Impact of 2-staged stereotactic radiosurgery for treatment of brain metastases ≥ 2 cm

OBJECTIVEStereotactic radiosurgery (SRS) is the primary modality for treating brain metastases. However, effective radiosurgical control of brain metastases ≥ 2 cm in maximum diameter remains challenging and is associated with suboptimal local control (LC) rates of 37%–62% and an increased risk of treatment-related toxicity. To enhance LC while limiting adverse effects (AEs) of radiation in these patients, a dose-dense treatment regimen using 2-staged SRS (2-SSRS) was used. The objective of this study was to evaluate the efficacy and toxicity of this treatment strategy.METHODSFifty-four patients (with 63 brain metastases ≥ 2 cm) treated with 2-SSRS were evaluated as part of an institutional review board–approved retrospective review. Volumetric measurements at first-stage stereotactic radiosurgery (first SSRS) and second-stage SRS (second SSRS) treatments and on follow-up imaging studies were determined. In addition to patient demographic data and tumor characteristics, the study evaluated 3 primary outcomes: 1) response at first follow-up MRI, 2) time to local progression (TTP), and 3) overall survival (OS) with 2-SSRS. Response was analyzed using methods for binary data, TTP was analyzed using competing-risks methods to account for patients who died without disease progression, and OS was analyzed using conventional time-to-event methods. When needed, analyses accounted for multiple lesions in the same patient.RESULTSAmong 54 patients, 46 (85%) had 1 brain metastasis treated with 2-SSRS, 7 patients (13%) had 2 brain metastases concurrently treated with 2-SSRS, and 1 patient underwent 2-SSRS for 3 concurrent brain metastases ≥ 2 cm. The median age was 63 years (range 23–83 years), 23 patients (43%) had non–small cell lung cancer, and 14 patients (26%) had radioresistant tumors (renal or melanoma). The median doses at first and second SSRS were 15 Gy (range 12–18 Gy) and 15 Gy (range 12–15 Gy), respectively. The median duration between stages was 34 days, and median tumor volumes at the first and second SSRS were 10.5 cm3 (range 2.4–31.3 cm3) and 7.0 cm3 (range 1.0–29.7 cm3). Three-month follow-up imaging results were available for 43 lesions; the median volume was 4.0 cm3 (range 0.1–23.1 cm3). The median change in volume compared with baseline was a decrease of 54.9% (range −98.2% to 66.1%; p < 0.001). Overall, 9 lesions (14.3%) demonstrated local progression, with a median of 5.2 months (range 1.3–7.4 months), and 7 (11.1%) demonstrated AEs (6.4% Grade 1 and 2 toxicity; 4.8% Grade 3). The estimated cumulative incidence of local progression at 6 months was 12% ± 4%, corresponding to an LC rate of 88%. Shorter TTP was associated with greater tumor volume at baseline (p = 0.01) and smaller absolute (p = 0.006) and relative (p = 0.05) decreases in tumor volume from baseline to second SSRS. Estimated OS rates at 6 and 12 months were 65% ± 7% and 49% ± 8%, respectively.CONCLUSIONS2-SSRS is an effective treatment modality that resulted in significant reduction of brain metastases ≥ 2 cm, with excellent 3-month (95%) and 6-month (88%) LC rates and an overall AE rate of 11%. Prospective studies with larger cohorts and longer follow-up are necessary to assess the durability and toxicities of 2-SSRS.

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The Volumetric Response of Brain Metastases After Stereotactic Radiosurgery and Its Post-treatment Implications

Neurosurgery ◽

10.1227/neu.0000000000000190 ◽

2013 ◽

Vol 74 (1) ◽

pp. 9-16 ◽

Cited By ~ 21

Author(s):

Suzanne R. Sharpton ◽

Eric K. Oermann ◽

Dominic T. Moore ◽

Eric Schreiber ◽

Riane Hoffman ◽

...

