Radiosurgery alone or in combination with whole-brain radiotherapy for brain metastases.

PURPOSE Evaluation of the treatment outcome after radiosurgery (RS) alone or in combination with whole-brain radiotherapy (WBRT) with special attention to prescribed dose and its influence on local control and survival. PATIENTS AND METHODS Between September 1984 and January 1997, 236 patients with 311 brain metastases treated with radiosurgery met the following inclusion criteria: one to three brain metastases per patient; no previous WBRT; and Kamofsky performance status (KPS) > or = 50%. One hundred fifty-eight patients treated only with RS received a median dose of 20 Gy prescribed to the 80% isodose line; 78 patients received RS with a median dose of 15 Gy/80% and an additional course of WBRT. RESULTS For the entire series, overall median survival was 5.5 months, with control of CNS disease achieved in 92% of the treated brain metastases; the results were not significantly different between patients treated by RS with or without WBRT. However, in patients without evidence of extracranial disease, median survival was increased for patients who received WBRT (15.4 vs 8.3 months; P=.08). Additionally, there was a suggestion that increased doses for patients treated with RS only resulted in improved outcome. Four lesions were suspicious for radiation necrosis by magnetic resonance imaging (MRI); in one of the four lesions, radiation necrosis was confirmed histologically. The incidence of transient low-grade toxicity was 18%; symptoms could be treated by the temporary administration of steroids. CONCLUSION RS is an effective, noninvasive means of controlling brain metastases when used alone or in combination with WBRT. There is a trend for superior local control and especially in patients without extracranial disease for superior survival when RS is used in conjunction with WBRT. Randomized trials would seem to be warranted, comparing the benefit of RS with or without additional WBRT.

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373P Brain metastases: Extracranial disease status as a prognostic factor after whole brain radiotherapy. Results from a prospective, population-based study

Annals of Oncology ◽

10.1016/j.annonc.2021.08.037 ◽

2021 ◽

Vol 32 ◽

pp. S526

Author(s):

O.E. Yri ◽

G.L. Astrup ◽

M.J. Hjermstad ◽

N.K. Aass ◽

J-Å. Lund ◽

...

Keyword(s):

Prognostic Factor ◽

Brain Metastases ◽

Whole Brain Radiotherapy ◽

Disease Status ◽

Population Based ◽

Population Based Study ◽

Whole Brain ◽

Brain Radiotherapy ◽

Extracranial Disease

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Gamma Knife surgery for metastatic brain tumors without prophylactic whole-brain radiotherapy: results in 1000 consecutive cases

Journal of Neurosurgery ◽

10.3171/sup.2006.105.7.86 ◽

2006 ◽

Vol 105 (Supplement) ◽

pp. 86-90 ◽

Cited By ~ 27

Author(s):

Toru Serizawa ◽

Yoshinori Higuchi ◽

Junichi Ono ◽

Shinji Matsuda ◽

Osamu Nagano ◽

...

Keyword(s):

