Radiosurgery and Whole-Brain Radiation Therapy for Brain Metastases

Abstract

RAIN METASTASES ARE THE MOST FEARED AND DEBILI-tating complication of systemic cancers. They affect approximately 170 000 patients a year, with the most common primary tumors being lung cancer, breast cancer, and melanoma. 1 The traditional approach for patients with brain metastases has been whole-brain radiation therapy (WBRT), irrespective of lesion number or primary site.A shift in treatment occurred for patients with a single brain metastasis after 3 randomized trials were completed. [2][3][4] In these trials patients were randomized to receive WBRT alone or surgical resection of a single brain metastasis followed by WBRT. In studies by Patchell et al 2 and Noordijk et al, 3 resection of a single brain metastasis prior to WBRT led to an increase in median survival of 25 and 17 weeks, respectively. There was also a significant increase in functionality for the surgical group in both studies. A study by Mintz et al 4 did not show a survival advantage for the surgery plus WBRT group, but patient selection (poorer performance status and more advanced systemic disease) most likely accounted for this result.Patchell et al 5 performed the only randomized trial comparing resection of a single brain metastasis to observation or WBRT. Patients treated with resection of their brain metastasis followed by WBRT had better local (10% vs 46%) and distant (18% vs 70%) brain control (ie, development of metastases in other parts of the brain), with fewer patients dying of neurologic causes; importantly, there was no survival advantage or increase in functional independence with WBRT. Only a small number of patients have a single brain metastasis and are good surgical candidates.Stereotactic radiosurgery has an advantage over conventional surgery in that it is noninvasive and allows more than 1 lesion to be treated, including those in areas not surgically accessible. One reason to use stereotactic radiosurgery is to increase effectiveness against "radioresistant tumors," as the dose used is significantly higher than that for WBRT. An additional potential advantage is elimination of the neurotoxicity associated with WBRT. 6 The main limitation of stereotactic radiosurgery is tumor size; tumor num-ber and location may also limit the use of stereotactic radiosurgery. 7 Since 50% to 60% of patients have 1 to 4 brain metastases, 8 they may be candidates for stereotactic radiosurgery but not surgery. Although stereotactic radiosurgery is "functionally" similar to surgery, no randomized trials have been published as to the comparative efficacy of these treatments. Auchter et al 9 used stereotactic radiosurgery with WBRT to treat patients with a single brain metastasis, and outcomes were similar to those reported by Patchell et al 2 and Noordijk et al. 3 Despite these similar outcomes, prospective trials are needed to define optimal treatment using stereotactic radiosurgery and WBRT.In this issue of JAMA, Aoyama and colleagues 10 report the first randomized trial of stereotactic radiosurgery with or without WBRT in patients with up...

Number of metastases, serum lactate dehydrogenase level, and type of treatment are prognostic factors in patients with brain metastases of malignant melanoma

“…An additional benefit of WBRT in conjunction with STR or surgery is still controversial. One investigation has demonstrated that WBRT may delay the development of new BM,17, 28 whereas others have not 24, 29. In our cohort of 200 evaluable patients who were treated with surgery or STR, the subsequent application of WBRT prolonged the median OS by 2 months (7 months vs 9 months).…”

“…One investigation has demonstrated that WBRT may delay the development of new BM, 17,28 whereas others have not. 24,29 In our cohort of 200 evaluable patients who were treated with surgery or STR, the subsequent application of WBRT prolonged the median OS by 2 months (7 months vs 9 months). Not surprisingly, patients who responded to treatment had a better prognosis compared with those who failed treatment.…”

The melanoma-specific graded prognostic assessment does not adequately discriminate prognosis in a modern population with brain metastases from malignant melanoma

“…Further work is needed to refine this model including incorporation of biomarkers (BRAF, RAS, CTLA4 and PD-L1/PD-1) and the effect of treatment options based on their presence or absence. Other prognostic factors previously shown to be important in this disease and excluded from the msGPA, including LDH ( Staudt et al , 2010 ; Eigentler et al , 2011 ; Nieder et al , 2011 ; Partl et al , 2013 ), leptomeningeal disease ( Morris et al , 2004 ), extra-cerebral metastases ( Broadbent et al , 2004 ; Raizer, 2006 ; Rades et al , 2010 ) and size of intra-cranial metastases ( Mathieu et al , 2007 ; Likhacheva et al , 2012 ), may also be relevant to future prognostic indices. Such indices are certainly needed to underpin high-quality randomised controlled trials in an area with a wide disparity in clinical care.…”

The Little Black Book of Neuropsychology

“…Unilateral and/or bilateral radiation therapy is thus the mainstay treatment for brain tumors . Whole-brain radiation therapy (WBRT) is typically employed for brain metastases, irrespective of the number of lesions or location of the tumor (Raizer 2006).…”