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Local Control ◽

Tumor Volume ◽

Neurological Symptoms ◽

Volume Reduction ◽

Whole Brain Radiation ◽

Local Progression ◽

Tumor Volume Reduction

Abstract BACKGROUND: Changes in tumor volume are seen on magnetic resonance imaging within weeks after stereotactic radiosurgery (SRS), but it remains unclear what clinical outcomes early radiological changes portend. OBJECTIVE: We hypothesized that rapid, early reduction in tumor volume post-SRS is associated with prolonged local control and favorable clinical outcome. METHODS: A retrospective review of patients treated with CyberKnife SRS for brain metastases at the University of North Carolina from 2007 to 2009 was performed. Patients with at least 1 radiological follow-up, minimal initial tumor volume of 0.1 cm3, no previous focal radiation, and no recent whole-brain radiation therapy were eligible for inclusion. RESULTS: Fifty-two patients with 100 metastatic brain lesions were analyzed and had a median follow-up of 15.6 months (range, 2-33 months) and a median of 2 (range, 1–8) metastatic lesions. In treated metastases in which there was a significant tumor volume reduction by 6 or 12 weeks post-SRS, there was no local progression for the duration of the study. Furthermore, patients with metastases that did not reduce in volume by 6 or 12 weeks post-SRS were more likely to require corticosteroids (P = .01) and to experience progression of neurological symptoms (P = .003). CONCLUSION: Significant volume reductions of brain metastases measured at either 6 or 12 weeks post-SRS were strongly associated with prolonged local control. Furthermore, early volume reduction was associated with less corticosteroid use and stable neurological symptoms.

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RADI-27. ROLE OF STEREOTACTIC RADIOSURGERY IN THE CARE OF PATIENTS WITH >/= 25 CUMULATIVE BRAIN METASTASES

Neuro-Oncology Advances ◽

10.1093/noajnl/vdz014.119 ◽

2019 ◽

Vol 1 (Supplement_1) ◽

pp. i27-i27

Author(s):

Carolina Benjamin ◽

Monica Mureb ◽

Bernadine Donahue ◽

Erik Sulman ◽

Joshua Silverman ◽

...

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Tumor Volume ◽

Median Number ◽

Median Dose ◽

Total Tumor Volume ◽

Whole Brain Radiation ◽

Brain Radiation

Abstract INTRODUCTION: Stereotactic radiosurgery (SRS) is an accepted treatment for multiple brain metastases. However, the upper limit of the number of brain metastases over the course of care suitable for this approach is controversial. METHODS: From a review of our prospective registry, 48 patients treated with SRS for ≥ 25 brain metastases in either single or multiple sessions between 2013 and 2019 were identified. Patient, tumor, and treatments characteristics were evaluated. Clinical outcomes and overall survival (OS) were analyzed. RESULTS: Thirty-one females (64.6%) and 17 males (35.4%) with a median age of 56 years (25–91) were included. Primary diagnoses included lung (n=23, 47.9%), breast (n=13, 27.1%), melanoma (n=8, 16.7%), and other (n=4, 8.33%). Initial median GPA index was 2 (0.5–3). Nine patients (18.8%) had received whole brain radiation therapy (WBRT) prior to first SRS treatment, with a median dose of 35Gy (30–40.5Gy). Ten patients (20.8%) received WBRT after initial SRS, with a median dose of 30Gy (20-30Gy). Thus, only 19 patients (40%) ever received WBRT. Median number of radiosurgeries per patient was 3 (1–12). Median number of cumulative tumors irradiated was 31 (25–110). Median number of tumors irradiated at first SRS was 10 (1–35). Median marginal dose for the largest tumor per session was 16Gy (10-21Gy). Median SRS total tumor volume was 6.8cc (0.8–23.4). Median follow-up since initial SRS was 16 months (1–71). At present, 21 (43.7%) are alive. Median OS from the diagnosis of brain metastases was 31 months (2–97), and OS from the time of first SRS, 22 months (1–70). Median KPS at first SRS and last follow-up was the same (90). Sixty-three percent did not require a corticosteroid course. CONCLUSION: In selected patients with a large number of cumulative brain metastases (≥ 25), SRS is effective and safe. Therefore, WBRT may not be required in this population.

