Stereotactic Radio-Surgery in the Treatment of Patients with >5 Radio-Resistant Brain Metastases

Keywords: melanoma, gamma knife, renal cancer, brain metastasis, outcome

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     Whole brain radiation therapy (WBRT) is considered standard treatment in patients with multiple brain metastases. However, WBRT has limited efficacy in patients with radio-resistant brain metastases (RBM) such as renal cell carcinoma (RCC) and melanoma. 
     The aim of this study was to evaluate outcomes in patients with >5 RBM treated with Stereotactic Radio-surgery (SRS) monotherapy or as part of a multimodality regimen.
     Data from 16 consecutive RCC and 28 melanoma patients with >5 simultaneous brain metastases (total of 44 patients, 278 lesions) treated with SRS at the Cleveland Clinic (1998-2010) were analyzed.
      Patient demographics, tumor characteristics, treatment related factors and outcomes were statistically evaluated.
     24 males and 20 females (median age of 57) were treated. 57% of patients had concurrent systemic metastases to multiple organs and 30% of patients were on active systemic treatment before SRS. Patients had prior cranial surgery 10(22%), WBRT 19(43%) or SRS 8(18%) previous to their presentation with ?5 RBM. Median interval between primary diagnoses and SRS was 1.7 years (range 0-16). At the time of current SRS treatment, 82% of patients had minimal or no neurological symptoms and a median KPS of 80. 80% of patients were Recursive Partitioning Analysis (RPA) Class II. Median number of lesion was 6 (range 5-10), and median total intracranial disease burden was 4.4cc (range 0.2-36.4). Local control rate was achieved in 91% of targets as evaluated in follow up imaging. Post SRS for ?5 RBM, 19 of 44 patients required further intracranial therapy for new lesions, surgery 4%, WBRT 25% and SRS 31%. Mean follow up was 5.5 months from SRS for ?5 RBM (range 1-43). 36 patients (82%) died during follow up with neurological cause of death in 13(36%). Mean overall survival (OS) was 6.2 months (range1-43) and 13% one year OS.
     This was a retrospective study.
     SRS is traditionally used to treat patients with a limited number of RBM. We demonstrate that using SRS in ?5 RBM patients results in excellent local disease control (91%) and acceptable OS.
     Hence, SRS should be considered in the ongoing management of RBM patients even with extensive intracranial disease.


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