Linac radiosurgery for brain metastasis of melanoma

PURPOSE: To evaluate the efficacy and toxicity of stereotactic radiotherapy in the treatment of brain metastases of melanoma. PATIENTS AND METHODS: From 1994 to 2001, 25 patients presenting with 61 metastases of cutaneous melanoma were treated with radiosurgery. Median age was 47 years (range: 25-73 years) and median Karnofski performance status 80 (range: 50-100). Twenty patients had one radiosurgery, 5 had two or three. Median metastasis diameter was 21 mm (range: 6-54.4 mm), and median metastasis volume was 1.7 cm(3) (range: 0.4-25.6 cm(3)). Irradiation was delivered by a linear accelerator. Median minimal dose was 14.1 Gy (range: 10-19.4 Gy), and median maximal dose was 20.5 Gy (range: 16-48 Gy). RESULTS: Mean follow-up was 12.6 months (range: 1-85 months). Five metastases progressed (9.8%), 2-12 months after radiosurgery. Three-, 6- and 12-month local control rates were 95 +/- 3, 90 +/- 5 and 84 +/- 7%, respectively. By univariate analysis, only absence of extracranial tumor was a prognostic factor of local control. Three-, 6- and 12-month brain-disease-free survival rates were 75 +/- 9, 68 +/- 11 and 38 +/- 13%, respectively. According to univariate analysis, only the Score Index for Radiosurgery in brain metastases (SIR) was a prognostic factor of brain-event-free survival (p = 0.03). Median survival was 8 months. Three-, 6- and 12-month overall survival rates were 75 +/- 9, 53 +/- 10, and 29 +/- 10%, respectively. According to univariate analysis, extracranial controlled disease status (p = 0.03), and SIR (p = 0.04) were prognostic factors for overall survival. According to multivariate analysis, none was an independent prognosticator for overall survival. Complications were minimal. CONCLUSION: Radiosurgical treatment of brain metastases of melanoma is effective and accurate. The use of radiosurgery alone is an appropriate management strategy for many patients with brain metastases of melanoma.     

Stereotactic radiosurgery for brainstem metastases.

OBJECT: Brainstem metastases portend a dismal prognosis. Surgical resection is not part of routine management and radiation therapy has offered little clinical benefit. Radiosurgery provides a safe and effective treatment for many patients with brain metastasis, but its role in the brainstem has not been evaluated. In this study the authors examine the role of radiosurgery in the treatment of brainstem metastases. METHODS: The authors reviewed the outcomes after stereotactic radiosurgery in 26 patients with 27 brainstem metastases. Tumor locations included the pons (21 tumors) and midbrain (six tumors): 14 patients had additional tumors in other locations. Twenty patients presented with brainstem signs. The median dose to the tumor margin was 16 Gy (range 12-20 Gy). Twenty-four patients received fractionated whole-brain radiation therapy (WBRT) and 12 underwent additional chemotherapy or immunotherapy. The median follow-up time in these patients was 9.5 months (range 1-43 months). After radiosurgery, the local control rate in brainstem tumors was 95%. In one patient in whom the tumor initially decreased in size, tumor enlargement was seen 7 months later. The median survival time was 11 months after diagnosis and 9 months after radiosurgery. Thirteen patients improved, 10 were stable, and three deteriorated. Eventually, 22 patients died, 18 of progression of their extracranial disease, three of new tumor growth (including one hemorrhage into a new brain metastasis), and one of extracranial disease plus new brain tumor growth. CONCLUSIONS: Although they have slightly lower than the expected survival rates of patients with nonbrainstem tumors, patients with brainstem metastases may achieve effective palliation after stereotactic radiosurgery and WBRT.     

Stereotactic radiosurgery without radiation therapy providing high local tumor control of multiple brain metastases from renal cell carcinoma.