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Long-Term Survivorship Following Stereotactic Radiosurgery Alone for Brain Metastases: Risk of Intracranial Failure and Implications for Surveillance and Counseling

Neurosurgery ◽

10.1093/neuros/nyx376 ◽

2017 ◽

Vol 83 (2) ◽

pp. 203-209

Author(s):

Emile Gogineni ◽

John A Vargo ◽

Scott M Glaser ◽

John C Flickinger ◽

Steven A Burton ◽

...

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Tumor Volume ◽

Cox Regression ◽

Primary Study ◽

Regression Methods ◽

Kaplan Meier ◽

Relapse Rates

Abstract BACKGROUND Historically, survival for even highly select cohorts of brain metastasis patients selected for SRS alone is <2 yr; thus, limited literature on risks of recurrence exists beyond 2 yr. OBJECTIVE To investigate the possibility that for subsets of patients the risk of intracranial failure beyond 2 yr is less than the commonly quoted 50% to 60%, wherein less frequent screening may be appropriate. METHODS As a part of our institutional radiosurgery database, we identified 132 patients treated initially with stereotactic radiosurgery (SRS) alone (± pre-SRS surgical resection) with at least 2 yr of survival and follow-up from SRS. Primary study endpoints were rates of actuarial intracranial progression beyond 2 yr, calculated using the Kaplan–Meier and Cox regression methods. RESULTS The median follow-up from the first course of SRS was 3.5 yr. Significant predictors of intracranial failure beyond 2 yr included intracranial failure before 2 yr (52% vs 25%, P < .01) and total SRS tumor volume ≥5 cc (51% vs 25%, P < .01). On parsimonious multivariate analysis, failure before 2 yr (HR = 2.2, 95% CI: 1.2-4.3, P = .01) and total SRS tumor volume ≥5 cc (HR = 2.3, 95% CI: 1.2-4.3, P = .01) remained significant predictors of intracranial relapse beyond 2 yr. CONCLUSION Relapse rates beyond 2 yr following SRS alone for brain metastases are low in patients who do not suffer intracranial relapse within the first 2 yr and with low-volume brain metastases, supporting a practice of less frequent screening beyond 2 yr. For remaining patients, frequent (every 3-4 mo) screening remains prudent, as the risk of intracranial failure after 2 yr remains high.

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RADI-05. Metastatic Neoplasm Volume Kinetics Following Two-Staged Stereotactic Radiosurgery

Neuro-Oncology Advances ◽

10.1093/noajnl/vdab071.075 ◽

2021 ◽

Vol 3 (Supplement_3) ◽

pp. iii18-iii19

Author(s):

Ethan Damron ◽

Antonio Dono ◽

Hatim Chafi ◽

Magda Martir ◽

Tse-Kuan Yu ◽

...

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Local Progression ◽

Alternative Approach ◽

Large Brain ◽

Metastatic Neoplasm ◽

Grade 3 ◽

Volume Kinetics ◽

To Receive

Abstract Introduction Multisession staged stereotactic radiosurgery (2-SSRS) represents an alternative approach for management of large brain metastases (LBMs), with potential theoretical advantages over fractionated SRS and represents an alternative to surgery in poor surgical candidates. We aimed to investigate the clinical efficacy and safety of 2-SSRS in patients with LBMs. Methods LBMs of patients treated with 2-SSRS between 2014 and 2020 were evaluated. Demographic, clinical, and radiologic information was obtained. Volumetric measurements at first SSRS, second SSRS, and follow-up imaging studies were obtained. Results Twenty-six patients with 28 LBMs were included in the study. Fifteen patients (58%) were male. Median age at 2-SSRS was 61 years (range: 31–84). Median marginal doses for first and second SSRS were 15 Gy (range: 12–18 Gy) and 15 Gy (range: 12–16 Gy), respectively. Median duration between sessions was 32 days. Two patients (8%) failed to receive their second SSRS due to local progression. Median tumor volumes at first SSRS, second SSRS, 3-month follow-up, and 6-month follow-up were 8.7 cm3 (range: 1.5–34.7 cm3), 3.3 cm3 (range: 0.8–26.1 cm3), 1.7 cm3 (range: 0.2–10.1 cm3), and 1.4 cm3 (range: .04–20.7 cm3), respectively. The median absolute and relative decrement between S-SRS sessions was 3.7 cm3 (range: 2.8–16.5 cm3) and 49.5% (range: 17.1- 87.1%), respectively. Overall, 26 of the 28 lesions (93%) demonstrated early local control following the first SSRS with 18 lesions (69%) demonstrating a decrease in volume of >30% and 3 lesions (12%) remaining stable. Six lesions (23%) showed disease progression. There were no grade 3 adverse events. Conclusions Our study supports the effectiveness and safety of 2-SSRS as a treatment modality for patients with large, symptomatic brain metastases, especially in non-surgical candidates. The local failure rate and low occurrence of adverse effects are comparable to other staged radiosurgery series.

