was significantly associated with high 90-day mortality (adjusted hazard ratio 3.46, 95% confidence interval 1.24-9.67, P = 0.018), 180-day mortality (adjusted hazard ratio 2.67, 95% confidence interval 1.37-5.22, P = 0.004), 1-year mortality (adjusted hazard ratio 2.39, 95% confidence interval 1.42-4.02, P = 0.001), 3-year mortality (adjusted hazard ratio 2.39, 95% confidence interval 1.53-3.74, P < 0.001) and overall mortality (adjusted hazard ratio 2.11, 95% confidence interval 1.37-3.26, P < 0.001).

CONCLUSION

Sarcopenia could be a risk factor for short- and long-term mortality in patients undergoing GKRS for brain metastasis from breast cancer.

Cystic Brain Metastasis Outcomes After Gamma Knife Radiation Therapy

Purpose

The response of cystic brain metastases (BMets) to radiation therapy is poorly understood, with conflicting results regarding local control, overall survival, and treatment-related toxicity. This study aims to examine the role of Gamma Knife (GK) in managing cystic BMets.

Methods and Materials

Volumetric analysis was conducted to measure tumor and edema volume at the time of GK and follow-up magnetic resonance imaging studies. Survival was described using the Kaplan-Meier method, and the cumulative incidence of progression was described using the Aalen-Johansen estimator. We evaluated the association of 4 variables with survival using Cox regression analysis.

Results

Between 2016 and 2021, 54 patients with 83 cystic BMets were treated with GK at our institution. Lung cancer was the most common pathology (51.9%), followed by breast cancer (13.0%). The mean target volume was 2.7 cm3 (range, 0.1-39.0 cm3), and the mean edema volume was 13.9 cm3 (range, 0-165.5 cm3). The median prescription dose of single-fraction and fractionated GK was 20 Gy (range, 14-27.5 Gy). With a median follow-up of 8.9 months, the median survival time (MST) was 11.1 months, and the 1-year local control rate was 75.9%. Gamma Knife was associated with decreased tumor and edema volumes over time, although 68.5% of patients required steroids after GK. Patients whose tumors grew beyond baseline after GK received significantly more whole-brain radiation therapy (WBRT) before GK than those whose tumors declined after GK. Higher age at diagnosis of BMets and pre-GK systemic therapy were associated with worse survival, with an MST of 7.8 months in patients who received it compared with 23.3 months in those who did not.

Conclusions

Pre-GK WBRT may select for BMets with increased radioresistance. This study highlights the ability of GK to control cystic BMets with the cost of high posttreatment steroid use.

Frameless Fractionated Gamma Knife Radiosurgery with ICON™ for Large Metastatic Brain Tumors

BACKGROUND

Recently, a new generation of gamma knife radiosurgery (GKRS) equipped with a frameless immobilization system has encouraged the use of fractionated GKRS as an increasingly favorable treatment option. We investigated the preliminary outcome of efficacy and toxicity associated with frameless fractionated gamma knife radiosurgery (FF GKRS) for the treatment of large metastatic brain tumors.

METHODS

Fifteen patients with 17 lesions were treated using FF GKRS and included in this study, because of the large tumor size of more than 10 cm³. FF GKRS was performed based on a thermoplastic mask system for 3 to 5 consecutive days.

RESULTS

The mean duration of clinical follow-up was 12 months (range, 4-24), and the local control rate was 100%. Tumor volume decreased in 13 lesions (76.5%), and remained stable in 4 lesions (23.5%). One patient was classified as new lesion development because of the occurrence of leptomeningeal seeding regardless of the tumor volume change. Compared with the initial volume at the time of FF GKRS, tumor volume change at the last follow-up was 62.32% ± 29.80%. Cumulative survival rate at 12 months was 93.3% ± 6.4%. One patient died during the follow-up period because of the progression of the primary disease. No patient showed radiation necrosis on the follow-up images.

CONCLUSION

Daily FF GKRS by gamma knife ICON™ revealed satisfactory tumor control rate and low morbidity, despite the short follow-up period. Further prospective studies and a longer follow-up of a large cohort of patients diagnosed with brain metastases are required to elucidate the effect of FF GKRS in brain metastases.

Brain metastases from colorectal cancer: characteristics and management

BACKGROUND

Brain metastases (BMs) are the most common intracranial neoplasms in adults, but they rarely arise from colorectal cancer (CRC). The objective of this study was to report an overview of the characteristics and current management of CRC BMs.

METHODS

A systematic review on CRC BMs was performed using Medline database from 1983 to 2015. The search was limited to studies published in English. Review articles, not relevant case report or studies or studies relating to animal and in vitro experiments were excluded.

RESULTS

BMs occurred in 0.06-4% of patients with CRC. Most BMs were metachronous and were associated with lung (27-92%) and liver (12-80%) metastases. Treatment options depended on the number of BMs, the general conditions of the patient and the presence of other metastases. Most frequent treatment was whole-brain radiotherapy (WBRT) alone (36%), with median overall survival comprised between 2 and 9 months. Median overall survival was better after surgery alone (from 3 to 16.2 months), or combined with WBRT (from 7.6 to 14 months). After stereotactic radiosurgery alone, overall survival could reach 9.5 months. Many favourable prognostic factors were identified, such as high Karnofsky performance status, low recursive partitioning analysis classes, lack of extracranial disease, low number of BMs and possibility to perform surgical treatment.

CONCLUSION

BMs from CRC are rare. In the presence of favourable prognostic factors, an aggressive management including surgical resection with or without WBRT or stereotactic radiosurgery can improve the overall survival.

Clinical Outcomes of Gamma Knife Radiosurgery for Metastatic Brain Tumors from Gynecologic Cancer : Prognostic Factors in Local Treatment Failure and Survival

Objective

Brain metastases in gynecologic cancer (ovarian, endometrial, and cervical cancer) patients are rare, and the efficacy of Gamma Knife Radiosurgery (GKRS) to treat these had not been evaluated. We assessed the efficacy of GKRS and prognostic factors for tumor control and survival in brain metastasis from gynecologic cancers.

Methods

This retrospective study was approved by the institutional review board. From May 1995 to October 2012, 26 women (mean age 51.3 years, range 27–70 years) with metastatic brain tumors from gynecologic cancer were treated with GKRS. We reviewed their outcomes, radiological responses, and clinical status.

Results

In total 24 patients (59 lesions) were available for follow-up imaging. The median follow-up time was 9 months. The mean treated tumor volume at the time of GKRS was 8185 mm³ (range 10–19500 mm³), and the median dose delivered to the tumor margin was 25 Gy (range, 10–30 Gy). A local tumor control rate was 89.8% (53 of 59 tumors). The median overall survival was 9.5 months after GKRS (range, 1–102 months). Age-associated multivariate analysis indicated that the Karnofsky performance status (KPS), the recursive partitioning analysis (RPA) classification, and the number of treated lesions were significant prognostic factors for overall survival (HR=0.162, p=0.008, HR=0.107, p=0.038, and HR=2.897, p=0.045, respectively).

Conclusion

GKRS is safe and effective for the management of brain metastasis from gynecologic cancers. The clinical status of the patient is important in determining the overall survival time.