The aim of this study was to analyse treatment effects after stereotactic radiosurgery (SRS) without whole brain radiation therapy (WBRT) as primary treatment for patients harboring brain metastases of renal cell carcinoma (RCC). During an 8-year period, 85 patients with 376 brain metastases from RCC underwent 134 outpatient SRS procedures. 65 % of all patients had multiple brain metastases. The median tumor volume was 1.2 cm (3) (range: 0.1 - 14.2 cm (3)). Mean prescribed tumor dose was 21.2 (+/- 3.2) Gy. Local/distant tumor recurrences were treated by additional SRS in cases of stable systemic disease. Overall median survival was 11.1 months after SRS. The local tumor control rate after SRS was 94 %. Most patients (78 %) died because of systemically progressing cancer. A KPS > 70 and RTOG class I were related to prolonged survival time. Patients of the RTOG groups I, II and III survived for 24.2 months, 9.2 months and 7.5 months, respectively. There was no permanent morbidity after SRS. 11 patients (12.9 %) showed transient radiogenic complications and 3 patients (3.5 %) died because of intratumoral bleedings after SRS. Stereotactic radiosurgery alone achieves excellent local tumor control rates for patients with small brain metastases from renal cell carcinoma.     

The expanding role of neurosurgeons in the management of brain metastases

BACKGROUND: Brain metastases are the most common type of intracranial tumor. Until recently, whole brain fractionated radiation therapy (WBRT) was the mainstay of treatment, thereby confining the role of neurosurgeons to resection of an occasional solitary, accessible, and symptomatic brain metastasis. Median survival after surgery and radiation typically ranged from 5 to 11 months. METHODS: We analyzed various demographic incidence reports and our series of brain metastasis patients treated with radiosurgery. During a 15-year interval (1987-2002), radiosurgery was performed on 5,032 patients of whom 1,088 (21.6%) had metastatic brain tumors. RESULTS: In the United States, 266,820 to 533,640 new cases of brain metastases will be diagnosed in the year 2003. Evidence to date demonstrates that radiosurgery provides effective local tumor control for brain metastases. Important prognostic factors affecting patient survival include the absence of active systemic disease, the patient's preoperative performance status, age, and the number of metastases. Survival and local tumor control rates attained with radiosurgery are superior to those of either conventional surgery or WBRT. The morbidity associated with radiosurgery of brain metastasis is very low, and the mortality rate approaches zero. CONCLUSIONS: Compelling evidence indicates that radiosurgery is an effective neurosurgical management strategy for intracranial brain metastases. Quite often, favorable tumor control and survival can be achieved without WBRT. With radiosurgery as a therapeutic option, neurosurgeons now have a vastly expanded armamentarium for treatment of patients with brain metastases. The large number of patients with brain metastases who require care by a neurosurgeon for optimal treatment has significant implications for both the patterns of neurosurgical training and practice in the United States.     

Stereotactic radiosurgery for patients with "radioresistant" brain metastases

OBJECTIVE: Our aim was to evaluate the efficacy of stereotactic radiosurgery (SRS) for the treatment of patients with brain metastases that have been determined to be "radioresistant" on the basis of histological examination. METHODS: We reviewed the medical records of 41 consecutive patients who presented with 83 brain metastases from radioresistant primaries and subsequently underwent SRS. All patients were followed until death or for a median of 31 months after SRS. Tumor histologies included renal cell carcinoma (16 patients), melanoma (23 patients), and sarcoma (2 patients). Eighteen patients (44%) had a solitary metastasis, and 23 patients (56%) had multiple metastases. RESULTS: The median overall survival time was 14.2 months after SRS. On the basis of univariate analysis, systemic disease status (P = 0.006) and Radiation Therapy Oncology Group recursive partitioning analysis (RPA) class (P = 0.005) were associated with survival. The median survival time was 23.5 months for patients in RPA Class I status and 10.5 months for patients in RPA Class II or III status. There was a trend (P = 0.12) toward improved median survival for patients with renal cell carcinoma (17.8 mo) as compared with patients with melanoma (9.7 mo). Multivariate analysis showed RPA class (P = 0.038) and histological diagnosis of primary tumor (P < 0.001) to be independent predictors for overall survival. In the 35 patients who underwent follow-up imaging, 9 (12%) of 73 tumors recurred locally. In 54% of the patients, distant brain failure (DBF) developed. Whole brain radiotherapy (WBRT) improved local control and decreased DBF, according to the univariate and multivariate analyses. Patients who received adjuvant WBRT in addition to SRS had 6-month actuarial local control of 100% as compared with 85% among those who did not receive WBRT (P = 0.018). Patients who received adjuvant WBRT with SRS had a 6-month actuarial DBF rate of 17%, as compared with a rate of 64% among patients who had SRS alone (P = 0.0027). CONCLUSION: Well-selected patients with brain metastases from radioresistant primary tumors who undergo SRS survive longer than historical controls. RPA Class I status and primary renal cell carcinoma predict longer survival. Adjuvant WBRT improves local control and decreases DBF but does not affect overall survival. Further studies are needed to determine which patients should receive WBRT.     