Brain Tumors ◽

Brain Metastases ◽

Gamma Knife ◽

Whole Brain Radiotherapy ◽

Gamma Knife Surgery ◽

Carcinomatous Meningitis ◽

Metastatic Brain Tumors ◽

Whole Brain ◽

Brain Radiotherapy ◽

Extracranial Disease

ObjectThe authors analyzed the effectiveness of Gamma Knife surgery (GKS) for metastatic brain tumors without adjuvant prophylactic whole-brain radiotherapy (WBRT). Salvage GKS was performed as the sole treatment for new distant lesions.MethodsAmong 1127 patients in whom new brain metastases had been diagnosed, 97 who met one or more of the following three criteria were excluded from the study: any surgically inaccessible huge (≥ 35 mm) lesion; tumor number and size requiring an internal skull dose exceeding 10 J; or symptomatic carcinomatous meningitis. Thus, 1030 consecutive patients formed the basis for this study. Huge tumors were totally removed, whereas smaller lesions were treated with GKS. No adjuvant WBRT was given prior to GKS, and new distant lesions were appropriately retreated with GKS. Overall, neurological and new lesion–free survival curves were calculated and the prognostic values of covariates were obtained. In total, 1853 separate GKS sessions were required to treat 10,163 lesions.The patients' median overall survival period was 8.6 months. Neurological survival and new lesion–free rates at 1 year were 89.1 and 49.3%, respectively. In a multivariate analysis, the significant factors for poor prognosis were the development of more than four new brain metastases and active extracranial disease.Conclusions In meeting the goal of preventing neurological death and maintaining activities of daily living for patients with brain metastases, GKS alone provides excellent palliation without prophylactic WBRT. New distant lesions were quite well controlled with GKS salvage treatment alone.

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Clinical outcomes in patients with brain metastases from breast cancer treated with single-session radiosurgery or whole brain radiotherapy

Journal of Neurosurgery ◽

10.3171/2016.7.gks161541 ◽

2016 ◽

Vol 125 (Supplement_1) ◽

pp. 26-30 ◽

Cited By ~ 6

Author(s):

Michael Mix ◽

Rania Elmarzouky ◽

Tracey O'Connor ◽

Robert Plunkett ◽

Dheerendra Prasad

Keyword(s):

Breast Cancer ◽

Brain Metastases ◽

Median Survival ◽

Tumor Volume ◽

Whole Brain Radiotherapy ◽

Metastatic Tumor ◽

Whole Brain ◽

Receptor Status ◽

Brain Radiotherapy ◽

Her 2

OBJECTIVEGamma Knife radiosurgery (GKRS) is used to treat brain metastases from breast cancer (BMB) as the sole treatment or in conjunction with tumor resection and/or whole brain radiotherapy (WBRT). This study evaluates outcomes in BMB based on treatment techniques and tumor biological features.METHODSThe authors reviewed all patients treated with BMB between 2004 and 2014. Patients were identified from a prospectively collected radiosurgery database and institutional tumor registry; 214 patients were identified. Data were collected from aforementioned sources and supplemented with chart review where needed. Independent radiological review was performed for all available brain imaging in those treated with GKRS. Survival analyses are reported using Kaplan-Meier estimates.RESULTSDuring the 10-year study period, 214 patients with BMB were treated; 23% underwent GKRS alone, 46% underwent a combination of GKRS and WBRT, and 31% underwent WBRT alone. Median survival after diagnosis of BMB in those treated with GKRS alone was 21 months, and in those who received WBRT alone it was 3 months. In those treated with GKRS plus WBRT, no significant difference in median survival was observed between those receiving WBRT upfront or in a salvage setting following GKRS (19 months vs 14 months, p = 0.63). The median survival of patients with total metastatic tumor volume of ≤ 7 cm3 versus > 7 cm3 was 20 months vs 7 months (p < 0.001). Human epidermal growth factor receptor-2 (Her-2) positively impacted survival after diagnosis of BMB (19 months vs 12 months, p = 0.03). Estrogen receptor status did not influence survival after diagnosis of BMB. No difference was observed in survival after diagnosis of BMB based on receptor status in those who received WBRT alone.CONCLUSIONSIn this single-institution series of BMB, the addition of WBRT to GKRS did not significantly influence survival, nor did the number of lesions treated with GKRS. Survival after the diagnosis of BMB was most strongly affected by Her-2 positivity and total metastatic tumor volume.

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Resection and brain brachytherapy with permanent iodine-125 sources for brain metastasis

Journal of Neurosurgery ◽

10.3171/2016.4.jns152530 ◽

2016 ◽

Vol 126 (6) ◽

pp. 1749-1755 ◽

Cited By ~ 10

Author(s):

David R. Raleigh ◽

Zachary A. Seymour ◽

Bryan Tomlin ◽

Philip V. Theodosopoulos ◽

Mitchel S. Berger ◽

...

