Surgical results of brain metastasis from lung cancer--prognostic factors

Dose optimization and indication of Linac radiosurgery for brain metastases

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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

The prognostic factors of lung cancer patients with brain metastases treated with radiotherapy

PURPOSE

To analyze the prognostic factors of lung cancer with brain metastases (BM) and evaluate the role of cranial irradiation on survival.

METHODS AND MATERIALS

From 1987 to 1994, 159 lung cancer patients with CT scan documented BM were reviewed. All of them underwent cranial irradiation (median radiation dose: 30 Gy). Chemotherapy and surgery of BM were performed in 21 and 10 cases, respectively.

RESULTS

Overall median survival was 3.5 months and one year survival rate was 10.69%. Univariate analysis showed that the significant factors were performance status, age, total radiation dose to brain, BM as the first metastasis, neurosurgery, symptoms of urine/stool incontinence, and synchronous BM. Multivariate analysis indicated that (1) performance status (p = 0.0002), (2) total radiation dose (p = 0.0032), (3) BM as the first metastasis (p = 0.0449), (4) neurosurgery (p = 0.0233), (5) symptoms of urine/stool incontinence (p = 0.0002), and (6) the presence of a midline shift on cranial CT scans (p = 0.0063) were significant prognostic factors.

CONCLUSION

The prognosis of BM in lung cancer patients is extremely poor. Radiotherapy appears as an effective means of palliation with 75% overall symptomatic response rate. Higher radiation dose (> or = 30 Gy) and neurosurgery are associated with longer survival. Good performance status, BM as the first metastasis, absence of sphincter dysfunction, and midline shift on CT scans are favorable prognostic predictors. The role of midline shift is very interesting and needs to be explored further.

Cost and survival analysis of metastatic cerebral tumors treated by resection and radiation

The surgical treatment of metastatic brain tumors remains controversial, primarily because of the limited prognosis of patients with metastatic cancer. The cost effectiveness of even standard therapies is of increasing concern to third-party payers. We reviewed the records of patients who had a single metastatic brain tumor resected at the Medical Center Hospital of Vermont (a referral center in a rural state) since cost data recording began. The 32 patients ranged in age from 35 to 77 years, with a 2.2:1 female-to-male ratio. Thirty-four percent of tumors originated in the lung, 15.6% were renal, 12.5% were breast, 12.5% were gynecological, 9.4% were gastrointestinal, and 9.4% were ultimately of unknown origin. Thirty-one tumors were completely resected; 30 patients were irradiated, most after surgery (mean dose, 3,908 +/- 1,250 cGy). Karnofsky scores improved from 80 +/- 11 to 88 +/- 16 postoperatively (P = 0.0038, one-tailed paired t-test). Patients were hospitalized an average of 8.22 +/- 6.26 days postoperatively, with total operative and postoperative charges of $19,190 +/- 5,684, noninclusive of radiotherapy. The expected median survival of all patients was 26 months (Kaplan-Meier estimate). The presence of disseminated disease was not significantly correlated with survival (P = 0.237). The number of postoperative days was more for patients with disseminated disease (P = 0.0274), but not for patients with infratentorial tumors (P = 0.6991). Age higher than the median was not correlated with an increased number of postoperative days (P = 0.1366) nor was a preoperative Karnofsky score of 70 or less (P = 0.1382).(ABSTRACT TRUNCATED AT 250 WORDS)