Single-Fraction Radiosurgery for Primary and Recurrent Malignant Gliomas

From November 1990 to May 1993, 37 patients with malignant gliomas were treated with single-fraction radiosurgery. Nineteen patients had newly diagnosed tumors. Twelve of these were gliob-lastoma multiforme (GBM) and 7 were anaplastic astrocytoma (AA). Tumors were recurrent after standard radiotherapy in 18 patients. Twelve were GBM and 6 were AA. Median ages were 56 years for those with primary tumors and 52 years for those with recurrent tumors. Strict neuroimaging criteria were not used to select patients for radiosurgery. Median tumor volumes for primary GBM and AA were 15 cc and 9.4 cc, respectively. Median volumes for recurrent GBM and AA were 22.6 cc and 19.6 cc, respectively. Karnofsky Performance Status was above 60% in all patients. Median tumor minimum doses were 30 Gy for primary tumors and 27 Gy for recurrent tumors. Median tumor maximum doses were 50 Gy and 55 Gy, respectively. Median follow-up was 14 months for primary glioma patients and 7.5 months for those with recurrent tumors. Survival analysis was performed using the Kaplan–Meier method. Comparison of prognostic factors was performed using the log-rank and Wilcoxon tests No patient in this series remains alive. Median survivals of those with primary GBM and AA were 13 and 12 months, respectively, from diagnosis. Median survivals of those with recurrent GBM and AA were 7 and 8 months, respectively, from the date of radio-surgery. Thirty-three of 37 patient deaths were due to tumor progression within the radiosurgery treatment volume. Tumor recurred outside the high-dose volume of radiosurgery in 3 patients. Acute complications necessitating hospitalization occurred in 3 patients. Fourteen patients (38%) became dependent on corticosteroids after radiosurgery. Six patients (16%) were resected after radiosurgery. Coagulative necrosis and morphologically intact tumor cells were identified in all resected patients. There was no significant influence of the following factors on actuarial survival of primary or recurrent tumors: age, gender, tumor volume, tumor location, duration from conventional radiotherapy, or radiosurgery dose. Tumor volume was a predictor of reoperation for AA. Indiscriminate application of radiosurgery in this series did not increase the survival of patients with primary or recurrent GBM. Central recurrence represents the predominant form of relapse when patients with malignant gliomas receive radiosurgery in the absence of imaging selection criteria. These criteria include tumor volume and evidence for a discreet lesion. Radiosurgery planning should provide a margin of normal brain parenchyma. Advances in tumor imaging and radiosurgery techniques may improve results of this unique modality for patients with malignant gliomas.     

大肠癌脑转移的临床特征及其手术治疗

目的 分析大肠癌脑转移的临床特征及其手术治疗转归. 方法回顾性分析手术治疗的大肠癌伴脑转移28例患者的临床资料,统计数据采用单因素Log-Rank分析和多因素Cox回归分析法.结果 大肠癌继发脑转移的中位年龄为57(41～75)岁,原发肿瘤与转移瘤间隔的中位时间为13.5个月,其中合并颅外(肺、肝、骨)转移占61%(17/28),仅有脑转移的占39%(11/28).脑转移瘤主要表现为头痛、呕吐等颅内压升高征候群和偏瘫、下肢乏力、失语等定位症状以及癫痫等,颅内转移瘤以单发病灶为多见,占82%(23/28),位于幕上(枕叶、顶叶、额叶)者占57%(16/28),位于幕下(小脑)者占43%(12/28);转移性脑瘤手术切除后中位生存时间为9.4个月,1年生存率为28.9%,5年生存率为7.1%.多因素分析提示颅内单发病灶转移(χ2=7.35,P<0.05)和无颅外其他部位转移(χ2=6.47,P<0.05)是大肠癌脑转移预后的独立影响因素.28例均接受手术切除和多学科协作治疗,无手术死亡和出血及再手术病例.结论 大肠癌脑转移总体预后欠佳,手术切除脑转移病灶可延长部分患者的存活时间.     