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What Factors Predict the Response of Larger Brain Metastases to Radiosurgery?

Neurosurgery ◽

10.1227/neu.0b013e318207a58b ◽

2011 ◽

Vol 68 (3) ◽

pp. 682-690 ◽

Cited By ~ 32

Author(s):

Huai-che Yang ◽

Hideyuki Kano ◽

L Dade Lunsford ◽

Ajay Niranjan ◽

John C Flickinger ◽

...

Keyword(s):

Brain Metastases ◽

Tumor Volume ◽

Volume Reduction ◽

Maximum Diameter ◽

Recent Experience ◽

Peritumoral Edema ◽

Persistent Symptoms ◽

Whole Brain Radiation ◽

Edema Volume

Abstract BACKGROUND: Approximately 20 to 40% of patients with systemic malignancies develop brain metastases. OBJECTIVE: To assess the potential role of stereotactic radiosurgery (SRS) for larger metastatic brain tumors, we reviewed our recent experience. METHODS: Between 2004 and 2008, 70 patients with a metastatic brain tumor larger than 3 cm in maximum diameter underwent Gamma knife SRS. Thirty-three patients had received previous whole brain radiation therapy (WBRT) and 37 received only SRS. RESULTS: The overall median follow-up was 8.1 months. At the first planned imaging follow-up at 2 months, 29 (41%) tumors had >50% volume reduction, 22 (31%) had 10 to 50% volume reduction, and 19 (28%) were stable or larger. We also evaluated brain edema using MRI T2 images. In 11 patients (16%) the peritumoral edema volume was reduced by more than 50%, in 25 (36%) it was reduced by 10 to 50%, in 21 (30%) it was stable, and in 13 (19%) it was increased. Twenty (36%) discontinued corticosteroids by the time of first imaging follow-up. Because of persistent symptoms, 7 patients (10%) required a craniotomy to remove the tumor. Tumor volume reduction (>50%) was associated with a single metastasis (P = .012), no previous WBRT (P = .002), and a tumor volume <16 cm3 (P = .002). The better peritumoral edema volume reduction (>50%) was associated with a single metastasis (P = .024), no previous WBRT (P = .05), and breast cancer histology (P = .044). CONCLUSION: Surgical resection remains the primary approach for larger brain metastases if feasible. Tumor volume is a better indicator than maximum diameter. Tumor volume and edema responded better in patients who underwent SRS alone.

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Long-term metabolic evolution of brain metastases with suspected radiation necrosis following stereotactic radiosurgery: longitudinal assessment by F-DOPA PET

Neuro-Oncology ◽

10.1093/neuonc/noaa239 ◽

2020 ◽

Author(s):

Francesco Cicone ◽

Luciano Carideo ◽

Claudia Scaringi ◽

Andrea Romano ◽

Marcelo Mamede ◽

...

