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Properly Selected Patients with Multiple Brain Metastases May Benefit from Aggressive Treatment of their Intracranial Disease

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Abstract

To determine whether properly selected patients with multiple brain metastases benefit from aggressive treatment of their intracranial disease, we reviewed 52 patients having stereotactic radiosurgery (SRS), tumor resection, or both between April 1997 and March 2000. Tumor histology included lung (n = 18, 35%), breast (n = 11, 21%), renal (n = 6, 12%), melanoma (n = 6, 12%), and other (n = 11, 21%). The median patient age was 58 years, the median Karnofsky performance status (KPS) was 90, and the median number of tumors was three. Twenty patients (39%) had progressed after prior radiation therapy. Treatment included multiple craniotomies and tumor resection (n = 5, 10%), radiosurgery (n = 31, 60%), or resection and radiosurgery (n = 16, 30%). Median survival was 15.5 months. The one- and two-year actuarial survivals were 63% and 27%, respectively. Multivariate analysis found radiation therapy oncology group recursive partitioning analysis (RTOG RPA) Class (1 vs. 2/3) correlated with improved survival (Relative risk = 2.60, 95% CI 1.13–5.97, p = 0.03). Class 1 patients (KPS ≥ 70, age > 65 years, and controlled primary with no extracranial metastases) survived a median of 19 months whereas Class 3 patients (KPS > 70) survived 8 months. Class 2 patients (all other patients) survived a median of 13 months. Thirty-five patients (67%) had intracranial progression at a median of 8.0 months. Intracranial progression was local (n = 6), distant (n = 23), or local and distant (n = 6); 26 patients with intracranial progression underwent additional brain tumor treatments. Multivariate analysis found patients with radiosensitive tumors (lung, breast, other) had fewer intracranial recurrences compared to patients with radio-resistant tumors (melanoma, renal, sarcoma) (Relative risk = 2.43, 95% CI 1.13–5.10, p = 0.02). The length of survival in our series is quite comparable to historical reports on the management of brain metastasis patients, and supports aggressive intervention for RTOG RPA Class 1 patients and Class 2 patients with controlled primary disease who have a limited number of brain metastases.

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References

  1. Nussbaum ES, Djalilian HR, Cho KH, Hall WA: Brain metastases: histology, multiplicity, surgery and survival. Cancer 78: 1781–1788, 1996

    Google Scholar 

  2. Posner J: Management of brain metastases. Rev Neurol 148: 477–487, 1992

    Google Scholar 

  3. Lagerwaard FJ, Levendag PC, Nowak PJ, Eijkenboom WMH, Hanssens PEJ, Schmitz PIM: Identifi-cation of prognostic factors in patients with brain metastases: a review of 1292 patients. Int J Radiat Oncol Biol Phys 43: 795–803, 1999

    Google Scholar 

  4. Nieder C, Nestle U, Motaref B, Walter K, Niewald M, Schnabel K: Prognostic factors in brain metastases: should patients be selected for aggressive treatment according to recursive partitioning analysis (RPA) classes? Int J Radiat Oncol Biol Phys 46: 297–302, 2000

    Google Scholar 

  5. Gaspar L, Scott C, Rotman M, Asbell S, Phillips T, Wasserman T, McKenna WG, Byhardt R: Recursive partitioning analysis (RPA) of prognostic factors in three radiation therapy oncology group (RTOG) brain metastases trials. Int J Radiat Oncol Biol Phys 37: 745–751, 1997

    Google Scholar 

  6. Bindal RK, Sawaya R, Leavens ME, Lee JJ: Surgical treatment of multiple brain metastases. J Neurosurg 79: 210–216, 1993

    Google Scholar 

  7. Alexander E III, Moriarty TM, Davis RB, Wen PY, Fine HA, Black PMcL, Kooy HM, Loeffler JS: Stereotactic radiosurgery for the definitive, noninvasive treatment of brain metastases. J Natl Cancer Inst 87: 34–40, 1995

    Google Scholar 

  8. Auchter RM, Lamond JP, Alexander E III, Buatti JM, Chappell R, Friedman WA, Knisella TJ, Levin AB, Noyes WR, Schultz CJ, Loeffler JS, Mehta MP: a multiinstitutional outcome and prognostic factor analysis of radiosurgery for resectable single brain metastasis. Int J Radiat Oncol Biol Phys 35: 27–35, 1996