Systematic review: brain metastases from colorectal cancer--Incidence and patient characteristics

Background

Brain metastases (BM) from colorectal cancer (CRC) are a rare event. However, the implications for affected patients are severe, and the incidence has been reported to be increasing. For clinicians, knowledge about the characteristics associated with BM is important and could lead to earlier diagnosis and improved survival.

Method

In this paper, we describe the incidence as well as characteristics associated with BM based on a systematic review of the current literature, following the PRISMA guidelines.

Results

We show that the incidence of BM in CRC patients ranges from 0.6 to 3.2 %. BM are a late stage phenomenon, and young age, rectal primary and lung metastases are associated with increased risk of developing BM. Molecular markers such as KRAS, BRAF, NRAS mutation as well as an increase in CEA and CA19.9 levels are suggested predictors of brain involvement. However, only KRAS mutations are reasonably well investigated and associated with an increased risk of BM.

Conclusion

The incidence of BM from CRC is 0.6 to 3.2 % and did not seem to increase over time. Development of BM is associated with young age, lung metastases, rectal primary and KRAS mutation. Increased awareness of brain involvement in patients with these characteristics is necessary.

Five-fraction stereotactic radiosurgery (SRS) for single inoperable high-risk non-small cell lung cancer (NSCLC) brain metastases

BACKGROUND

Achieving durable local control while limiting normal tissue toxicity with definitive radiation therapy in the management of high-risk brain metastases remains a radiobiological challenge. The objective of this study was to examine the local control and toxicity of a 5-fraction stereotactic radiosurgical approach for treatment of patients with inoperable single high-risk NSCLC brain metastases.

METHODS

This retrospective analysis examines 20 patients who were deemed to have "high-risk" brain metastases. High-risk tumors were defined as those with a maximum diameter greater than 2 cm and/or those located within an eloquent cortex. Patients were evaluated by a neurosurgeon prior to treatment and determined to be inoperable due to tumor or patient characteristics. Patients were treated using the CyberKnife® SRS system in 5 fractions to a total dose of 30 Gy, 35 Gy, or 40 Gy.

RESULTS

Twenty patients with a median age of 65.5 years were treated from April 2010 to August 2014 in 5 fractions to a median total dose of 35 Gy. At a median follow up of 11.3 months local tumor control was observed in 18 of 20 metastases (90 %). Both local failures were observed in patients receiving a lower dose of 30 Gy. Median pre-treatment dexamethasone dose was 10 mg/day and median post-treatment nadir dose was 0 mg/day. Salvage intracranial therapy was required in 45 % of patients. Symptomatic radionecrosis was observed in 4 of 20 patients (20 %), two of which were treated to 40 Gy and the remainder to 35 Gy. Kaplan-Meier 1-year, 2-year, and median survival were calculated to be 45 %, 20 %, and 13.2 months, respectively.

CONCLUSIONS

Five-fraction SRS to a total dose of 35 Gy appears to be a safe and effective management strategy for single high-risk NSCLC brain metastases, while a total dose of 40 Gy leads to an excess risk of neurotoxicity.

Brain metastases of breast cancer

Brain metastases of breast cancer remain a difficult problem for clinical management. Their incidence appears to be increasing, which is likely due to longer survival times for advanced breast cancer patients as well as additional and improved tools for detection. Molecular features of tumors associated with this syndrome are not yet understood. In general, survival may be improving for brain metastases due to better local control in the CNS, as well as improvements in systemic disease management. Selected patients with brain metastases are able to undergo surgical resection, which has been associated with extended disease control in some patients. However, whole-brain radiation has been the mainstay for treatment for most patients. Stereotactic radiosurgery is playing an increasing role in the primary treatment of brain metastases, as well as for salvage after whole-brain radiation. Recent series have reported median survivals of 13 months or longer with stereotactic radiosurgery. Further improvements in radiation-based approaches may come from ongoing studies of radiosensitizing agents. The ability of systemic treatments to impact brain metastases has been debated, and specific treatment regimens have yet to be defined. New approaches include chemotherapy combinations, biologic therapies and novel drug-delivery strategies.

Safety and efficacy of outpatient gamma knife radiosurgery for multiple cerebral metastases

This review highlights the experience of a single institution using the Leksell gamma knife for 8 years. More than 500 patients with multiple cerebral metastases received outpatient radiosurgery. The results prove that there is a high efficacy and attractively low morbidity of modern outpatient radiosurgery. When compared with whole brain radiation therapy, radiosurgery improved survival in patients with cerebral metastases. Most importantly, the number of brain metastases had no prognostic impact in patients with non-small cell lung cancer, renal cell cancer, malignant melanoma and gastrointestinal cancer.

Stereotactic radiosurgery in the treatment of brain metastases: the current evidence

Chemotherapy has made substantial progress in the therapy of systemic cancer, but the pharmacological efficacy is insufficient in the treatment of brain metastases. Fractionated whole brain radiotherapy (WBRT) has been a standard treatment of brain metastases, but provides limited local tumor control and often unsatisfactory clinical results. Stereotactic radiosurgery using Gamma Knife, Linac or Cyberknife has overcome several of these limitations, which has influenced recent treatment recommendations. This present review summarizes the current literature of single session radiosurgery concerning survival and quality of life, specific responses, tumor volumes and numbers, about potential treatment combinations and radioresistant metastases. Gamma Knife and Linac based radiosurgery provide consistent results with a reproducible local tumor control in both single and multiple brain metastases. Ideally minimum doses of ≥18Gy are applied. Reported local control rates were 90-94% for breast cancer metastases and 81-98% for brain metastases of lung cancer. Local tumor control rates after radiosurgery of otherwise radioresistant brain metastases were 73-90% for melanoma and 83-96% for renal cell cancer. Currently, there is a tendency to treat a larger number of brain metastases in a single radiosurgical session, since numerous studies document high local tumor control after radiosurgical treatment of >3 brain metastases. New remote brain metastases are reported in 33-42% after WBRT and in 39-52% after radiosurgery, but while WBRT is generally applied only once, radiosurgery can be used repeatedly for remote recurrences or new metastases after WBRT. Larger metastases (>8-10cc) should be removed surgically, but for smaller metastases Gamma Knife radiosurgery appears to be equally effective as surgical tumor resection (level I evidence). Radiosurgery avoids the impairments in cognition and quality of life that can be a consequence of WBRT (level I evidence). High local efficacy, preservation of cerebral functions, short hospitalization and the option to continue a systemic chemotherapy are factors in favor of a minimally invasive approach with stereotactic radiosurgery.

A review of the clinical outcomes for patients diagnosed with brainstem metastasis and treated with stereotactic radiosurgery

Only 3%-5% of all brain metastases are located in the brainstem. We present a comprehensive review of the clinical outcomes from modern studies that treated patients with brainstem metastasis using either a Gamma Knife or a linear accelerator-based stereotactic radiosurgery. The median survival time of patients was compared to better understand what clinical or treatment factors are predictive of improved survival. This information can then be utilized to optimize patient care. The data suggests that higher prescribed marginal dose and the associated greater local control of brainstem lesions are associated with longer patient survival. Further research is necessary to better describe the most effective dose for individual brainstem lesions and to tailor optimum therapy to specific patient subgroups.

