scholarly journals The Expanding Role of Radiosurgery for Brain Metastases

2018 ◽  
Author(s):  
Mark O'Beirn ◽  
Helen Benghiat ◽  
Sara Meade ◽  
Geoff Heyes ◽  
Vijay Sawlani ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Local Control ◽  
Systemic Disease ◽  
Whole Brain Radiotherapy ◽  
Targeted Agents ◽  
Brain Radiotherapy ◽  
Multiple Metastases ◽  
Rising Incidence ◽  
Molecular Information

Stereotactic radiosurgery (SRS) has become increasingly important in the management of brain metastases due to improving systemic disease control and rising incidence. Initial trials demonstrated SRS with whole brain radiotherapy (WBRT) improved local control rates versus WBRT alone. Concerns with WBRT associated neurocognitive toxicity have contributed to greater use of SRS alone, including for patients with multiple metastases and following surgical resection. Molecular information, targeted agents and immunotherapy have also altered the landscape for the management of brain metastases. This review summarises current and emerging data on the role of SRS in the management of brain metastases.

scholarly journals The Expanding Role of Radiosurgery for Brain Metastases

Medicines ◽  
2018 ◽  
Vol 5 (3) ◽  
pp. 90 ◽  
Author(s):  
Mark O’Beirn ◽  
Helen Benghiat ◽  
Sara Meade ◽  
Geoff Heyes ◽  
Vijay Sawlani ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Local Control ◽  
Systemic Disease ◽  
Whole Brain Radiotherapy ◽  
Targeted Agents ◽  
Brain Radiotherapy ◽  
Multiple Metastases ◽  
Rising Incidence ◽  
Molecular Information

Stereotactic radiosurgery (SRS) has become increasingly important in the management of brain metastases due to improving systemic disease control and rising incidence. Initial trials demonstrated SRS with whole-brain radiotherapy (WBRT) improved local control rates compared with WBRT alone. Concerns with WBRT associated neurocognitive toxicity have contributed to a greater use of SRS alone, including for patients with multiple metastases and following surgical resection. Molecular information, targeted agents, and immunotherapy have also altered the landscape for the management of brain metastases. This review summarises current and emerging data on the role of SRS in the management of brain metastases.

scholarly journals Current treatment of patients with multiple brain metastases

2000 ◽  
Vol 9 (2) ◽  
pp. 1-5 ◽  
Author(s):  
Steven D. Chang ◽  
John R. Adler
Keyword(s):  
Brain Metastases ◽  
Treatment Options ◽  
Whole Brain Radiotherapy ◽  
Mass Effect ◽  
Current Treatment ◽  
Rapid Reduction ◽  
Multiple Brain Metastases ◽  
Brain Radiotherapy ◽  
Multiple Metastases ◽  
Difficult Challenge

The management of patients with multiple brain metastases remains a difficult challenge for neurosurgeons. This patient population has a poor prognosis when compared with those harboring a solitary brain metastasis, and historically treatment has generally consisted of administering whole-brain radiotherapy once the diagnosis of multiple brain metastases is made. Resection can be useful in a subset of patients with multiple metastases in whom one or two of the lesions are symptomatic, as this may provide rapid reduction of mass effect and edema. Furthermore, the authors of recent studies have shown that stereotactic radiosurgery can be used in certain patients with multiple brain metastases as part of the treatment regimen. In this review the authors outline the treatment options and indications as well as a management strategy for the treatment of patients with multiple brain metastases.

Clinical Outcomes of Upfront Stereotactic Radiosurgery Alone for Patients With 5 to 15 Brain Metastases

Neurosurgery ◽  
2018 ◽  
Vol 85 (2) ◽  
pp. 257-263 ◽  
Author(s):  
Ryan T Hughes ◽  
Emory R McTyre ◽  
Michael LeCompte ◽  
Christina K Cramer ◽  
Michael T Munley ◽  
...  
Keyword(s):  
Overall Survival ◽  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Clinical Outcomes ◽  
Whole Brain Radiotherapy ◽  
Cox Proportional Hazards ◽  
Whole Brain ◽  
Brain Radiotherapy ◽  
Increased Risk