Keyword(s):

Overall Survival ◽

Brain Metastasis ◽

Brain Metastases ◽

Local Control ◽

Whole Brain Radiotherapy ◽

Cavity Volume ◽

Term Survival ◽

Whole Brain ◽

Brain Radiotherapy ◽

Iodine 125

OBJECTIVEStereotactic radiosurgery (SRS) with or without whole-brain radiotherapy can be used to achieve local control (> 90%) for small brain metastases after resection. However, many brain metastases are unsuitable for SRS because of their size or previous treatment, and whole-brain radiotherapy is associated with significant neurocognitive morbidity. The purpose of this study was to investigate the efficacy and toxicity of surgery and iodine-125 (125I) brachytherapy for brain metastases.METHODSA total of 95 consecutive patients treated for 105 brain metastases at a single institution between September 1997 and July 2013 were identified for this analysis retrospectively. Each patient underwent MRI followed by craniotomy with resection of metastasis and placement of 125I sources as permanent implants. The patients were followed with serial surveillance MRIs. The relationships among local control, overall survival, and necrosis were estimated by using the Kaplan-Meier method and compared with results of log-rank tests and multivariate regression models.RESULTSThe median age at surgery was 59 years (range 29.9–81.6 years), 53% of the lesions had been treated previously, and the median preoperative metastasis volume was 13.5 cm3 (range 0.21–76.2 cm3). Gross-total resection was achieved in 81% of the cases. The median number of 125I sources implanted per cavity was 28 (range 4–93), and the median activity was 0.73 mCi (range 0.34–1.3 mCi) per source. A total of 476 brain MRIs were analyzed (median MRIs per patient 3; range 0–22). Metastasis size was the strongest predictor of cavity volume and shrinkage (p < 0.0001). Multivariable regression modeling failed to predict the likelihood of local progression or necrosis according to metastasis volume, cavity volume, or the rate of cavity remodeling regardless of source activity or previous SRS. The median clinical follow-up time in living patients was 14.4 months (range 0.02–13.6 years), and crude local control was 90%. Median overall survival extended from 2.1 months in the shortest quartile to 62.3 months in the longest quartile (p < 0.0001). The overall risk of necrosis was 15% and increased significantly for lesions with a history of previous SRS (p < 0.05).CONCLUSIONSTherapeutic options for patients with large or recurrent brain metastases are limited. Data from this study suggest that resection with permanent 125I brachytherapy is an effective strategy for achieving local control of brain metastasis. Although metastasis volume significantly influences resection cavity size and remodeling, volumetric parameters do not seem to influence local control or necrosis. With careful patient selection, this treatment regimen is associated with minimal toxicity and can result in long-term survival for some patients.▪ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: retrospective case series; evidence: Class IV.

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CMET-31. WHOLE BRAIN RADIOTHERAPY VERSUS STEREOTACTIC RADIOSURGERY IN POOR-PROGNOSIS PATIENTS WITH 1 – 10 BRAIN METASTASES: A RANDOMIZED FEASIBILITY STUDY

Neuro-Oncology ◽

10.1093/neuonc/noz175.232 ◽

2019 ◽

Vol 21 (Supplement_6) ◽

pp. vi58-vi58

Author(s):

Alan Nichol ◽

Srinivas Raman ◽

Benjamin Mou ◽

Fred Hsu ◽

Boris Valev ◽

...