Gamma knife radiosurgery for the treatment of cystic cerebral metastases

PURPOSE

To assess the role of Gamma Knife radiosurgery (GKRS) in the treatment of nonsurgical cystic brain metastasis, and to determine predictors of response to GKRS.

METHODS

We reviewed a prospectively maintained database of brain metastases patients treated at our institution between 2006 and 2010. All lesions with a cystic component were identified, and volumetric analysis was done to measure percentage of cystic volume on day of treatment and consecutive follow-up MRI scans. Clinical, radiologic, and dosimetry parameters were reviewed to establish the overall response of cystic metastases to GKRS as well as identify potential predictive factors of response.

RESULTS

A total of 111 lesions in 73 patients were analyzed; 57% of lesions received prior whole-brain radiation therapy (WBRT). Lung carcinoma was the primary cancer in 51% of patients, 10% breast, 10% colorectal, 4% melanoma, and 26% other. Fifty-seven percent of the patients were recursive partitioning analysis class 1, the remainder class 2. Mean target volume was 3.3 mL (range, 0.1-23 mL). Median prescription dose was 21 Gy (range, 15-24 Gy). Local control rates were 91%, 63%, and 37% at 6, 12, and 18 months, respectively. Local control was improved in lung primary and worse in patients with prior WBRT (univariate). Only lung primary predicted local control in multivariate analysis, whereas age and tumor volume did not. Lesions with a large cystic component did not show a poorer response compared with those with a small cystic component.

CONCLUSIONS

This study supports the use of GKRS in the management of nonsurgical cystic metastases, despite a traditionally perceived poorer response. Our local control rates are comparable to a matched cohort of noncystic brain metastases, and therefore the presence of a large cystic component should not deter the use of GKRS. Predictors of response included tumor subtype. Prior WBRT decreased effectiveness of SRS for local control rates.

A novel paradigm in the treatment of oligometastatic non-small cell lung cancer

BACKGROUND

Stage IV non-small cell lung cancer (NSCLC) is thought to uniformly carry a poor prognosis with a median survival of less than 1 year and 5-year survival of less than 5%. In patients with a low volume (i.e. single site) of distant disease, the prognosis is slightly more favorable than that of more advanced (i.e. multiple sites of metastases) disease. For those with limited metastases, we developed a paradigm of adding concurrent chemotherapy and radiotherapy to the primary tumor once the tumor demonstrated chemotherapy sensitivity.

METHODS

Charts of patients from 1999-2006 with non-small cell lung cancer were reviewed to find those with a single extra-thoracic site of disease treated with combined modality therapy. We found nine patients of 640 who met these criteria. Initial treatment consisted of induction chemotherapy, except for brain metastases which were managed first (n=1). If patients experienced a response to chemotherapy without new metastases, the extra-thoracic site was treated for total control with curative dose chemoradiotherapy to the primary site. Survival, time to progression, and sites of progression were assessed.

RESULTS

Median survival was 28 months (95% CI 18-50 mo) with median time to progression of 15 months (95% CI 8-24 mo). All except one patient progressed in the CNS, either with brain metastases (n=7) or leptomeningeal disease (n=1).

CONCLUSIONS

Such an approach offers the potential for enhanced quality and quantity of survival by incorporating aggressive RT for select patients without disease progression after induction chemotherapy. Patients tended to fail in the CNS, suggesting the importance of continued surveillance of the neuraxis or possibly prophylactic cranial irradiation. Future plans will correlate outcomes with molecular markers.

The role of whole brain radiation therapy for the management of brain metastases in the era of stereotactic radiosurgery

The goals of treatment for brain metastases (BMs) include preservation of function and improvement of survival. Although whole brain radiotherapy (WBRT) has been a mainstay in the treatment of BMs, stereotactic radiosurgery (SRS) monotherapy has been increasingly used because of concern about the deterioration of neurocognitive function as a late adverse effect of WBRT. The results of four randomized controlled trials comparing focal treatment alone versus focal treatment combined with WBRT have shown, however, that SRS monotherapy significantly increases the risk of brain tumor recurrence (BTR) and that this increased risk of BTR may cause deterioration of neurocognitive function. We suggest identifying patients according to their risk of BTR when selecting treatment. Patients who have solitary BM with the absence of extracranial metastases may be indicated for SRS monotherapy given the lower risk of BTR compared with those having multiple BMs or extracranial metastases.

Radiographic response of brain metastasis after linear accelerator radiosurgery

BACKGROUND

Radiographic response of brain metastasis to stereotactic radiosurgery (SRS) over time has not been well characterized. Being able to predict SRS-induced changes in tumor size over time may allow improved counseling of patients and potentially earlier recognition of poor response to SRS.

OBJECTIVE

To quantify the rate of change in size of metastatic brain tumors after treatment with a linear accelerator (LINAC) SRS.

METHODS

We performed a retrospective analysis of patients with single metastatic brain tumors treated with LINAC SRS at the University of Florida between 1992 and 2009 who had at least one MRI after treatment. A total of 218 patients with 406 follow-up MRI scans were included in the study. Tumor area was calculated by measuring the largest tumor area on axial imaging and using the equation for area of an ellipse. Primary outcome was percent change in tumor size. The contribution of several factors including gender, primary tumor histology, synchronous or asynchronous presentation, prior treatment, primary tumor control, and SRS dose were examined using multivariate analysis.

RESULTS

Mean patient age was 58.3 years (range 4-86), and 48.6% of patients were female. Sixty-three percent of patients had primary tumor control and 70.6% had asynchronous presentation of their brain metastases. SRS peripheral dose range was 1,000-2,250 cGy with a median of 1,750 cGy. The mean percent size change was -22.6% with a mean rate of change of -7.0% per month. The median percent change was -49.7% with a median rate of change of -8.8% per month. The median follow-up was 4.8 months (range 0.3-52.5). Female gender and melanoma histology were found to be significant predictors of an increase in tumor size. Lack of previous surgical resection was a significant predictor of a decrease in tumor size after SRS. Other factors tested with multivariate analysis, including age, synchronicity of presentation, dose, dose volume, Karnofsky performance score, and primary tumor control, were not significant in predicting tumor size change after SRS.

CONCLUSION

In this study, brain metastases decreased in size by a median of 50% for a median follow-up of 4.8 months after SRS. The overall rate of decrease was 9% per month after treatment with SRS. Melanoma histology was a predictor of poor tumor control.

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.

Gamma Knife surgery for brain metastases from colorectal cancer. Clinical article

OBJECT

The outcomes after Gamma Knife surgery (GKS) were retrospectively analyzed in patients with brain metastases from radioresistant primary colorectal cancer to evaluate the efficacy of GKS and the prognostic factors for local tumor control and overall survival.

METHODS

The authors reviewed the medical records of 152 patients with 616 tumors. The group included 102 men and 50 women aged 35-85 years (mean age 64.4 years), who underwent GKS for metastatic brain tumors from colorectal cancer between April 1992 and September 2008 at Yokohama Rosai Hospital.