大肠癌脑转移的临床特征及其手术治疗

目的 分析大肠癌脑转移的临床特征及其手术治疗转归. 方法回顾性分析手术治疗的大肠癌伴脑转移28例患者的临床资料,统计数据采用单因素Log-Rank分析和多因素Cox回归分析法.结果 大肠癌继发脑转移的中位年龄为57(41～75)岁,原发肿瘤与转移瘤间隔的中位时间为13.5个月,其中合并颅外(肺、肝、骨)转移占61%(17/28),仅有脑转移的占39%(11/28).脑转移瘤主要表现为头痛、呕吐等颅内压升高征候群和偏瘫、下肢乏力、失语等定位症状以及癫痫等,颅内转移瘤以单发病灶为多见,占82%(23/28),位于幕上(枕叶、顶叶、额叶)者占57%(16/28),位于幕下(小脑)者占43%(12/28);转移性脑瘤手术切除后中位生存时间为9.4个月,1年生存率为28.9%,5年生存率为7.1%.多因素分析提示颅内单发病灶转移(χ2=7.35,P<0.05)和无颅外其他部位转移(χ2=6.47,P<0.05)是大肠癌脑转移预后的独立影响因素.28例均接受手术切除和多学科协作治疗,无手术死亡和出血及再手术病例.结论 大肠癌脑转移总体预后欠佳,手术切除脑转移病灶可延长部分患者的存活时间.     

Radiosurgery in patients with renal cell carcinoma metastasis to the brain: long-term outcomes and prognostic factors influencing survival and local tumor control

OBJECT: Renal cell carcinoma is a leading cause of death from cancer and its incidence is increasing. In many patients with renal cell cancer, metastasis to the brain develops at some time during the course of the disease. Corticosteroid therapy, radiotherapy, and resection have been the mainstays of treatment. Nonetheless, the median survival in patients with renal cell carcinoma metastasis is approximately 3 to 6 months. In this study the authors examined the efficacy of gamma knife surgery in treating renal cell carcinoma metastases to the brain and evaluated factors affecting long-term survival. METHODS: The authors conducted a retrospective review of 69 patients undergoing stereotactic radiosurgery for a total of 146 renal cell cancer metastases. Clinical and radiographic data encompassing a 14-year treatment interval were collected. Multivariate analyses were used to determine significant prognostic factors influencing survival. The overall median length of survival was 15 months (range 1-65 months) from the diagnosis of brain metastasis. After radiosurgery, the median survival was 13 months in patients without and 5 months in those with active extracranial disease. In a multivariate analysis, factors significantly affecting the rate of survival included the following: 1) younger patient age (p = 0.0076); 2) preoperative Karnofsky Performance Scale score (p = 0.0012); 3) time from initial cancer diagnosis to brain metastasis diagnosis (p = 0.0017); 4) treatment dose to the tumor margin (p = 0.0252); 5) maximal treatment dose (p = 0.0127); and 6) treatment isodose (p = 0.0354). Prior tumor resection, chemotherapy, immunotherapy, or whole-brain radiation therapy did not correlate with extended survival. Postradiosurgical imaging of the brain demonstrated that 63% of the metastases had decreased, 33% remained stable, and 4% eventually increased in size. Two patients (2.9%) later underwent a craniotomy and resection for a tumor refractory to radiosurgery or a new symptomatic metastasis. Eighty-three percent of patients died of progression of extracranial disease. CONCLUSIONS: Stereotactic radiosurgery for treatment of renal cell carcinoma metastases to the brain provides effective local tumor control in approximately 96% of patients and a median length of survival of 15 months. Early detection of brain metastases, aggressive treatment of systemic disease, and a therapeutic strategy including radiosurgery can offer patients an extended survival.     

Brain metastases treated with radiosurgery alone: an alternative to whole brain radiotherapy?