    Google Scholar 

  9. Buatti JM, Friedman WA, Bova FJ, Mendenhall WM: Treatment selection factors for stereotactic radiosurgery of intracranial metastases. Int J Radiat Oncol Biol Phys 32: 1161–1166, 1995

    Google Scholar 

  10. Flickinger JC, Kondziolka D, Lunsford LD, Coffey RJ, Goodman ML, Shaw EG, Hudgins WR, Weiner R, Harsh GR, Sneed PK, Larson DA: A multi-institutional experience with stereotactic radiosurgery for solitary brain metastasis. Int J Radiat Oncol Biol Phys 28: 797–802, 1994

    Google Scholar 

  11. Joseph J, Adler JR, Cox RS, Hancock SL: Linear accelerator-based stereotactic radiosurgery for brain metastases: the influence of number of lesions on survival. J Clin Oncol 14: 1085–1092, 1996.

    Google Scholar 

  12. Lavine SD, Petrovich Z, Cohen-Gadol AA, Marsi LS, Morton DL, O'Day SJ, Essner R, Zelman V, Yu C, Luxton G, Apuzzo MLJ: Gamma knife radiosurgery for metastatic melanoma: an analysis of survival, outcome, and complications. Neurosurgery 44: 59–66, 1999

    Google Scholar 

  13. Matsuo T, Shibata S, Yasunga A, Iwanaga M, Mori K, Shimizu T, Hayashi N, Ochi M, Hayashi K: Dose optimization and indications of Linac radiosurgery for brain metastases. Int J Radiat Oncol Biol Phys 45: 931–939, 1999

    Google Scholar 

  14. Mori Y, Kondziolka D, Lunsford LD, Logan T, Flickinger JC: Stereotactic radiosurgery for brain metastases from renal cell carcinoma. Cancer 83: 344–353, 1998

    Google Scholar 

  15. Muacevic A, Kreth FW, Horstmann GA, Schmid-Elsaesser R, Wowra B, Steiger HJ, Reulen HJ: Surgery and radiotherapy compared to gamma knife radiosurgery in the treatment of solitary cerebral metastases of small diameter. J Neurosurg 91: 35–43, 1999

    Google Scholar 

  16. Pirzkall A, Debrus J, Lohr F, Fuss M, Rhein B, Engenhart-Cabillic R, Wannenmacher M: Radiosurgery alone or in conjunction with whole-brain radiotherapy for brain metastases. J Clin Oncol 16: 3563–3569, 1998

    Google Scholar 

  17. Schoeggl A, Kitz K, Ertel A, Reddy M, Bavinski G, Schneider B: Prognostic factor analysis for multiple brain metastases after gamma knife radiosurgery: results in 97 patients. J Neuro-Oncol 42: 169–175, 1999

    Google Scholar 

  18. Sneed PK, Lamborn KR, Forstner JM, McDermott MW, Chang S, Park E, Gutin PH, Phillips TL, Wara WM, Larson DA: Radiosurgery for brain metastases: is whole brain radiotherapy necessary. Int J Radiat Oncol Biol Phys 43: 549–558, 1999

    Google Scholar 

  19. Weltman E, Salvajoli JV, Brandt RA, Hanriot RM, Prisco FE, Cruz JC, De Oliveria SR, Wajsbrot DB: Radiosurgery for brain metastases: a score index for predicting prognosis. Int J Radiat Oncol Biol Phys 46: 1155–1161, 2000

    Google Scholar 

  20. Kondziolka D, Patel A, Lunsford LD, Kassam A, Flickinger JC: Stereotactic radiosurgery plus whole brain radiotherapy versus radiotherapy alone for patients with multiple brain metastases. Int J Radiat Oncol Biol Phys 45: 427–434, 1999

    Google Scholar 

  21. Pollock BE: Management of patients with multiple brain metastases. Cont Neurosurg 21(18): 1–6, 1999

    Google Scholar 

  22. Kormarnicky LT, Phillips TL, Martz K, Asbell S, Isaacson S, Urtasun R: A randomized Phase III protocol for the evaluation of misonidazole combined with radiation in the treatment of patients with brain metastases (RTOG-79-16). Int J Radiat Oncol Biol Phys 20: 53–58, 1991