RESULTS

The mean prescription dose to the tumor margin was 18.5 Gy (range 8-30 Gy). The mean tumor volume at GKS was 2.0 cm(3) (range 0.004-10.0 cm(3)). The primary tumors were located in the colon in 88 patients and the rectum in 64. The median interval between the diagnosis of primary lesions and the diagnosis of brain metastases was 27 months (range 0-180 months). The median neuroradiological follow-up period after GKS was 3 months (mean 6.4 months, range 1-93 months). The local tumor growth control rate, based on MR imaging, was 91.2%. The significant factors for unfavorable local tumor growth control, based on multivariate analysis, were larger tumor volume (p = 0.001) and lower margin dose (p = 0.016). The median overall survival time was 6 months. Lower Karnofsky Performance Scale (KPS) score (p = 0.026) and the presence of extracranial metastases (p = 0.004) at first GKS were significantly correlated with poor overall survival period in multivariate analysis. The cause of death was systemic disease in 112 patients and neurological disease in 13 patients. Leptomeningeal carcinomatosis was significantly correlated with a shorter duration of neurological survival in multivariate analysis (p < 0.0001).

CONCLUSIONS

Gamma Knife surgery is effective for suppression of local tumor growth in patients with brain metastases from radioresistant colorectal primary cancer. Therefore, clinical and radiological screening of intracranial metastases for patients with lower KPS scores and/or the presence of extracranial metastases as well as follow-up examinations after GKS for brain metastases should be performed periodically in patients with colorectal cancer, because the neurological prognosis is improved by initial and repeat GKS for newly diagnosed or recurrent tumors leading to a prolonged high-quality survival period.

A comparison between surgical resection in combination with WBRT or hypofractionated stereotactic irradiation in the treatment of solitary brain metastases

BACKGROUND

The standard treatment of solitary brain metastases previously has been tumour resection in combination with whole-brain radiation therapy (WBRT). Stereotactic radiotherapy has emerged as a non-invasive treatment option especially for small brain metastases. We now report our results on resection + WBRT or hypofractionated stereotactic irradiation (HCSRT) in the treatment of solitary brain metastases.

METHODS

Between 1993 and 2004 patients with metastatic cancer and solitary brain metastases were selected for surgical resection + WBRT or HCSRT alone at the Umeå University Hospital. Fifty-nine patients were treated with surgical resection + WBRT (34 male, 25 female, mean age 63.3 years). Forty-seven patients were treated with HCSRT alone (15 male, 32 female, mean age 64.9 years).

FINDINGS

In patients followed radiologically, 28% treated with resection + WBRT showed a local recurrence after a median time of 8.0 months, whereas there was a lack of local control in 16% in the HCSRT group after a median time of 3.0 months. There was a significantly longer survival time for patients treated with resection + WBRT (median 7.9, mean 12.9 months) compared to HCSRT (median 5.0, mean 7.6 months). Even in patients with a tumour volume <10 cc, there was a significantly longer survival in favour of resection + WBRT (median 8.4, mean 17.4 months) compared to HCSRT (median 5.0, mean 7.9 months).

CONCLUSION

This retrospective and non-randomised study indicates that surgical resection in combination with WBRT may be an option even for small brain metastases suitable for treatment with HCSRT. Since survival and local control following resection + WBRT was at least as favourable as compared to HCSRT alone, tumour location and expected neurological outcome may be the strongest aspect when selecting treatment modality.

Current management of metastatic brain disease

Brain metastases are the most common intracranial tumor in adults. The incidence of metastases is thought to be rising due to better detection and treatment of systemic malignancy. More widespread use and improved quality of MRI may lead to early detection of brain metastases. Available evidence suggests that survival is longer and quality of life improved if brain metastases are treated aggressively. This article reviews current therapeutic management used for brain metastases. To select the appropriate therapy, the physician must consider the extent of the systemic disease, primary histology, and patient age and performance status, as well as the number, size, and location of the brain metastases. Available treatment options include whole-brain radiotherapy (WBRT), stereotactic radiosurgery (SRS), surgery, and chemotherapy. Multidisciplinary approaches such as the combination of WBRT with SRS or surgery have shown superior results in terms of survival time, neurocognitive function, and quality of life. The utility and optimal use of chemotherapy and radiosensitizing agents is less clear. It is hoped that further advances and multidisciplinary approaches currently under study will result in improved patient outcomes.

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.

Radiosurgery in the treatment of brain metastases: critical review regarding complications

Stereotactic radiosurgery (SRS) has been described as an effective treatment option for brain metastases. In general, SRS has been indicated for the treatment of lesions smaller than 3 cm in maximum diameter and for lesions considered not surgically treatable, owing to the patient's clinical status or because the lesion was located in or near eloquent brain areas. In several studies, SRS has been associated with clinical and radiographic improvement of the lesions and has been compared with surgery as the modality of choice for brain metastases. Beyond the high rate of local disease control with SRS, the few complications that have been described occurred mainly in the acute post treatment period. Most publications have addressed the outcome and effectiveness of this treatment modality but have not critically analyzed long-term complications, steroid dependency, or results relating to specific brain locations. It is important to understand the radiobiologic effects of a well-demarcated high dose of radiation on the brain lesion, controlling the tumor growth and not causing significant alteration of the related brain region, especially in an area controlling eloquent function.

A simple treatment planning strategy for patients with multiple metastases treated with Gamma Knife surgery

OBJECT

In a substantial number of patients treated at the authors' facility for brain metastases, additional lesions are identified at the time of Gamma Knife surgery (GKS). These lesions are often widely dispersed and may number over 10, which is the maximal number of matrices that can be currently placed for treatment with Leksell Gamma-Plan 4C. The authors describe a simple planning method for GKS in patients with multiple, widely dispersed central nervous system (CNS) metastases.

METHODS

Two patients presented with three to five identified recurrent metastases from non-small cell lung carcinoma and breast carcinoma after having received whole-brain radiotherapy. At the time of treatment with GKS in each patient, spoiled-gradient Gd-enhanced magnetic resonance (MR) imaging revealed substantially more metastases than originally thought, which were widely scattered throughout all regions of the brain. The authors simplified the treatment planning approach by dividing the entire CNS contents into six contiguous, nonoverlapping matrices, which allowed for the planning, calculation, and treatment of all lesions. Two patients were successfully treated with GKS for more than 10 CNS metastases by using this simple planning method. Differing peripheral doses to varied-size lesions were delivered by prescribing to different isodose curves within any given matrix when required. Dose-volume histograms showed brain doses as follows: 10% of the total brain volume received 5 to 6.4 Gy; 25% received 3.8 to 4.8 Gy; 50% received 2.7 to 3.1 Gy; and 75% received 2.2 to 2.5 Gy.

CONCLUSIONS

The delineation of more metastases than appreciated on the diagnostic MR imaging is a common occurrence at the time of GKS at the authors' institution. The treatment of multiple (>10), widely dispersed CNS metastases can be simplified by the placement of multiple, contiguous, non-overlapping matrices, which can be employed to treat lesions in all areas of the brain when separate matrices cannot be utilized.