OBJECTIVE: Whole brain radiotherapy (WBRT) provides benefit for patients with brain metastases but may result in neurological toxicity for patients with extended survival times. Stereotactic radiosurgery in combination with WBRT has become an important approach, but the value of WBRT has been questioned. As an alternative to WBRT, we managed patients with stereotactic radiosurgery alone, evaluated patients' outcomes, and assessed prognostic factors for survival and tumor control. METHODS: One hundred seventy-two patients with brain metastases were managed with radiosurgery alone. One hundred twenty-one patients were evaluable with follow-up imaging after radiosurgery. The median patient age was 60.5 years (age range, 16-86 yr). The mean marginal tumor dose and volume were 18.5 Gy (range, 11-22 Gy) and 4.4 ml (range, 0.1-24.9 ml). Eighty percent of patients had solitary tumors. RESULTS: The overall median survival time was 8 months. The median survival time in patients with no evidence of primary tumor disease or stable disease was 13 and 11 months. The local tumor control rate was 87%. At 2 years, the rate of local control, remote brain control, and total intracranial control were 75, 41, and 27%, respectively. In multivariate analysis, advanced primary tumor status (P = 0.0003), older age (P = 0.008), lower Karnofsky Performance Scale score (P = 0.01), and malignant melanoma (P = 0.005) were significant for poorer survival. The median survival time was 28 months for patients younger than 60 years of age, with Karnofsky Performance Scale score of at least 90, and whose primary tumor status showed either no evidence of disease or stable disease. Tumor volume (P = 0.02) alone was significant for local tumor control, whereas no factor affected remote or intracranial tumor control. Eleven patients developed complications, six of which were persistent. Nineteen (16.5%) of 116 patients in whom the cause of death was obtained died as a result of causes related to brain metastasis. CONCLUSION: Brain metastases were controlled well with radiosurgery alone as initial therapy. We advocate that WBRT should not be part of the initial treatment protocol for selected patients with one or two tumors with good control of their primary cancer, better Karnofsky Performance Scale score, and younger age, all of which are predictors of longer survival.     

大肠癌脑转移的临床特征及其手术治疗

目的 分析大肠癌脑转移的临床特征及其手术治疗转归. 方法回顾性分析手术治疗的大肠癌伴脑转移28例患者的临床资料,统计数据采用单因素Log-Rank分析和多因素Cox回归分析法.结果 大肠癌继发脑转移的中位年龄为57(41～75)岁,原发肿瘤与转移瘤间隔的中位时间为13.5个月,其中合并颅外(肺、肝、骨)转移占61%(17/28),仅有脑转移的占39%(11/28).脑转移瘤主要表现为头痛、呕吐等颅内压升高征候群和偏瘫、下肢乏力、失语等定位症状以及癫痫等,颅内转移瘤以单发病灶为多见,占82%(23/28),位于幕上(枕叶、顶叶、额叶)者占57%(16/28),位于幕下(小脑)者占43%(12/28);转移性脑瘤手术切除后中位生存时间为9.4个月,1年生存率为28.9%,5年生存率为7.1%.多因素分析提示颅内单发病灶转移(χ2=7.35,P<0.05)和无颅外其他部位转移(χ2=6.47,P<0.05)是大肠癌脑转移预后的独立影响因素.28例均接受手术切除和多学科协作治疗,无手术死亡和出血及再手术病例.结论 大肠癌脑转移总体预后欠佳,手术切除脑转移病灶可延长部分患者的存活时间.     

Ambulatory radiosurgery in cerebral metastatic renal cell carcinoma. 5-year outcome in 58 patients

Brain metastases (BM) indicate an advanced stage of renal cell cancer (RCC). They pose an increasing challenge to urologists as a result of improved survival due to modern therapy. Median survival of untreated patients with BM who often suffer from neurological deficits is 3 months. Radiosurgery with the Gamma Knife (GK) has increased in use as an alternative to whole brain radiation therapy (WBRT) and/or surgery. This study reports the results of a consecutive series of RCC patients treated for BM by GK radiosurgery during a 5-year period. Between 1994 and 1999, 58 patients with a total of 277 BM and 3.0 (1-19) BM/patient were treated. Because of recurrent BM, 23 (40%) patients received repeated (multiple) GK sessions. The median tumor volume was 3.4 cm3 (0.1-19.1). The median interval between diagnosis of RCC and GK treatment was 2.2 years (0.1-17.2). Symptomatic side effects were detected in 9 (16%) of 58 patients. The median actuarial survival time was 9.9 months. Local tumor control could be achieved in 95% of patients. The GK therapy induced a significant tumor remission accompanied by rapid neurological improvement in 70% of patients. Compared to standard radiotherapy, GK radiosurgery is more effective, less time consuming, and can be repeated. Compared to surgery, radiosurgery is less invasive and better suited to treat multiple metastases in one single session. Surgery and radiosurgery, however, are supplementary methods that are highly effective to control intracerebral metastasizing RCC.     

