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

Lilyana Angelov1, Alireza Mohammad Mohammadi2, Samuel Chao1, Gene Barnett2, John Suh2, Robert Weil2, Michael Vogelbaum2

1Cleveland, United States 2Burkhardt Brain Tumor Center, Cleveland Clinic, Cleveland, Ohio, USA

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.


Project Roles:

L. Angelov (), A. Mohammadi (), S. Chao (), G. Barnett (), J. Suh (), R. Weil (), M. Vogelbaum ()