Phase II trial of hypofractionated stereotactic radiotherapy for brain metastases: Results and toxicity

PURPOSE

To prospectively evaluate efficacy and side effects of hypofractionated stereotactic radiotherapy (hfSRT) for irresectable brain metastases not amenable to radiosurgery (SRS).

METHODS AND MATERIALS

From 1/2003 to 2/2005, 51 patients with 72 brain metastases were included in a prospective phase II-trial and accepted for treatment at the dedicated stereotactic radiosurgery system Novalis (BrainLAB, Heimstetten, Germany). In case of planned or prior whole brain radiotherapy (WBRT), hfSRT was to be performed with 5 x 6 Gy, otherwise with 5 x 7 Gy. This dose was prescribed to the 90% isodose line which should cover 100% of the planning target volume (PTV).

RESULTS

Rates of complete remission (CR), partial remission (PR), no change (NC) and progressive disease (PD) were 66.7%, 18.1%, 12.5% and 2.8%, respectively, after a median follow-up of 7 months. Median survival was 11 months. Disease-specific survival and survival related to brain metastases were strongly associated with the size of gross tumor volume (GTV), the planning target volume (PTV), Karnofsky Performance Score (KPS) and number of metastases. Side effects, i.e., increase in T2w-signal area, duration of steroid intake and size of new or progressive necrotic centre of metastasis, were dependent on the volume of normal brain irradiated with more than 4 Gy per fraction (V(4Gy)). Significantly more patients with a V(4Gy)> or =23 cc developed radiological signs of side effects from hfSRT.

CONCLUSION

Hypofractionated stereotactic radiotherapy with 5 x 6-7 Gy is an effective and safe treatment for brain metastases not amenable to single high-dose radiosurgery. The normal brain volume receiving >4 Gy per fraction may not exceed 20 cc.

Gamma Knife surgery for metastatic brainstem tumors

Object

The authors review imaging and clinical outcomes in patients with metastatic brainstem tumors treated using Gamma Knife surgery (GKS).

Methods

Between March 1989 and March 2005, 53 patients (24 men and 29 women) with metastatic brainstem lesions underwent GKS. The metastatic deposits were located in the midbrain in eight patients, the pons in 42, and the medulla oblongata in three. Lung cancer was the most common primary malignancy, followed by breast cancer, melanoma, and renal cell carcinoma. The mean volume of the metastatic deposits at the time of treatment was 2.8 cm3 (range 0.05–21 cm3). The prescription doses varied from 9 to 25 Gy (mean 17.6 Gy).

Imaging follow-up studies were not completed in 16 patients, because of the short-term survival in 11 and patient refusal in five. Of the remaining 37 patients, who underwent an imaging follow-up evaluation at a mean of 9.8 months (range 1–25 months), the tumors disappeared in seven, shrank in 22, remained unchanged in three, and grew in five. All but one of 18 patients with asymptomatic brainstem deposits remained free of symptoms. In 35 patients with symptomatic brainstem deposits, neurological symptoms improved in 21, remained stable in 11, and worsened in three. At the time of this study, 10 patients were alive, and their survival ranged from 3 to 52 months after treatment. Thirty-four patients died of extracranial disease, three of the progressing metastatic brainstem lesion, and six of additional progressing intracranial deposits in other parts of the brain. The overall median survival period was 11 months after GKS. In terms of survival, the absence of active extracranial disease was the only favorable prognostic factor. Neither previous whole-brain radiation therapy nor a single brainstem metastasis was statistically related to the duration of survival.

Conclusions

Compared with allowing a metastatic brainstem lesion to take its natural course, GKS prolongs survival. The risks associated with such treatment are low. The severity of systemic diseases largely determines the prognosis of metastases to the brainstem.

Surgery versus radiosurgery for patients with a solitary brain metastasis from non-small cell lung cancer

BACKGROUND

Non-small cell lung cancer is one of the leading causes of death in the developed countries. Patients die of local progression, disseminated disease or both. Brain metastases are often seen in non-small cell lung cancer patients and although they are frequently multiple, a subset of patients with a solitary brain metastasis (with controlled primary tumour) is regularly seen in clinical practice. Treatment of a solitary brain metastasis has usually been surgery, when possible, but the development of new stereotactic techniques of radiotherapy using a linear accelerator or the 'gamma knife' have provided new treatment options.

OBJECTIVES

To compare the effectiveness of surgery with that of radiosurgery, either combined with whole brain radiotherapy or administered alone, for patients with a solitary brain metastasis from successfully treated non-small cell lung cancer.

SEARCH STRATEGY

The following electronic databases were searched: the Cochrane Central Register of Controlled Trials (CENTRAL, 2004 issue 2), MEDLINE (1966 to present), EMBASE (1974 to present), CINAHL (1982 to present). Finally the Cochrane Lung Cancer Specialised Register was also searched.

SELECTION CRITERIA

Randomised and controlled trials that compared surgery (with or without whole brain irradiation) with all types of radiosurgery (with or without whole brain irradiation) for solitary brain metastasis from non-small cell lung cancer. All other types of studies i.e.prospective or retrospective cohort studies were not considered appropriate.Studies including patients with multiple brain metastasis or diagnosed without the support of CT scan/MRI diagnostic imaging were also excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results to identify suitable trials.

MAIN RESULTS

Despite extensive searching no randomised trials were found. Electronic search identified 686 references. A total of 47 were selected for further evaluation but none was relevant to this review.

AUTHORS' CONCLUSIONS

The reviewers felt that the inclusion of studies less rigorous than randomised trials would result in misleading findings. Cohort or single arm studies only provide partial information and have the risk of significant bias. From the evaluated studies, we found that a variety of different criteria were used for the definition of solitary brain metastasis. We observed that the term "single brain metastasis" was misused as synonymous with solitary brain metastasis. Some of the single arm or cohort studies come from single institutions where the availability of both techniques (radiosurgery and surgery) is not described. Therefore, a tendency to use the most accessible technique could be suspected. Finally, in order to determine which technique is superior for patients with a solitary brain metastasis from non-small cell lung cancer, an appropriate randomised trial should be designed. Based on the available evidence a meaningful conclusion cannot be drawn.

Linac stereotactic radiosurgery: An effective and safe treatment for elderly patients with brain metastases

PURPOSE

To evaluate the outcomes of radiosurgery for brain metastases in patients 65 years or older.

PATIENTS AND METHODS

Between January 1994 and January 2003, 117 patients (47 women, 70 men), median age 71 years (range, 65-86 years), received radiosurgery for 227 metastases. Sixty-one patients (55%) presented symptoms in relation to the brain metastases. Thirty-eight patients (32%) received whole-brain radiotherapy. Median metastasis diameter and volume were 21 mm (range, 0.5-75 mm) and 1.7 cc (range, 0.02-71 cc), respectively.