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Radiation Necrosis ◽

Standardized Uptake Value ◽

Longitudinal Assessment ◽

Metabolic Evolution ◽

Local Progression ◽

Pet Ct

Abstract Background The evolution of radiation necrosis (RN) varies depending on the combination of radionecrotic tissue and active tumor cells. In this study, we characterized the long-term metabolic evolution of RN by sequential PET/CT imaging with 3,4-dihydroxy-6-[18F]-fluoro-l-phenylalanine (F-DOPA) in patients with brain metastases following stereotactic radiosurgery (SRS). Methods Thirty consecutive patients with 34 suspected radionecrotic brain metastases following SRS repeated F-DOPA PET/CT every 6 months or yearly in addition to standard MRI monitoring. Diagnoses of local progression (LP) or RN were confirmed histologically or by clinical follow-up. Semi-quantitative parameters of F-DOPA uptake were extracted at different time points, and their diagnostic performances were compared with those of corresponding contrast-enhanced MRI. Results Ninety-nine F-DOPA PET scans were acquired over a median period of 18 (range: 12–66) months. Median follow-up from the baseline F-DOPA PET/CT was 48 (range 21–95) months. Overall, 24 (70.6%) and 10 (29.4%) lesions were classified as RN and LP, respectively. LP occurred after a median of 18 (range: 12–30) months from baseline PET. F-DOPA tumor-to-brain ratio (TBR) and relative standardized uptake value (rSUV) increased significantly over time in LP lesions, while remaining stable in RN lesions. The parameter showing the best diagnostic performance was rSUV (accuracy = 94.1% for the optimal threshold of 1.92). In contrast, variations of the longest tumor dimension measured on contrast-enhancing MRI did not distinguish between RN and LP. Conclusion F-DOPA PET has a high diagnostic accuracy for assessing the long-term evolution of brain metastases following SRS.

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Volume of Disease as a Predictor for Clinical Outcomes in Patients With Melanoma Brain Metastases Treated With Stereotactic Radiosurgery and Immune Checkpoint Therapy

Frontiers in Oncology ◽

10.3389/fonc.2021.794615 ◽

2022 ◽

Vol 11 ◽

Author(s):

Aidan M. Burke ◽

Michael Carrasquilla ◽

Walter C. Jean ◽

Brian T. Collins ◽

Amjad N. Anaizi ◽

...

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Clinical Outcomes ◽

Tumor Volume ◽

Cytotoxic T Lymphocyte ◽

Increased Risk ◽

Historical Series ◽

Melanoma Brain Metastases ◽

Median Volume ◽

Cell Death Protein

Purpose/ObjectivesClinical trials of anti-Programmed cell death protein 1 (PD-1) and cytotoxic T-lymphocyte-associated protein (CTLA-4) therapies have demonstrated a clinical benefit with low rates of neurologic adverse events in patients with melanoma brain metastases (MBMs). While the combined effect of these immunotherapies (ITs) and stereotactic radiosurgery (SRS) has yielded impressive results with regard to local control (LC) and overall survival (OS), it has also been associated with increased rates of radiation necrosis (RN) compared to historical series of SRS alone. We retrospectively reviewed patients treated with IT in combination with SRS to report on predictors of clinical outcomes.Materials and MethodsPatients were included if they had MBMs treated with SRS within 1 year of receiving anti-PD-1 and/or CTLA-4 therapy. Clinical outcomes including OS, LC, intracranial death (ID), and RN were correlated with type and timing of IT with SRS, radiation dose, total volume, and size and number of lesions treated.ResultsTwenty-nine patients with 171 MBMs were treated between May 2012 and May 2018. Patients had a median of 5 lesions treated (median volume of 6.5 cm3) over a median of 2 courses of SRS. The median dose was 21 Gy. Most patients were treated with ipilimumab (n = 13) or nivolumab-ipilimumab (n = 10). Most patients underwent SRS concurrently or within 3 months of receiving immunotherapy (n = 21). Two-year OS and LC were 54.4% and 85.5%, respectively. In addition, 14% of patients developed RN; however, only 4.7% of the total treated lesions developed RN. The median time to development of RN was 9.5 months. Patients with an aggregate tumor volume >6.5 cm3 were found to be at increased risk of ID (p = 0.05) and RN (p = 0.03). There was no difference in OS, ID, or RN with regard to type of IT, timing of SRS and IT, number of SRS courses, SRS dose, or number of cumulative lesions treated.ConclusionsIn our series, patients treated with SRS and IT for MBMs had excellent rates of OS and LC; however, patients with an aggregate tumor volume >6.5 cm3 were found to be at increased risk of ID and RN. Given the efficacy of combined anti-PD-1/CTLA-4 therapy for MBM management, further study of optimal selection criteria for the addition of SRS is warranted.

