161: Surgical Resection(S) Plus Stereotactic Radiosurgery (SRS) Versus SRS Alone for Large Brain Metastases: A Comparative Study

Abstract Purpose Large brain metastases (BRM) are challenging to manage. Therapeutic options include Stereotactic Radiosurgery (SRS) or surgery (S) with adjuvant SRS. We sought to compare overall survival (OS), radionecrosis (RN), local failure (LF), pachymeningeal (PMD) and leptomeningeal (LMD) disease in patients treated with SRS vs. S+SRS. Methods We reviewed a prospective registry database from 2009 to 2020 and identified all patients with BRM (≥4cc in volume) treated with SRS or S+SRS. WBRT or SRS re-targeting the index lesion were censoring events. Survival percentages were calculated using the Kaplan-Meier method. Differences between groups were tested using the Cox proportional hazards model. Results 383 patients were identified, 128 and 255 were treated with S+SRS and SRS, respectively. Median ages in the S+SRS and SRS groups were 62.2 (23.6–98.5) and 60.2 (20.2–97.4) (P 0.33). OS at 12 and 24 months was 69% and 41% vs 55% and 20% for the S+SRS and SRS groups, respectively hazard ratio (HR) 1.64 (1.23–2.18) (P<0.001). LF requiring salvage surgery at 12 and 24 months were 3% and 5% vs 8% and 10% for S+SRS and SRS groups, respectively (P 0.067). RN at 12 and 24 months were 9% and 17% vs 15% and 21% for S+SRS and SRS groups, respectively 1.32 HR (0.77–2.29) (P =0.32). PMD disease at 12 and 24 months were 16% and 21% vs 3% and 7% for S+SRS and SRS groups, respectively HR 0.26(0.12–0.56) (P < 0.001). LMD at 12 and 24 months were 4% and 6% vs 2% and 4% for S+SRS and SRS groups, respectively HR 0.73(0.25–2.17) (P 0.57). Conclusion Surgical resection plus SRS correlated with improved OS and a trend towards a decreased incidence of LF compared to SRS alone. However, patients treated with S experienced an increased incidence of PMD.

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Single-Fraction Stereotactic Radiosurgery (SRS) Alone Versus Surgical Resection and SRS for Large Brain Metastases: A Multi-institutional Analysis

International Journal of Radiation Oncology*Biology*Physics ◽

10.1016/j.ijrobp.2017.04.006 ◽

2017 ◽

Vol 99 (2) ◽

pp. 459-467 ◽

Cited By ~ 34

Author(s):

Roshan S. Prabhu ◽

Robert H. Press ◽

Kirtesh R. Patel ◽

Danielle M. Boselli ◽

James T. Symanowski ◽

...

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Surgical Resection ◽

Institutional Analysis ◽

Single Fraction ◽

Large Brain

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P13.11 Outcome evaluation of oligometastatic patients with single, large brain metastases treated with gross total resection (GTR) followed by hypofractionated stereotactic radiosurgery (HSRS) on the tumor bed

Neuro-Oncology ◽

10.1093/neuonc/now188.255 ◽

2016 ◽

Vol 18 (suppl_4) ◽

pp. iv71-iv71 ◽

Cited By ~ 1

Author(s):

P. Navarria ◽

F. Pessina ◽

A. Ascolese ◽

L. Cozzi ◽

S. Tomatis ◽

...

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Outcome Evaluation ◽

Gross Total Resection ◽

Total Resection ◽

Tumor Bed ◽

Large Brain ◽

Hypofractionated Stereotactic Radiosurgery

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Hemorrhagic and Cystic Brain Metastases Are Associated With an Increased Risk of Leptomeningeal Dissemination After Surgical Resection and Adjuvant Stereotactic Radiosurgery

Neurosurgery ◽

10.1093/neuros/nyy436 ◽

2018 ◽

Vol 85 (5) ◽

pp. 632-641 ◽

Cited By ~ 6

Author(s):

Robert H Press ◽

Chao Zhang ◽

Mudit Chowdhary ◽

Roshan S Prabhu ◽

Matthew J Ferris ◽

...