RESULTS

Median follow-up was 7 months (range, 1-45 months), 9.5 months for alive patients (range, 1-45 months). Median minimum and maximum doses were 14.5 Gy (6.5 Gy, 19.5 Gy), and 20.4 Gy (13.2 Gy, 41.9 Gy), respectively. Median survival was 8 months from the date of radiosurgery. Overall survival rates at 6 and 24 months were 58% +/- 5% and 13% +/- 4%, respectively. According to multivariate analysis, a low Karnofsky performance status was an independent unfavorable prognostic factor for overall survival (p = 0.003; odds ratio [OR] = 0.28; 95% confidence interval [CI], 0.14-0.56). Median brain disease-free survival was 10 months. Brain disease-free survival rates at 6 and 24 months were 67% +/- 6% and 40% +/- 7%, respectively. According to multivariate analysis, a radiosensitive lesion was an independent favorable factor (p = 0.038; OR = 0.42; 95% CI, 0.18-0.95); more than two metastases and a low Karnofsky performance status were independent unfavorable factors for brain disease-free survival (p = 0.046; OR = 2.15; 95% CI, 1.01-4.58 and p = 0.003; OR = 30.4; 95% CI, 3.1-296, respectively). Local control rates were 98% +/- 2% and 91% +/- 8.5% at 6 and 24 months. Out of the 61 patients presenting symptoms before radiosurgery, complete symptomatic response was achieved in 12 patients (20%), partial improvement in 25 (41%), stabilization in 7 (11%), and worsening in 4 (6%) related to a progression of the irradiated metastasis. Seven cases of radionecrosis were described and were related to the margin dose (p = 0.03).

CONCLUSION

Radiosurgery for elderly patients was effective and safe. Age alone should not be a criterion for denying radiosurgery to any patient with brain metastases.

Two cases with long-term disease-free survival after resection and radiotherapy for solitary brain metastasis from breast cancer with extensive nodal metastases

Two rare cases, each with a solitary brain metastasis from breast cancer with extensive nodal metastases as the first site of distant metastasis, were locally treated with surgery and irradiation. The outcome of the two treated cases indicated an excellent and non-recurrent post-therapeutic survival period of more than 3 and 8 years, respectively. In a 50-year-old woman (Case 1), a solitary brain metastasis was found to have developed after standard radical mastectomy and adjuvant chemotherapy with doxorubicin and tegafur-uracil (UFT) and hormonal therapy with tamoxifen for left breast cancer. The brain metastasis was treated twice surgically followed by radiotherapy. One year and 6 months later, local recurrence of the brain metastasis appeared and was treated surgically again. No other treatment was done thereafter. Since then, no other distant or lymph node metastasis occurred, and to date her outcome has been non-eventful for 8 years and 5 months. In a 63-year-old woman (Case 2), a solitary brain metastasis was found to have developed after standard radical mastectomy and adjuvant chemotherapy with cyclophosphamide, epirubicin and fluorouracil (CEF) for right breast cancer. The brain metastasis was treated locally with surgery and irradiation of 50 Gy. She thereafter received no further treatments. Since then neither distant metastases nor local recurrence have developed, and to date the post-treatment outcome has been uneventful for 37 months. Our findings suggest that patients who developed a solitary brain metastasis as the first site of distant metastasis from breast cancer have a chance of achieving long-term disease-free survival when treated with aggressive local therapy, even in the presence of extensive lymph node metastases at the primary surgery site for breast cancer.

The American Society for Therapeutic Radiology and Oncology (ASTRO) evidence-based review of the role of radiosurgery for brain metastases

PURPOSE

To systematically review the evidence for the use of stereotactic radiosurgery in adult patients with brain metastases.

METHODS

Key clinical questions to be addressed in this evidence-based review were identified. Outcomes considered were overall survival, quality of life or symptom control, brain tumor control or response and toxicity. MEDLINE (1990-2004 June Week 2), CANCERLIT (1990-2003), CINAHL (1990-2004 June Week 2), EMBASE (1990-2004 Week 25), and the Cochrane library (2004 issue 2) databases were searched using OVID. In addition, the Physician Data Query clinical trials database, the proceedings of the American Society of Clinical Oncology (ASCO) (1997-2004), ASTRO (1997-2004), and the European Society of Therapeutic Radiology and Oncology (ESTRO) (1997-2003) were searched. Data from the literature search were reviewed and tabulated. This process included an assessment of the level of evidence.

RESULTS

For patients with newly diagnosed brain metastases, managed with whole-brain radiotherapy alone vs. whole-brain radiotherapy and radiosurgery boost, there were three randomized controlled trials, zero prospective studies, and seven retrospective series (which satisfied inclusion criteria). For patients with up to three (<4 cm) newly diagnosed brain metastases (and in one study up to four brain metastases), radiosurgery boost with whole-brain radiotherapy significantly improves local brain control rates as compared with whole-brain radiotherapy alone (Level I-III evidence). In one large randomized trial, survival benefit with whole-brain radiotherapy was observed in patients with single brain metastasis. In this trial, an overall increased ability to taper down on steroid dose and an improvement in Karnofsky performance status was seen in patients who were treated with radiosurgery boost as compared with patients treated with whole-brain radiotherapy alone. However, Level I evidence regarding overall quality of life outcomes using a validated instrument has not been reported. All randomized trials showed improved local control with the addition of radiosurgery to whole-brain radiotherapy. For patients with multiple brain metastases, there is no overall survival benefit with the use of radiosurgery boost to whole-brain radiotherapy (Level I-III evidence). Radiosurgery boost is associated with a small risk of early or late toxicity. In patients treated with radiosurgery alone (withholding whole-brain radiotherapy) as initial treatment, there were 2 randomized trials, 2 prospective cohort studies, and 16 retrospective series. There is Level I to Level III evidence that the use of radiosurgery alone does not alter survival as compared to the use of whole-brain radiotherapy. However, there is Level I to Level III evidence that omission of whole-brain radiotherapy results in poorer intracranial disease control, both local and distant (defined as remaining brain, outside the radiosurgery field). Quality of life outcomes have not been adequately reported. Radiosurgery is associated with a small risk of early or late toxicity. Radiosurgery as salvage for patients with brain metastases was reported in zero randomized trials, one prospective study, and seven retrospective series.

CONCLUSIONS

Based on Level I-III evidence, for selected patients with small (up to 4 cm) brain metastases (up to three in number and four in one randomized trial), the addition of radiosurgery boost to whole-brain radiotherapy improves brain control as compared with whole-brain radiotherapy alone. In patients with a single brain metastasis, radiosurgery boost with whole-brain radiotherapy improves survival. There is a small risk of toxicity associated with radiosurgery boost as compared with whole-brain radiotherapy alone. In selected patients treated with radiosurgery alone for newly diagnosed brain metastases, overall survival is not altered. However, local and distant brain control is significantly poorer with omission of upfront whole-brain radiotherapy (Level I-III evidence). Whether neurocognition or quality of life outcomes are different between initial radiosurgery alone vs. whole-brain radiotherapy (with or without radiosurgery boost) is unknown, because this has not been adequately tested. There was no statistically significant difference in overall toxicity between those treated with radiosurgery alone vs. whole-brain radiotherapy and radiosurgery boost based on an interim report from one randomized study. There is insufficient evidence as to the clinical benefit/risks radiosurgery used in the setting of recurrent or progressive brain metastases, although radiographic responses are well-documented.