Abstract BACKGROUND The role of primary stereotactic radiosurgery (SRS) for patients with >4 brain metastases (BM) remains controversial. OBJECTIVE To compare the outcomes of patients treated with upfront SRS alone for 1, 2 to 4, and 5 to 15 BM and assess for predictors of clinical outcomes in the 5 to 15 BM group. METHODS A total of 478 patients treated with upfront SRS were stratified by number of lesions: 220 had 1 BM, 190 had 2 to 4 BM, and 68 patients had 5 to 15 BM. Overall survival and whole brain radiotherapy-free survival were estimated using the Kaplan–Meier method. The cumulative incidences of local failure and distant brain failure (DBF) were estimated using competing risks methodology. Clinicopathologic and dosimetric parameters were evaluated as predictors of survival and DBF in patients with 5 to 15 BM using Cox proportional hazards. RESULTS Median overall survival was 8.0, 6.3, and 4.7 mo for patients with 1, 2 to 4, and 5 to 15 BM, respectively (P = .14). One-year DBF was 27%, 44%, and 40%, respectively (P = .01). Salvage SRS and whole brain radiotherapy rates did not differ. Progressive extracranial disease and gastrointestinal primary were associated with poor survival while RCC primary was associated with increased risk of DBF. No evaluated dose-volume parameters predicted for death, neurologic death or toxicity. CONCLUSION SRS for 5 to 15 BM is well tolerated without evidence of an associated increase in toxicity, treatment failure, or salvage therapy. Further prospective, randomized studies are warranted to clarify the role of SRS for these patients.

Phase II trial of sunitinib as adjuvant therapy after stereotactic radiosurgery (SRS) in patients with 1-3 newly diagnosed brain metastases.

2012 ◽  
Vol 30 (15_suppl) ◽  
pp. 2018-2018
Author(s):  
David M. Peereboom ◽  
Samuel T. Chao ◽  
John H. Suh ◽  
Ding Wang ◽  
Tom Mikkelsen ◽  
...  
Keyword(s):  
Adjuvant Therapy ◽  
Brain Metastases ◽  
Systemic Disease ◽  
Neuropsychological Testing ◽  
Local Therapy ◽  
Whole Brain Radiotherapy ◽  
Growth Factor Signaling ◽  
Newly Diagnosed ◽  
Brain Radiotherapy ◽  
Primary Disease

2018 Background: For patients with 1-3 brain metastases, standard therapy after SRS is adjuvant whole brain radiotherapy (WBRT). SRS without WBRT carries a higher rate of brain relapse. Due to concerns about neurologic sequelae of WBRT, however, many patients and physicians opt to defer WBRT until the time of central nervous system (CNS) progression. This trial used sunitinib as an alternative to WBRT for post-SRS adjuvant therapy. Sunitinib inhibits vascular endothelial growth factor signaling, and we hypothesized that it would prevent growth of microscopic brain metastases presumed to be present. The objective was to use adjuvant sunitinib after SRS to prevent the emergence of new or progressive disease in the brain or at the site of SRS and to preserve neurocognitive function. Methods: Eligible patients had 1-3 newly diagnosed brain metastases, RTOG RPA class 1-2, and started sunitinib < 1 month after SRS and baseline neuropsychological testing (NPT). Patients with controlled systemic disease were allowed to continue chemotherapy for their primary disease according to a list of published regimens (therapy + sunitinib) included in the protocol. Patients received sunitinib 37.5 or 50 mg/d days 1-28 every 42 days until CNS progression. NPT and MRIs were obtained every 2 cycles. The primary endpoint was the rate of CNS progression at 6 months (PFS6) after SRS. Results: Fourteen patients enrolled. The median age was 59 (range 46-80). Main histologies: lung 36%, breast 21%, melanoma 14%. Toxicities: Grade 4: neutropenia [ANC] (1 pt); Grade 3: fatigue (5), ANC (2), rash (1). Dose reduction due to toxicity: 1 pt (to 37.5 mg/d). The CNS PFS6 and PFS12 were 50% + 13% and 43% + 13%, respectively. The median PFS was 6.6 months (95% C.I. 1.5-19). NPT results will be reported at the meeting. Conclusions: Sunitinib after SRS for 1-3 brain metastases was well tolerated with a PFS6 of 50%. The use of novel agents to prevent progressive brain metastasis after SRS requires the incorporation of chemotherapy regimens to control the patient’s primary disease. Future trials should continue to explore the paradigm of secondary chemoprevention of brain metastases after definitive local therapy (surgery or SRS).

