Follow-up results of brain metastasis patients undergoing repeat Gamma Knife radiosurgery

Abstract

OBJECTIVEStereotactic radiosurgery (SRS) without upfront whole-brain radiotherapy (WBRT) has influenced recent treatment recommendations for brain metastasis patients. However, in brain metastasis patients who undergo SRS alone, new brain metastases inevitably appear with relatively high incidences during post-SRS follow-up. However, little is known about the second SRS results. The treatment results of second SRS were retrospectively reviewed, mainly for newly developed or, uncommonly, for recurrent brain metastases in order to reappraise the efficacy of this treatment strategy with a special focus on the maintenance of neurological status and safety.METHODSThis was an institutional review board–approved, retrospective cohort study that used a prospectively accumulated database, including 3102 consecutive patients with brain metastases who underwent SRS between July 1998 and June 2015. Among these 3102 patients, 859 (376 female patients; median age 64 years; range 21–88 years) who underwent a second SRS without WBRT were studied with a focus on overall survival, neurological death, neurological deterioration, local recurrence, salvage SRS, and SRS-induced complications after the second SRS. Before the second SRS, the authors also investigated the clinical factors and radiosurgical parameters likely to influence these clinical outcomes. For the statistical analysis, the standard Kaplan-Meier method was used to determine post–second SRS survival and neurological death. A competing risk analysis was applied to estimate post–second SRS cumulative incidences of local recurrence, neurological deterioration, salvage SRS, and SRS-induced complications.RESULTSThe post–second SRS median survival time was 7.4 months (95% CI 7.0–8.2 months). The actuarial survival rates were 58.2% and 34.7% at 6 and 12 months after the second SRS, respectively. Among 789 deceased patients, the causes of death could not be determined in 24 patients, but were confirmed in the remaining 765 patients to be nonbrain diseases in 654 (85.5%) patients and brain diseases in 111 (14.5%) patients. The actuarial neurological death–free survival rates were 94.4% and 86.6% at 6 and 12 months following the second SRS. Multivariable analysis revealed female sex, Karnofsky Performance Scale score of 80% or greater, better modified recursive partitioning analysis class, smaller tumor numbers, and higher peripheral dose to be significant predictive factors for longer survival. The cumulative incidences of local recurrence were 11.2% and 14.9% at 12 and 24 months after the second SRS. The crude incidence of neurological deterioration was 7.1%, and the respective cumulative incidences were 4.5%, 5.8%, 6.7%, 7.2%, and 7.5% at 12, 24, 36, 48, and 60 months after the second SRS. SRS-induced complications occurred in 25 patients (2.9%) after a median post–second SRS period of 16.8 months (range 0.6–95.0 months; interquartile range 5.6–29.3 months). The cumulative incidences of complications were 1.4%, 2.0%, 2.4%, 3.0%, and 3.0% at 12, 24, 36, 48, and 60 months after the second SRS, respectively.CONCLUSIONSCarefully selected patients with recurrent tumors—either new or locally recurrent—are favorable candidates for a second SRS, particularly in terms of neurological status maintenance and the safety of this treatment strategy.

Clinical significance of conformity index and gradient index in patients undergoing stereotactic radiosurgery for a single metastatic tumor

“…All of these criteria for local progression and complications have remained consistent for more than 20 years at our facilities and have also been widely confirmed based on our previous publications. 6,16,[18][19][20]22,24…”

Combination of apatinib and continuous nutritional support for a gastric cancer patient with brain metastasis prolongs survival

“…Several trials suggested that stereotactic radiosurgery is better than WBRT in patients with brain metastases and has shown a survival benefit for patients with good performance status, especially for single brain metastasis . However, a relatively higher incidence of new brain metastases has occurred in the group who underwent stereotactic radiosurgery alone . Another trial suggested that patients who underwent stereotactic radiosurgery plus post‐operative WBRT show better local control and overall survival than those who underwent stereotactic radiosurgery alone, with a median survival of only 16.7 months .…”

“…7-10 However, a relatively higher incidence of new brain metastases has occurred in the group who underwent stereotactic radiosurgery alone. 11 Another trial suggested that patients who underwent stereotactic radiosurgery plus post-operative WBRT show better local control and overall survival than those who underwent stereotactic radiosurgery alone, with a median survival of only 16.7 months. 12 However, there is a lack of consensus about the best way to manage brain metastases of gastric and oesophageal primary tumours, with a variety of different interventions used (eg surgery, RT, WBRT or multimodality treatments).…”

Three-stage Gamma Knife treatment for metastatic brain tumors larger than 10 cm3: a 2-institute study including re-analyses of earlier results using competing risk analysis

“…Our above-mentioned criteria for neurological death, neurological deterioration, local recurrence, and complications have been widely confirmed based on our previous publications. 14,[31][32][33][34][35][36]38…”