Lymphopenia: A new independent prognostic factor for survival in patients treated with whole brain radiotherapy for brain metastases from breast carcinoma

BACKGROUND AND PURPOSE

To determine overall survival (OS) and independent prognostic factors in patients with brain metastases (BM) from breast cancer treated by whole brain radiotherapy (WBR).

PATIENTS AND METHODS

One hundred and twenty (120) women with BM, treated in a single French cancer center between 02/91 and 06/01, were reviewed. BM were confirmed by computed tomography or magnetic resonance imaging. Survival time was defined as the time interval from the date of BM to the date of death or last follow-up. A Cox proportional hazards regression model was used to determine significant prognostic factors in a multivariate analysis.

RESULTS

Surgery was followed by WBR in 5 patients. One hundred and four (104) patients received exclusive WBR, eight received concomitant chemo-radiation, and one received chemo-radiation after surgery. The median survival time was 5 months (95% CI: 3-7 months). In the multivariate analysis, performance status over 1 and lymphopenia (<0.7 G/L) were found to be independent prognostic factors for poor survival. Based on the number of these independent prognostic factors, we propose a predictive model for survival in brain metastatic cancer patients. Median survival was 7 months for patients presenting none or one poor prognosis factor at diagnosis versus 2 months for patients with 2 poor prognosis factors (p<0.0001)

CONCLUSION

Brain metastases from breast cancer remain associated with very poor prognosis and there is a need for better treatment procedures. If confirmed in predictive models, the identification of prognostic subgroups, based on KPS and lymphopenia, among patients with BM from breast cancer would help physicians select patients for future clinical trials.

The oligometastatic state in breast cancer: hypothesis or reality

The term 'oligometastasis' was initially used to describe a restricted locoregional tumour load, but the term has now become synonymous with isolated distant metastases. The existence of an oligometastatic state is still not widely recognised in the management of breast cancer patients. However, there are a number of patients who do develop isolated metastases and in whom long term survival can be achieved following appropriately targeted treatment. This review article discusses the possible biological mechanisms behind the development of an oligometastatic state and the findings from different trials which describe results following radical therapy for isolated metastatic disease. Although no large scale trials in this area have yet been undertaken, there is evidence to support the existence of an oligometastatic state in patients with breast cancer and we discuss the appropriate management for this clinical scenario.

[Local relapse and single site of metastatic involvement of renal tumour. Prognostic factors and survival]

OBJECTIVE

To evaluate the clinical and pathological characteristics and survival in patients surgically treated for renal tumours that had local recurrence or metastasis to a single site.

MATERIAL AND METHODS

A retrospective study of 321 nephrectomies, evaluating the clinical and pathological variables in patients having local recurrence or metastasis to a single site, and who were treated surgically. Study and comparison of survival in the different groups.

RESULTS

The only factor found to have an independent influence on local recurrence is pathological stage. Local recurrence and the presence of metastasis to a single site have similar survival rates, both being statistically worse than in patients without metastasis at diagnosis, but better than in those having metastasis at diagnosis.

CONCLUSIONS

The presence of local recurrence has the same prognosis as a single excisable metastatic site, the prognosis being better than those initially with metastasis subjected to nephrectomy before receiving systemic treatment.

Hypofractionated conformal stereotactic radiotherapy alone or in combination with whole-brain radiotherapy in patients with cerebral metastases

PURPOSE

The aim was to evaluate treatment of cerebral metastases with hypofractionated conformal stereotactic radiotherapy (HCSRT) or whole-brain radiotherapy (WBRT) in combination with a stereotactic boost.

METHODS AND MATERIALS

Forty-seven patients were treated with HCSRT and 14 patients with WBRT in combination with a stereotactic boost. Radiation doses were 40 Gy (5 fractions) in HCSRT or 30 Gy (WBRT) combined with a mean dose of 17 Gy stereotactically (1-3 fractions).

RESULTS

The median survival time in the HCSRT as well as the WBRT group was 5.0 months, and 87% died of extracranial disease. Radiologic follow-up (mean, 3.7 months after treatment) showed local control in the HCSRT group in 84% and in the WBRT group in 100%. Patients treated with HCSRT developed new brain metastases distant from the irradiated area in 25%. Two patients treated with HCSRT deteriorated neurologically during treatment, and in 2 patients radionecrosis developed.

CONCLUSIONS

Although there may be a higher risk of distant new metastases, HCSRT as a treatment for brain metastases seems to be as effective as WBRT in combination with a stereotactic boost. Complications are in the range of what has been reported previously.

Gamma Knife radiosurgery for intracranial metastatic melanoma: an analysis of survival and prognostic factors

Objective of this study was to evaluate retrospectively the effectiveness of Gamma Knife radiosurgery for intracranial metastatic melanoma and to identify prognostic factors related to survival. Twenty-six patients with intracranial metastases (72 lesions) from melanoma underwent Gamma Knife radiosurgery. In 14 patients (54%) whole-brain radiotherapy (WBRT) was performed as part of the initial treatment, and in 12 patients (38%) immunotherapy and/or chemotherapy was given after Gamma Knife radiosurgery. The median tumor volume for Gamma Knife radiosurgery treated lesions was 1.72 cm3. The median prescribed radiation dose was 18 Gy (range 8-22 Gy) typically prescribed to the isodose at the tumor margin. Univariate and multivariate analyses were used to determine significant prognostic factors affecting survival. Overall median survival was 6 months after Gamma Knife radiosurgery, and 1-year survival was 25%. The median survival from the onset of brain metastases was 9 months and from the original diagnosis of melanoma was 50 months (range 4-160 months). There were no major acute or late GKS complications. In univariate testing, the Karnofsky score equal to or higher than 90% (P < 0.01, log-rank test), supratentorial localization (P < 0.001, log-rank test), intracranial tumor volume less than 1 cm3 (P < 0.02, log-rank test), and absence of neurological signs or symptoms before Gamma Knife radiosurgery (P < 0.003, log-rank test) were significant favorable factors for survival. In multivariate regression analyses, the most important predictors associated with increased survival were a KPS > or = 90 (P < 0.023), female sex (P < 0.004), supratentorial localization (P < 0.01), and absence of neurological symptoms (P < 0.008). Radiosurgery is a noninvasive, safe, and effective treatment option for patients with single or multiple intracranial metastases from melanoma. Female sex, Karnofsky score > or = 90, supratentorial localization and lack of symptoms before the Gamma Knife radiosurgery were good independent predictors of survival.

Gamma knife surgery for brain metastases from lung cancer

Object. The authors conducted a study to evaluate the safety and efficacy of gamma knife surgery (GKS) for the treatment of brain metastases from lung cancer.

Methods. Between February 1993 and May 2003 191 patients underwent treatment for 424 brain metastases from non—small (171 cases) and small cell lung carcinoma (20 cases). Imaging and clinical status were monitored every 3 months following the treatment. Kaplan-Meier survival curves, Cox proportional hazards regression for risk factor analysis, and nonparametric methods for evaluating tumor response were used.

