Prognostic factors for patients with brain metastases vary by diagnosis, and for each diagnosis, a robust separation into different GPA scores was discerned, implying considerable heterogeneity in outcome, even within a single tumor type. In summary, these indices and related worksheet provide an accurate and facile diagnosis-specific tool to estimate survival, potentially select appropriate treatment, and stratify clinical trials for patients with brain metastases.

BACKGROUND The diagnosis-specific Graded Prognostic Assessment (GPA) was published to clarify prognosis for patients with brain metastases. This study refines the existing Breast-GPA by analyzing a larger cohort and tumor subtype. METHODS A multi-institutional retrospective database of 400 breast cancer patients treated for newly-diagnosed brain metastases was generated. Prognostic factors significant for survival were analyzed by multivariate Cox regression (MCR) and recursive partitioning analysis (RPA). Factors were weighted by the magnitude of their regression coefficients to define the GPA index. RESULTS Significant prognostic factors by MCR and RPA were Karnofsky Performance Status (KPS), HER2, ER/PR status, and the interaction between ER/PR and HER2. RPA showed age was significant for patients with KPS 60–80. The median survival time (MST) overall was 13.8 months, and for GPA scores of 0–1.0, 1.5–2.0, 2.5–3.0 and 3.5–4.0 was 3.4 (n=23), 7.7 (n=104), 15.1 (n=140) and 25.3 (n=133) months, respectively (p < 0.0001). Among HER2-negative patients, being ER/PR-positive improved MST from 6.4 to 9.7 months whereas in HER2-positive patients, being ER/PR-positive improved MST from 17.9 to 20.7 months. The log-rank statistic (predictive power) was 110 for the Breast-GPA versus 55 for tumor subtype. CONCLUSIONS The Breast-GPA documents wide variation in prognosis and shows clear separation between subgroups of patients with breast cancer and brain metastases. This tool will aid clinical decision-making and stratification of clinical trials. These data confirm the effect of tumor subtype on survival and show the Breast-GPA offers significantly more predictive power than the tumor subtype alone.

Cirrhotic livers are characterized by advanced fibrosis and the formation of hepatocellular nodules, which are classified histologically as either (a) regenerative lesions (eg, regenerative nodules, lobar or segmental hyperplasia, focal nodular hyperplasia) or (b) dysplastic or neoplastic lesions (eg, dysplastic foci and nodules, hepatocellular carcinomas). The differentiation of these lesions is important because regenerative nodules are benign, whereas dysplastic and neoplastic nodules are premalignant and malignant, respectively. However, their accurate characterization may be difficult even at histopathologic analysis. Differential diagnosis may be facilitated by comparing the clinical and pathologic findings with radiologic imaging features; in particular, nodule size, vascularity, hepatocellular function, and Kupffer cell density assessed at magnetic resonance (MR) imaging are suggestive of the correct diagnosis. MR imaging is more useful than computed tomography for such assessments because it provides better soft-tissue contrast and a more nuanced depiction of different tissue properties. Moreover, a wider variety of contrast agents is available for use in MR imaging. Familiarity with the MR imaging characteristics of cirrhosis-associated hepatocellular nodules is therefore important for optimal diagnosis and management of cirrhotic disease.

In this series, SRS using a median dose of 16 Gy provided excellent local control with relatively low morbidity in patients with brainstem metastases less than 1 ml or non-melanoma, non-renal cell histology.