Traitement des métastases cérébrales par radiochirurgie stéréotaxique : étude de 33 cas liés à un accident de « surexposition »

The consequences of a dosimetric radiosurgery accident are not the same as a conventional radiotherapy accident. The objective of this study was to estimate the clinical and radiological outcome of patients treated by radiosurgery for metastasis during the period of the overexposure accident that occurred in the Toulouse Radiosurgery Unit. Between April 2006 and March 2007, 33 patients with 57 metastases were treated in the Toulouse Radiosurgery Unit (Novalis^®, BrainLab). An initial error in the estimation of the scatter factors led to an overexposure to radiation. The median age was 55 years [range, 35-85]. Twenty-one patients (64%) harbored a single metastasis. The primary tumor location was lung (16 cases), kidney (nine cases), breast (four cases), and others (four cases). The mean tumoral volume was 3.2 cm³ [0.04-14.07]. The mean prescribed dose at the isocenter was 20 Gy [range, 10-23], the mean delivered dose was 31.5 Gy [range, 13-52], and the mean overdose was 61.2% [range, 5.6-226.8]. In order to evaluate the consequences of the overdose, three parameters were analyzed: a risk index using dose and volume, the volume of parenchyma that received more than 12 Gy, and the mean dose in a sphere of 20 cm³ surrounding the target volume. Median actuarial survival was 14.1 months, the survival rate was 79.4 % at six months, 59.1% at 12 months, and 27.2% at 24 months. The rate of tumor control was 80.7%. No morbidity was observed. There was no correlation between death and the parameters studied. The survival rates and times observed in our study of the patients treated for brain metastases by radiosurgery and overexposed were among the good results of the international literature. Deaths were not related to the overdose and no side effect was noted. This dosimetric accident has not had worse consequences in this population.     

Stereotactic radiosurgical treatment of parenchymal brain metastases from prostate adenocarcinoma

BACKGROUND: Prostate cancer metastatic to the brain is uncommon and has been associated historically with a poor prognosis. It has been suggested that SRS may be an effective treatment. METHODS: We analyzed a prospective, institutional review board-approved database of patients treated with SRS and identified 5 patients with prostate cancer metastasis. Clinical, pathologic, radiographic, treatment, and outcome information regarding the primary/systemic disease status, and brain metastases were collected. RESULTS: Mean age at the time of treatment for CNS parenchymal metastasis was 72.0 +/- 8.3 years and lesions developed 82.0 +/- 65.1 months after the initial tumor was identified. Four patients had a single lesion and 1 had 4; 3 patients were treated with SRS alone, 1 with WBRT and SRS, and 1 with surgery, then WBRT and SRS. All were symptomatic. Stereotactic radiosurgery controlled the brain metastases in all 5 patients, with functional improvement and with a typical increase of 1 grade in the Karnofsky performance score. Mean survival was at least 10.0 +/- 6.7 months (range, 6-22+ months). Two patients died of conditions unrelated to prostate cancer and 2 of systemic disease progression; 1is alive and asymptomatic. There were no local SRS failures and no new CNS lesions. CONCLUSIONS: Stereotactic radiosurgery for prostate cancer metastatic to the brain, alone or in combination with brain radiation therapy and surgery, is a safe, effective treatment that improves neurologic symptoms and function and may prolong survival.     