There was no difference in median survival following combined whole-brain radiation therapy (WBRT) and gamma knife surgery (14 months) and GKS alone (15 months). There was also no difference between the median survival rates for either tumor type. In the multivariate analysis, age less than 65 years, Karnofsky Performance Scale score greater than 70, normal neurological status, multiple GKS treatments, and pre-GKS craniotomy were related to longer survival.

Tumor control rates varied according to the volume of the metastases and were as follows: 84.4% (< 0.5 cm3), 94% (0.5–2 cm3), 89.1% (2–4 cm3), 93.4% (4–8 cm3), 85.7% (8–14 cm3), and 87.5% (> 14 cm3). Four lesions required post-GKS craniotomy due to swelling or rapid tumor progression. The rate of tumor shrinkage was higher when a volume was 2 cm3, lower in cystic lesions, lower in tumors with previous WBRT, and lower for margin doses less than 14 Gy.

Conclusions. The risk—benefit ratio of GKS in this series was satisfactory. There was no difference in response rates of the two tumor types, and WBRT did not improve the duration of survival.

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 from lung cancer

OBJECT

The authors conducted a study to evaluate the safety and efficacy of gamma knife surgery (GKS) for the treatment of brain metastases from lung cancer.

METHODS

Between February 1993 and May 2003 191 patients underwent treatment for 424 brain metastases from non-small (171 cases) and small cell lung carcinoma (20 cases). Imaging and clinical status were monitored every 3 months following the treatment. Kaplan-Meier survival curves, Cox proportional hazards regression for risk factor analysis, and nonparametric methods for evaluating tumor response were used. There was no difference in median survival following combined whole-brain radiation therapy (WBRT) and gamma knife surgery (14 months) and GKS alone (15 months). There was also no difference between the median survival rates for either tumor type. In the multivariate analysis, age less than 65 years, Karnofsky Performance Scale score greater than 70, normal neurological status, multiple GKS treatments, and pre-GKS craniotomy were related to longer survival. Tumor control rates varied according to the volume of the metastases and were as follows: 84.4% (< 0.5 cm3), 94% (0.5-2 cm3), 89.1% (2-4 cm3), 93.4% (4-8 cm3), 85.7% (8-14 cm3), and 87.5% (> 14 cm3). Four lesions required post-GKS craniotomy due to swelling or rapid tumor progression. The rate of tumor shrinkage was higher when a volume was 2 cm3, lower in cystic lesions, lower in tumors with previous WBRT, and lower for margin doses less than 14 Gy.

CONCLUSIONS

The risk-benefit ratio of GKS in this series was satisfactory. There was no difference in response rates of the two tumor types, and WBRT did not improve the duration of survival.

Radiosurgery for patients with recurrent small cell lung carcinoma metastatic to the brain: outcomes and prognostic factors

Object.Lung carcinoma is the leading cause of death from cancer. More than 50% of those with small cell lung cancer develop a brain metastasis. Corticosteroid agents, radiotherapy, and resection have been the mainstays of treatment. Nonetheless, median survival for patients with small cell lung carcinoma metastasis is approximately 4 to 5 months after cranial irradiation. In this study the authors examine the efficacy of gamma knife surgery for treating recurrent small cell lung carcinoma metastases to the brain following tumor growth in patients who have previously undergone radiation therapy, and they evaluate factors affecting survival.

Methods.A retrospective review of 27 patients (47 recurrent small cell lung cancer brain metastases) undergoing radiosurgery was performed. Clinical and radiographic data obtained during a 14-year treatment period were collected. Multivariate analysis was utilized to determine significant prognostic factors influencing survival.

The overall median survival was 18 months after the diagnosis of brain metastases. In multivariate analysis, factors significantly affecting survival included: 1) tumor volume (p = 0.0042); 2) preoperative Karnofsky Performance Scale score (p = 0.0035); and 3) time between initial lung cancer diagnosis and development of brain metastasis (p = 0.0127). Postradiosurgical imaging of the brain metastases revealed that 62% decreased, 19% remained stable, and 19% eventually increased in size. One patient later underwent a craniotomy and tumor resection for a tumor refractory to radiosurgery and radiation therapy. In three patients new brain metastases were demonstrating on follow-up imaging.

Conclusions.Stereotactic radiosurgery for recurrent small cell lung carcinoma metastases provided effective local tumor control in the majority of patients. Early detection of brain metastases, aggressive treatment of systemic disease, and a therapeutic strategy including radiosurgery can extend survival.

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.

Radiosurgery for patients with recurrent small cell lung carcinoma metastatic to the brain: outcomes and prognostic factors

Object. Lung carcinoma is the leading cause of death from cancer. More than 50% of those with small cell lung cancer develop a brain metastasis. Corticosteroid agents, radiotherapy, and resection have been the mainstays of treatment. Nonetheless, median survival for patients with small cell lung carcinoma metastasis is approximately 4 to 5 months after cranial irradiation. In this study the authors examine the efficacy of gamma knife surgery for treating recurrent small cell lung carcinoma metastases to the brain following tumor growth in patients who have previously undergone radiation therapy, and they evaluate factors affecting survival.

Methods. A retrospective review of 27 patients (47 recurrent small cell lung cancer brain metastases) undergoing radiosurgery was performed. Clinical and radiographic data obtained during a 14-year treatment period were collected. Multivariate analysis was utilized to determine significant prognostic factors influencing survival.

The overall median survival was 18 months after the diagnosis of brain metastases. In multivariate analysis, factors significantly affecting survival included: 1) tumor volume (p = 0.0042); 2) preoperative Karnofsky Performance Scale score (p = 0.0035); and 3) time between initial lung cancer diagnosis and development of brain metastasis (p = 0.0127). Postradiosurgical imaging of the brain metastases revealed that 62% decreased, 19% remained stable, and 19% eventually increased in size. One patient later underwent a craniotomy and tumor resection for a tumor refractory to radiosurgery and radiation therapy. In three patients new brain metastases were demonstrating on follow-up imaging.

Conclusions. Stereotactic radiosurgery for recurrent small cell lung carcinoma metastases provided effective local tumor control in the majority of patients. Early detection of brain metastases, aggressive treatment of systemic disease, and a therapeutic strategy including radiosurgery can extend survival.

Linear Accelerator Radiosurgery in the Treatment of Brain Metastases

OBJECTIVE:

To review a 12-year experience treating metastatic brain disease with linear accelerator-based stereotactic radiosurgery (SRS).

METHODS:

We performed a retrospective analysis of all patients treated between 1989 and 2001 with linear accelerator radiosurgery for brain metastases. Patients were followed up both clinically and with imaging studies to document local control, regional control, and survival. Demographic data, dosing parameters, number of lesions, histology, history of whole-brain radiation therapy, and other factors were obtained prospectively. Cox proportional-hazards regression with multivariate and univariate analysis was performed with Stata 8.0 software.

RESULTS:

A total of 383 patients received SRS for brain metastases during the study interval. Median survival was 9 months. Patients with tumor-type melanoma or multiple metastatic lesions had decreased survival. Actuarial 1-year local control was 75%. Differences in regional control rates were not statistically significant between patients treated with SRS and whole-brain radiation therapy versus SRS alone.

CONCLUSION:

Radiosurgery is an effective and safe method for treating selected patients with brain metastases.

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.