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

2016 ◽  
Vol 126 (6) ◽  
pp. 1749-1755 ◽  
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.

scholarly journals Hypofractionated stereotactic radiotherapy with or without whole-brain radiotherapy for patients with newly diagnosed brain metastases from non–small cell lung cancer

2012 ◽  
Vol 117 (Special_Suppl) ◽  
pp. 49-56 ◽  
Author(s):  
Liang-Hua Ma ◽  
Guang Li ◽  
Hong-Wei Zhang ◽  
Zhi-Yu Wang ◽  
Jun Dang ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Stereotactic Radiotherapy ◽  
Whole Brain Radiotherapy ◽  
Tumor Control ◽  
Newly Diagnosed ◽  
Small Cell Lung ◽  
Hypofractionated Stereotactic Radiotherapy ◽  
Brain Radiotherapy ◽  
Kaplan Meier ◽  
Multiple Metastases

Object This study was undertaken to analyze outcomes in patients with newly diagnosed brain metastases from non–small cell lung cancer (NSCLC) who were treated with hypofractionated stereotactic radiotherapy (HSRT) with or without whole-brain radiotherapy (WBRT). Methods One hundred seventy-one patients comprised the study population. Fifty-four patients received HSRT alone, and 117 patients received both HSRT and WBRT. The median survival time (MST) was determined using the Kaplan-Meier method. Recursive Partitioning Analysis (RPA) and Graded Prognostic Assessment (GPA) were also used to evaluate the results. Univariate and multivariate analyses were performed to determine significant prognostic factors for overall survival. Tumor control, radiation toxicity, and cause of death in the HSRT and HSRT+WBRT groups were evaluated. Results The MST for all patients was 13 months. According to the Kaplan-Meier method, the probability of survival at 1, 2, and 3 years was 51.2%, 21.7%, and 10.1%. The MSTs for RPA Classes I, II, and III were 19, 12, and 5 months, respectively; and the MSTs for GPA Scores 4, 3, 2, and 1 were 24, 14, 12, and 6 months, respectively. The MSTs in the HSRT+WBRT and HSRT groups were 13 and 9 months (p = 0.044), respectively, for all patients, 13 and 8 months (p = 0.031), respectively, for patients with multiple brain metastases, and 16 and 15 months (p = 0.261), respectively, for patients with a single brain metastasis. The multivariate analysis showed that HSRT+WBRT was a significant factor only for patients with multiple brain metastases (p = 0.010). The Kaplan-Meier–estimated tumor control rates at 3, 6, 9, and 12 months were 92.2%, 82.7%, 79.5%, and 68.3% in the HSRT+WBRT group and 73.5%, 58.4%, 51.0%, and 43.3% in the HSRT group, respectively, in all 165 patients (p = 0.001). The estimated tumor control rates at 3, 6, 9, and 12 months were 94.3%, 81.9%, 79.6%, and 76.7%, respectively, in the HSRT+WBRT group and 77.8%, 61.4%, 52.6%, and 48.2%, respectively, in the HSRT group in the 80 patients harboring a single metastasis (p = 0.009). The estimated tumor control rates at 3, 6, 9, and 12 months were 90.5%, 83.5%, 79.5%, and 60.9%, respectively, in the HSRT+WBRT group and 68.2%, 54.5%, 48.5%, and 36.4%, respectively, in the HSRT group in the 85 patients with multiple metastases (p = 0.010). The toxicity incidences of Grade 3 or worse were 6.0% (7 of 117 patients) in the HSRT+WBRT group and 1.9% (1 of 54 patients) in the HSRT group (p = 0.438). The differences in neurological death rates between the HSRT+WBRT group and the HSRT group were not statistically significant (34.4% vs 44.7%, p = 0.125, in all patients; 30.0% vs 52.0%, p = 0.114, in patients with a single metastasis; and 38.0% vs 36.4%, p = 0.397, in patients with multiple metastases). Conclusions The overall survival results in the present study were similar to those in other studies. Hypofractionated stereotactic radiotherapy provides an alternative method to traditional stereotactic radiosurgery. We suggest that WBRT should be combined with HSRT in patients with single or multiple newly diagnosed brain metastases from NSCLC.