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Median Survival ◽

Feasibility Study ◽

Systemic Therapy ◽

Poor Prognosis ◽

Whole Brain Radiotherapy ◽

Whole Brain ◽

Brain Radiotherapy ◽

Patients With Poor Prognosis

Abstract BACKGROUND The clinical advantage of stereotactic radiosurgery (SRS) over whole brain radiotherapy (WBRT) in patients with brain metastases and poor prognosis is controversial. To investigate the feasibility of a phase III clinical trial in a population of patients with poor prognosis, we conducted a randomized feasibility study of WBRT versus SRS. METHODS Patients with Karnofsky performance status (KPS) ≥ 70, life expectancy of 3–6 months, based on both Diagnosis-Specific Graded Prognostic Assessments and attending oncologist opinion, and 1– 10 brain metastases with a diameter ≤ 4 cm were enrolled at six Canadian cancer centers. Patients were randomly assigned to WBRT (20 Gy in 5 fractions) or SRS (15 Gy in 1 fraction). The primary endpoint was the rate of accrual. A secondary endpoint was the ratio of screened subjects to accrued subjects. This trial is registered with ClinicalTrials.gov (NCT02220491). RESULTS Between January 2015 and November 2017, 210 were screened to enroll 22 patients (9.5 screened/participant) and 20 patients were randomized. The accrual rate was 0.63 patients / month. The most common reasons for exclusion were: estimated median survival outside 3–6 months (n = 40), baseline KPS below 70 (n = 28), and > 10 brain metastases (n = 28). The median survival was 7.0 months. The overall survival was 9.5 months (n = 11) for patients who had subsequent systemic therapy, compared to 3.7 months (n = 9) in patients who had none. In both arms, the cumulative incidence of retreatment with brain radiotherapy was 40%. CONCLUSIONS Accrual was slow and the median survival was longer than expected, but a randomized trial evaluating WBRT vs SRS in patients with poor prognosis would likely be feasible by enrolling only patients with no remaining systemic therapy options.

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Radiation Necrosis – A Growing Problem in a Case of Brain Metastases Following Whole Brain Radiotherapy and Stereotactic Radiosurgery

Cureus ◽

10.7759/cureus.2037 ◽

2018 ◽

Cited By ~ 2

Author(s):

Yee Pei Song ◽

Rovel J Colaco

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Radiation Necrosis ◽

Whole Brain Radiotherapy ◽

Whole Brain ◽

Brain Radiotherapy

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A Dutch phase III randomized multicenter trial: whole brain radiotherapy vs. stereotactic radiotherapy for 4-10 brain metastases

Neuro-Oncology Advances ◽

10.1093/noajnl/vdab021 ◽

2021 ◽

Author(s):

Dianne Hartgerink ◽

Anna Bruynzeel ◽

Danielle Eekers ◽

Ans Swinnen ◽

Coen Hurkmans ◽

...

Keyword(s):

Quality Of Life ◽

Side Effects ◽

Brain Metastases ◽

Survival Rates ◽

Whole Brain Radiotherapy ◽

Phase Iii ◽

Whole Brain ◽

Brain Radiotherapy ◽

One Year

Abstract Background The clinical value of whole brain radiotherapy (WBRT) for brain metastases (BM) is a matter of debate due to the significant side effects involved. Stereotactic radiosurgery (SRS) is an attractive alternative treatment option that may avoid these side effects and improve local tumor control. We initiated a randomized trial (NCT02353000) to investigate whether quality of life is better preserved after SRS compared with WBRT in patients with multiple brain metastases. Methods Patients with 4 to 10 BM were randomized between the standard arm WBRT (total dose 20 Gy in 5 fractions) or SRS (single fraction or 3 fractions). The primary endpoint was the difference in quality of life (QOL) at three months post-treatment. Results The study was prematurely closed due to poor accrual. A total of 29 patients (13%) were randomized, of which 15 patients have been treated with SRS and 14 patients with WBRT. The median number of lesions were 6 (range, 4-9) and the median total treatment volume was 13.0 cc 3 (range, 1.8-25.9 cc 3). QOL at three months decreased in the SRS group by 0.1 (SD=0.2), compared to 0.2 (SD=0.2) in the WBRT group (p=0.23). The actuarial one-year survival rates were 57% (SRS) and 31% (WBRT) (p=0.52). The actuarial one-year brain salvage-free survival rates were 50% (SRS) and 78% (WBRT) (p=0.22). Conclusion In patients with 4 to 10 BM, SRS alone resulted in one-year survival for 57% of patients while maintaining quality of life. Due to the premature closure of the trial, no statistically significant differences could be determined.

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