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Surgical Resection ◽

Cumulative Incidence ◽

Postoperative Radiotherapy ◽

Multivariable Analysis ◽

Treatment Strategies ◽

Competing Risk ◽

Leptomeningeal Dissemination ◽

Increased Risk

Abstract BACKGROUND Brain metastases (BM) treated with surgical resection and focal postoperative radiotherapy have been associated with an increased risk of subsequent leptomeningeal dissemination (LMD). BMs with hemorrhagic and/or cystic features contain less solid components and may therefore be at higher risk for tumor spillage during resection. OBJECTIVE To investigate the association between hemorrhagic and cystic BMs treated with surgical resection and stereotactic radiosurgery and the risk of LMD. METHODS One hundred thirty-four consecutive patients with a single resected BM treated with adjuvant stereotactic radiosurgery from 2008 to 2016 were identified. Intracranial outcomes including LMD were calculated using the cumulative incidence model with death as a competing risk. Univariable analysis and multivariable analysis were assessed using the Fine & Gray model. Overall survival was analyzed using the Kaplan-Meier method. RESULTS Median imaging follow-up was 14.2 mo (range 2.5-132 mo). Hemorrhagic and cystic features were present in 46 (34%) and 32 (24%) patients, respectively. The overall 12- and 24-mo cumulative incidence of LMD with death as a competing risk was 11.0 and 22.4%, respectively. On multivariable analysis, hemorrhagic features (hazard ratio [HR] 2.34, P = .015), cystic features (HR 2.34, P = .013), breast histology (HR 3.23, P = .016), and number of brain metastases >1 (HR 2.09, P = .032) were independently associated with increased risk of LMD. CONCLUSION Hemorrhagic and cystic features were independently associated with increased risk for postoperative LMD. Patients with BMs containing these intralesion features may benefit from alternative treatment strategies to mitigate this risk.

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Single versus Multifraction Stereotactic Radiosurgery for Large Brain Metastases: An International Meta-analysis of 24 Trials

International Journal of Radiation Oncology*Biology*Physics ◽

10.1016/j.ijrobp.2018.10.038 ◽

2019 ◽

Vol 103 (3) ◽

pp. 618-630 ◽

Cited By ~ 32

Author(s):

Eric J. Lehrer ◽

Jennifer L. Peterson ◽

Nicholas G. Zaorsky ◽

Paul D. Brown ◽

Arjun Sahgal ◽

...

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Meta Analysis ◽

Large Brain ◽

Single Versus

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Feasibility of dose escalation using intraoperative radiotherapy following resection of large brain metastases compared to post-operative stereotactic radiosurgery

Journal of Neuro-Oncology ◽

10.1007/s11060-018-2968-4 ◽

2018 ◽

Vol 140 (2) ◽

pp. 413-420 ◽

Cited By ~ 2

Author(s):

John A. Vargo ◽

Kristie M. Sparks ◽

Rahul Singh ◽

Geraldine M. Jacobson ◽

Joshua D. Hack ◽

...

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Dose Escalation ◽

Intraoperative Radiotherapy ◽

Large Brain

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RTHP-42. OUTCOMES AFTER FRACTIONATED STEREOTACTIC RADIOSURGERY FOR BRAIN METASTASES

Neuro-Oncology ◽

10.1093/neuonc/noz175.912 ◽

2019 ◽

Vol 21 (Supplement_6) ◽

pp. vi218-vi218

Author(s):

Rebecca Anderson ◽

Liberty Bonestroo ◽

Christopher Spencer

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Surgical Resection ◽

Metastatic Disease ◽

Whole Brain Radiotherapy ◽

Symptomatic Patient ◽

Target Volume ◽

Time To Death ◽

Brain Radiotherapy ◽

Fractionated Stereotactic Radiosurgery

Abstract PURPOSE To examine outcomes in patients undergoing linear accelerator (LINAC) based fractionated stereotactic radiosurgery (fSRS) to 30 Gy in 5 fractions. METHODS We completed a retrospective review of patients with brain metastases treated with 5-fraction LINAC fSRS at Phelps Health. All patients with CNS metastatic disease treated with fSRS were included in the study. Incidence of symptomatic radionecrosis (sRN), local brain failure (LBF), time to death, target volume and dose, prior whole brain radiotherapy (WBRT), prior surgical resection, and concurrent immunotherapy were assessed. sRN was defined as grade 2 or higher per CTCAE v4.0. RESULTS From 2016–2019, 28 patients and 60 lesions were treated. The most common metastasis histology was non-small cell lung cancer (n = 22), renal cell carcinoma (n = 12), and melanoma (n = 11). Median follow-up time was 6.49 months (range 0.33 – 23.96). Of 60 lesions, three lesions developed sRN and one asymptomatic patient developed radiographic evidence of radiation necrosis. Mean GTV was 1.03cm3 in patients with sRN. Of 57 lesions without sRN, median GTV was 1.45cm3 (range 0.11 - 20.1). Mean time to sRN was 3.17 months. Two symptomatic patients received prior WBRT. One symptomatic patient received concurrent immunotherapy. No symptomatic patients had surgical resection prior to fSRS. Among 24 lesions without prior radiation, 1 (4.2%) developed sRN. 10 lesions underwent surgical resection prior to fSRS with none developing sRN. 34 lesions were treated with concurrent immunotherapy and one developed sRN (2.9%). Local failure occurred in 9 lesions (15%). Median time to death for all patients was 4.50 months (range 1.02 - 19.40). CONCLUSIONS fSRS to 30 Gy in 5 fractions has promising efficacy with low incidence of sRN in treatment of CNS metastatic disease. Further investigation is required to determine predictors in patient outcome.

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