Multiple brain metastases are associated with poor survival in patients treated with surgery and radiotherapy.

1993 ◽  
Vol 11 (2) ◽  
pp. 369-373 ◽  
Author(s):  
M B Hazuka ◽  
W D Burleson ◽  
D N Stroud ◽  
C E Leonard ◽  
K O Lillehei ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Randomized Study ◽  
Survival Rates ◽  
Whole Brain Radiotherapy ◽  
Whole Brain ◽  
Primary Tumor Site ◽  
Tumor Histology ◽  
Multiple Brain Metastases ◽  
Brain Radiotherapy

PURPOSE A retrospective analysis was performed to evaluate the role of surgery in the management of patients with solitary and multiple brain metastases. PATIENTS AND METHODS Between 1980 and 1990, 46 patients underwent surgical resection of brain metastases at the University of Colorado Health Sciences Center. All but two patients received postoperative whole-brain radiotherapy to a median total dose of 30 Gy (range, 11.4 Gy to 50.0 Gy). Lung was the most common (56%) primary site and adenocarcinoma was the most common (46%) tumor histology. Twenty-eight of 46 patients (61%) had solitary metastases, while the remaining 18 patients had two or more foci. RESULTS The median survival of all 46 patients was 11 months, and the 1- and 2-year survival rates were 40% and 12%, respectively. Moderately severe to severe neurologic impairment at the time of diagnosis and the presence of multiple brain metastases were associated with a significantly poorer survival. In patients with solitary metastasis, gross total resection and adenocarcinoma tumor histology significantly prolonged survival, whereas primary tumor site, the presence of active extracranial disease, and radiation dose had no significant effect on survival. CONCLUSION These results are consistent with a recent randomized study supporting the role of surgery and whole-brain radiation therapy in the management of patients with solitary brain metastases. We would caution against the generalization of this concept to patients with two or more brain metastases.

scholarly journals Survival in Melanoma Brain Metastases in the era of novel systemic therapies

2020 ◽  
Author(s):  
Joseph P Merola ◽  
Joanita Ocen ◽  
Satish Kumar ◽  
James Powell ◽  
Caroline Hayhurst
Keyword(s):  
Brain Metastases ◽  
Demographic Data ◽  
Systemic Disease ◽  
Whole Brain Radiotherapy ◽  
Progression Free Survival ◽  
Poor Overall Survival ◽  
Aggressive Approach ◽  
Brain Radiotherapy ◽  
Melanoma Brain Metastases ◽  
Receive Treatment

Abstract Background Melanoma brain metastases (MBM) have historically poor overall survival (OS). Recently introduced systemic anticancer therapies (SACT), namely targeted therapies (TT) such as BRAF inhibitors and immunotherapy (IO), to control advanced disease have shown improved survival. Today, increasingly aggressive strategies are sought for MBM. We review outcomes in MBM after surgery or stereotactic radiosurgery (SRS) and the survival impact in advanced systemic disease when combined with novel anticancer therapies. Methods Retrospective cohort study of patients referred to a regional neuro-oncology multidisciplinary (MDT) meeting with MBM. Demographic data, extent of systemic disease and data on surgical and oncological management were collected, plus use of SACT. The primary outcomes were median OS, 12 and 24 month survival and progression-free survival. Results Between 2010 – 2018 142 patients with MBM were referred. Following the introduction of SACT the rate of referrals to MDT more than doubled from 11.6 to 25.7 patients per year. A focal brain metastasis was treated surgically in 23 (16.2%) patients, and by SRS in 29 (20.4%). 56 (39.4%) patients underwent palliative whole brain radiotherapy (WBRT) and 34 (23.9%) did not receive treatment. Median OS was 11 months for the surgical cohort, 9 months for the SRS cohort and increased when treatment with or without SACT was considered to 23 months and 12 months respectively. Conclusion In the setting of SACTs, survival in MBM is significantly improved after surgery or SRS even in patients with advanced and uncontrolled systemic disease at the time of presentation, supporting an aggressive approach to MBM management.

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