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Biologically effective dose correlates with linear tumor volume changes after upfront single-fraction stereotactic radiosurgery for vestibular schwannomas

Neurosurgical Review ◽

10.1007/s10143-021-01538-w ◽

2021 ◽

Author(s):

Constantin Tuleasca ◽

Mohamed Faouzi ◽

Philippe Maeder ◽

Raphael Maire ◽

Jonathan Knisely ◽

...

Keyword(s):

Standard Deviation ◽

Effective Dose ◽

Stereotactic Radiosurgery ◽

Tumor Volume ◽

Vestibular Schwannomas ◽

Benign Tumors ◽

Biologically Effective Dose ◽

Volume Changes ◽

Single Fraction

AbstractVestibular schwannomas (VSs) are benign, slow-growing tumors. Management options include observation, surgery, and radiation. In this retrospective trial, we aimed at evaluating whether biologically effective dose (BED) plays a role in tumor volume changes after single-fraction first intention stereotactic radiosurgery (SRS) for VS. We compiled a single-institution experience (n = 159, Lausanne University Hospital, Switzerland). The indication for SRS was decided after multidisciplinary discussion. Only cases with minimum 3 years follow-up were included. The Koos grading, a reliable method for tumor classification was used. Radiosurgery was performed using Gamma Knife (GK) and a uniform marginal prescription dose of 12 Gy. Mean BED was 66.3 Gy (standard deviation 3.8, range 54.1–73.9). The mean follow-up period was 5.1 years (standard deviation 1.7, range 3–9.2). The primary outcome was changes in 3D volumes after SRS as function of BED and of integral dose received by the VS. Random-effect linear regression model showed that tumor volume significantly and linearly decreased over time with higher BED (p < 0.0001). Changes in tumor volume were also significantly associated with age, sex, number of isocenters, gradient index, and Koos grade. However, the effect of BED on tumor volume change was moderated by time after SRS and Koos grade. Lower integral doses received by the VSs were inversely correlated with BED in relationship with tumor volume changes (p < 0.0001). Six (3.4%) patients needed further intervention. For patients having uniformly received the same marginal dose prescription, higher BED linearly and significantly correlated with tumor volume changes after SRS for VSs. BED could represent a potential new treatment paradigm for patients with benign tumors, such as VSs, for attaining a desired radiobiological effect. This could further increase the efficacy and decrease the toxicity of SRS not only in benign tumors but also in other SRS indications.

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MRI Texture Analysis for the Prediction of Stereotactic Radiosurgery Outcomes in Brain Metastases from Lung Cancer

Journal of Clinical Medicine ◽

10.3390/jcm10020237 ◽

2021 ◽

Vol 10 (2) ◽

pp. 237

Author(s):

Jung Hyun Park ◽

Byung Se Choi ◽

Jung Ho Han ◽

Chae-Yong Kim ◽

Jungheum Cho ◽

...

Keyword(s):

Lung Cancer ◽

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Texture Analysis ◽

Multivariable Analysis ◽

Texture Features ◽

Progression Free Survival ◽

Clinical Parameter ◽

Imaging Biomarker ◽

Local Progression

This study aims to evaluate the utility of texture analysis in predicting the outcome of stereotactic radiosurgery (SRS) for brain metastases from lung cancer. From 83 patients with lung cancer who underwent SRS for brain metastasis, a total of 118 metastatic lesions were included. Two neuroradiologists independently performed magnetic resonance imaging (MRI)-based texture analysis using the Imaging Biomarker Explorer software. Inter-reader reliability as well as univariable and multivariable analyses were performed for texture features and clinical parameters to determine independent predictors for local progression-free survival (PFS) and overall survival (OS). Furthermore, Harrell’s concordance index (C-index) was used to assess the performance of the independent texture features. The primary tumor histology of small cell lung cancer (SCLC) was the only clinical parameter significantly associated with local PFS in multivariable analysis. Run-length non-uniformity (RLN) and short-run emphasis were the independent texture features associated with local PFS. In the non-SCLC (NSCLC) subgroup analysis, RLN and local range mean were associated with local PFS. The C-index of independent texture features was 0.79 for the all-patients group and 0.73 for the NSCLC subgroup. In conclusion, texture analysis on pre-treatment MRI of lung cancer patients with brain metastases may have a role in predicting SRS response.

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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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