Stereotactic interstitial radiosurgery for cerebral metastases

OBJECT: The Photon Radiosurgery System (PRS) is a miniature x-ray generator that can stereotactically irradiate intracranial tumors by using low-energy photons. Treatment with the PRS typically occurs in conjunction with stereotactic biopsy, thereby providing diagnosis and treatment in one procedure. The authors review the treatment of patients with brain metastases with the aid of the PRS and discuss the indications, advantages, and limitations of this technique. METHODS: Clinical characteristics, treatment parameters, neuroimaging-confirmed outcome, and survival were reviewed in all patients with histologically verified brain metastases who were treated with the PRS at the Massachusetts General Hospital between December 1992 and November 2000. Local control of lesions was defined as either stabilization or diminution in the size of the treated tumor as confirmed by Gd-enhanced magnetic resonance imaging. Between December 1992 and November 2000, 72 intracranial metastatic lesions in 60 patients were treated with the PRS. Primary tumors included lung (33 patients), melanoma (15 patients), renal cell (five patients), breast (two patients), esophageal (two patients), colon (one patient), and Merkle cell (one patient) cancers, and malignant fibrous histiocytoma (one patient). Supratentorial metastases were distributed throughout the cerebrum, with only one cerebellar metastasis. The lesions ranged in diameter from 6 to 40 mm and were treated with a minimal peripheral dose of 16 Gy (range 10-20 Gy). At the last follow-up examination (median 6 months), local disease control had been achieved in 48 (81%) of 59 tumors. An actuarial analysis demonstrated that the survival rates at 6 and 12 months were 63 and 34%, respectively. Patients with a single brain metastasis survived a mean of 11 months. Complications included four patients with postoperative seizures, three with symptomatic cerebral edema, two with hemorrhagic events, and three with symptomatic radiation necrosis requiring surgery. CONCLUSIONS: Stereotactic interstitial radiosurgery performed using the PRS can obtain local control of cerebral metastases at rates that are comparable to those achieved through open resection and external stereotactic radiosurgery. The major advantage of using the PRS is that effective treatment can be accomplished at the time of stereotactic biopsy.     

Surgery and radiotherapy compared with gamma knife radiosurgery in the treatment of solitary cerebral metastases of small diameter.

OBJECT: The aim of this retrospective study was to compare treatment results of surgery plus whole-brain radiation therapy (WBRT) with gamma knife radiosurgery alone as the primary treatment for solitary cerebral metastases suitable for radiosurgical treatment. METHODS: Patients who had a single circumscribed tumor that was 3.5 cm or smaller in diameter were included. Treatment results were compared between microsurgery plus WBRT (52 patients, median tumor dose 50 Gy) and radiosurgery alone (56 patients, median prescribed tumor dose 22 Gy). In case of local/distant tumor recurrence in the radiosurgery group, additional radiosurgical treatment was administered in patients with stable systemic disease. Survival time was analyzed using the Kaplan-Meier method, and prognostic factors were obtained from the Cox model. The patient groups did not differ in terms of age, gender, pretreatment Karnofsky Performance Scale (KPS) score, duration of symptoms, tumor location, histological findings, status of the primary tumor, time to metastasis, and cause of death. Patients who suffered from larger lesions underwent surgery (p < 0.01). The 1-year survival rate (median survival) was 53% (68 weeks) in the surgical group and 43% (35 weeks) in the radiosurgical group (p = 0.19). The 1-year local tumor control rates after surgery and radiosurgery were 75% and 83%, respectively (p = 0.49), and the 1-year neurological death rates in these groups were 37% and 39% (p = 0.8). Shorter overall survival time in the radiosurgery group was related to higher systemic death rates. A pretreatment KPS score of less than 70 was a predictor of unfavorable survival. Perioperative morbidity and mortality rates were 7.7% and 1.6% in the resection group, and 8.9% and 1.2% in the radiosurgery group, respectively. Four patients presented with transient radiogenic complications after radiosurgery. CONCLUSIONS: Radiosurgery alone can result in local tumor control rates as good as those for surgery plus WBRT in selected patients. Radiosurgery should not be routinely combined with radiotherapy.     

Brain metastasis: experience of the Xi-Jing hospital

BACKGROUND: The management of metastatic brain tumors is an important issue in patients with malignant tumors or cancer. The authors summarize the results of patients with brain metastases treated at the Xi-Jing Hospital during a 10-year period, in order to assess the best modality of treatment for patients with brain metastases. METHODS: Between 1990 and 2000, 463 patients with brain-metastatic tumors were treated at the Xi-Jing Hospital of the Fourth Military Medical University, Xian, China. In most patients, the pathologic diagnosis of primary cancer was obtained before they were referred for their brain metastasis. There were 34 (8.42%) cases with an unknown primary cancer site at the time of initial presentation. Patients were grouped according to treatment methods, which included neurosurgical craniotomy (NS; 130 patients), whole-brain radiotherapy (WBRT; 120 patients). Linac XKnife radiosurgery (RS; 130 patients) and Linac XKnife radiosurgery plus WBRT (RT; 83 cases). Survival was measured from the time of treatment and was analyzed by the Kaplan-Meier product-limit method and then plotted. Differences between curves were evaluated using the log-rank test. Multivariate factors associated with survival were analyzed using the Cox proportional hazards model. RESULTS: The survival time was 68.4 +/- 7.20 weeks after NS, 51.3 +/- 5.04 weeks after WBRT, 67.9 +/- 3.68 weeks after RS and 89.7 +/- 4.50 weeks after RT. The presence of active systemic cancer in a larger number of metastatic tumors was associated with a poor survival (p = 0.0003 and 0.0000). The female patients showed better survival rates over the male ones (p = 0.0000). Patients treated with RT had a better survival than those treated with NS, WBRT and RS (p = 0.0048, 0.0000 and 0.1222, respectively), although the latter did not show statistical significance. CONCLUSIONS: RS was an effective modality for patients with brain metastases, and if combined with WBRT, survival was better. Progression of systemic cancer and the number of metastatic tumors were the most significant factors for a poor survival after treatment of the brain metastases.     