    Google Scholar 

  23. Sause WT, Scott C, Krisch R, Rotman M, Sneed PK, Janjan N, Davis L, Curran W, Choi KW, Selim H: Phase I/II trial of accelerated fractionation in brain metastases RTOG 85—28. Int J Radiat Oncol Biol Phys 26: 653–657, 1993

    Google Scholar 

  24. Mintz AH, Kestle J, Rathbone MP, Gaspar L, Hugenholtz H, Fisher B, Duncan G, Skingley P, Foster G, Levine M: A randomized trial to assess the efficacy of surgery in addition to radiotherapy in patients with single cerebral metastasis. Cancer 78: 1470–1476, 1996

    Google Scholar 

  25. Patchell RA, Tibbs PA, Walsh JW, Dempsey RJ, Maruyama Y, Kryscio RJ, Markesberry WR, MacDonald JS, Young B: A randomized trial of surgery in the treatment of single brain metastases to the brain. N Engl J Med 322: 494–500, 1990

    Google Scholar 

  26. Vecht CJ, Haaxma-Reiche H, Noordijk EM, Padberg GW, Voormolen JHC, Hoekstra FH, Tans JTJ, Lambooij N, Metsaars JAL, Wattendorf AR, Brand R, Hermans J: Treatment of single brain metastasis: radiotherapy alone or combined with neurosurgery. Ann Neurol 33: 583–590, 1993

    Google Scholar 

  27. Smalley SR, Laws ER Jr, O'Fallon JR, Shaw EG, Schray MF: Resection for solitary brain metastasis. Role of 80 adjuvant radiation and prognostic variables in 229 patients. J Neurosurg 77: 531–540, 1992

    Google Scholar 

  28. Blindal AK, Blindal RK, Hess KR, Shiu A, Hassenbusch SJ, Shi WM, Sawaya R: Surgery versus radiosurgery in the treatment of brain metastasis. J Neurosurg 84: 748–754, 1996

    Google Scholar 

  29. Patchell RA, Tibbs PA, Regine WF, Dempsey RJ, Mohiuddin M, Kryscio RJ, Markesberry WR, Foon KA, Young B: Postoperative radiotherapy in the treatment of single metastasis to the brain: a randomized trial. JAMA 280: 1485–1489, 1998

    Google Scholar 

  30. Regine WF, Huhn JL, Patchell RA, Clair WH, Strottmann J, Meigooni A, Sanders M, Young AB: Risk of symptomatic brain tumor recurrence and neurologic deficit after radiosurgery alone in patients with newly diagnosed brain metastases: results and implications. Int J Radiat Oncol Biol Phys 52: 333–338, 2002

    Google Scholar 

  31. Shaw EG: Radiotherapeutic management of multiple brain metastases: “3000 in 10” whole brain radiation radiation is no longer a “no brainer”. Int J Radiat Oncol Biol Phys 45: 253–254, 1999

    Google Scholar 

  32. Agboola O, Benoit B, Cross C, Silva VD, Esche B, Lesiuk H, Gonsalves C: Prognostic factors derived from recursive partitioning analysis (RPA) of Radiation Therapy Oncology Group (RTOG) brain metastases trials applied to surgically resected and irradiated cases. Int J Radiat Oncol Biol Phys 42: 155–159, 1998

    Google Scholar 

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Authors and Affiliations

  1. Department of Neurological Surgery, Mayo Clinic and Foundation, Rochester, MN, USA

    Bruce E. Pollock

  2. Division of Radiation Oncology, Mayo Clinic and Foundation, Rochester, MN, USA

    Paul D. Brown, Robert L. Foote, Scott L. Stafford & Paula J. Schomberg

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  1. Bruce E. Pollock
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  2. Paul D. Brown
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  4. Scott L. Stafford
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Pollock, B.E., Brown, P.D., Foote, R.L. et al. Properly Selected Patients with Multiple Brain Metastases May Benefit from Aggressive Treatment of their Intracranial Disease. J Neurooncol 61, 73–80 (2003). https://doi.org/10.1023/A:1021262218151

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