Repeated gamma knife surgery for multiple brain metastases from renal cell carcinoma

OBJECT: The aim of this study was to evaluate the therapeutic profile of repeated gamma knife surgery (GKS) for renal cell carcinoma that has metastasized to the brain on multiple occasions. METHODS: Data from this study were culled from a single institution and cover a 6-year period of outpatient radiosurgery. A standard protocol for indication, dose planning, and follow up was established. In cases of distant or local recurrences, radiosurgery was undertaken repeatedly (up to six times in one individual). Seventy-five patients harboring 350 cerebral metastases were treated. Relief from pretreatment neurological symptoms occurred in 72% of patients within a few days or a few weeks after the procedure. The actuarial local tumor control rate after the initial GKS was 95%. In patients free from relapse of intracranial metastases after repeated radiosurgery, long-term survival was 91% after 4 years; median survival was 11.1+/-3.2 months after radiosurgery and 4.5+/-1.1 years after diagnosis of the primary kidney cancer. Survival following radiosurgery was independent of patient age and sex, side of the renal cell carcinoma, pretreatment of the cerebrum by using radiotherapy or surgery, number of brain metastases and their synchronization with the primary renal cell carcinoma, and the frequency of radiosurgical procedures. In contrast, survival was dependent on the patient's clinical performance score and the extracranial tumor status. Tumor bleeding was observed in seven patients (9%) and late radiation toxicity (LRT) in 15 patients (20%). Treatment-related morbidity was moderate and mostly transient. Late radiation toxicity was encountered predominantly in long-term survivors. CONCLUSIONS: Outpatient repeated radiosurgery is an effective and only minimally invasive treatment for multiple brain metastases from renal cell cancer and is recommended as being the method of choice to control intracranial disease, especially in selected patients with limited extracranial disease. Physicians dealing with such patients should be aware of the characteristic aspects of LRT.     

Radiosurgery to palliate symptoms in brain metastases from uterine cervix cancer

Background

The optimal management of brain metastases from uterine cervix cancer (UCC) is not well defined because of the rarity of the condition and the scarcity of published reports. Here we report our experience with stereotactic radiosurgery for the management of brain metastases from UCC.

Methods

Thirteen consecutive patients with brain metastases from UCC were managed with a Leksell gamma-knife at our institution between January 2003 and December 2010. Clinical features and radiosurgical outcomes of patients were analyzed retrospectively.

Results

Gamma-knife radiosurgery (GKRS) was chosen as the only treatment in four patients and performed in combination with whole-brain radiotherapy (WBRT) in nine patients. GKRS was conducted simultaneously with WBRT within a 1-month interval in six patients and was chosen as the salvage treatment after WBRT in three patients. The mean number of metastatic brain lesions per patient was 5.7 (range, 1–16). The median cumulative tumor volume was 23.7 cm³ (range, 2.7–40.2 cm³), and the median marginal dose covering the tumors was 14 Gy of a 50 % isodose line (range, 8–25 Gy). Nine patients showed relief of main neurologic symptoms after GKRS. The median length of time that the patients spent in an improved neurologic state was 11.1 weeks (range, 2–39.6 weeks). The local and distant control rates were 66.7 % and 77.8 %, respectively. The median survival from the date of GKRS until death was 4.6 months (range, 1.0–15.9 months). The 6-month and 12-month survival rates after GKRS were 38 and 15 %, respectively.

Conclusions

GKRS could be an efficient palliative measure to relieve neurologic symptoms caused by brain metastasis from UCC.