Management patterns of patients with cerebral metastases who underwent multiple stereotactic radiosurgeries

Published on Mar 7, 2016in Journal of Neuro-oncology4.13
· DOI :10.1007/S11060-016-2084-2
Deborah C. Marshall11
Estimated H-index: 11
(UCSD: University of California, San Diego),
Logan P. Marcus9
Estimated H-index: 9
(UC: University of California)
+ 9 AuthorsClark C. Chen57
Estimated H-index: 57
(UCSD: University of California, San Diego)
Sources
Abstract
With escalating focus on cost containment, there is increasing scrutiny on the practice of multiple stereotactic radiosurgeries (SRSs) for patients with cerebral metastases distant to the initial tumor site. Our goal was to determine the survival patterns of patients with cerebral metastasis who underwent multiple SRSs. We retrospectively analyzed survival outcomes of 801 patients with 3683 cerebral metastases from primary breast, colorectal, lung, melanoma and renal histologies consecutively treated at the University of California, San Diego/San Diego Gamma Knife Center (UCSD/SDGKC), comparing the survival pattern of patients who underwent a single (n = 643) versus multiple SRS(s) (n = 158) for subsequent cerebral metastases. Findings were recapitulated in an independent cohort of 2472 patients, with 26,629 brain metastases treated with SRS at the Katsuta Hospital Mito GammaHouse (KHMGH). For the UCSD/SDGKC cohort, no significant difference in median survival was found for patients undergoing 1, 2, 3, or ≥4 SRS(s) (median survival of 167, 202, 129, and 127 days, respectively). Median intervals between treatments consistently ranged 140–178 days irrespective of the number of SRS(s) (interquartile range 60–300; p = 0.25). Patients who underwent >1 SRSs tend to be younger, with systemic disease control, harbor lower cumulative tumor volume but increased number of metastases, and have primary melanoma (p < 0.001, <0.001, <0.001, 0.02, and 0.009, respectively). Comparable results were found in the KHMGH cohort. Using an independent validation study design, we demonstrated comparable overall survival between judiciously selected patients who underwent a single or multiple SRS(s).
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References36
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#2Roshan S. Prabhu (Carolinas Healthcare System)H-Index: 25
Last. Ian Crocker (Emory University)H-Index: 41
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BACKGROUND The purpose of this study was to evaluate predictors of early distant brain failure (DBF) and salvage whole-brain radiotherapy (WBRT) after treatment with stereotactic radiosurgery (SRS) for brain metastases and create a clinically relevant risk score to stratify patients’ risk for these events. METHODS The records of 270 patients with brain metastases who were treated with SRS between 2003 and 2012 were reviewed. Pretreatment patient and tumor characteristics were analyzed with univa...
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#2Kaveh Zakeri (UCSD: University of California, San Diego)H-Index: 10
Last. Kevin T. Murphy (UCSD: University of California, San Diego)H-Index: 18
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Background Stereotactic radiosurgery is a well-accepted treatment for patients with intracranial metastases, but outcomes with volumetric modulated arc radiosurgery (VMAR) are poorly described.
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Last. Hidetoshi KasuyaH-Index: 39
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Objectives We tested the validity of 5 prognostic indices, Recursive Partitioning Analysis (RPA), Score Index for Radiosurgery (SIR), Basic Score for Brain Metastases (BSBM), Graded Prognostic Assessment (GPA), and Modified-RPA, for patients who underwent repeat stereotactic radiosurgery (re-SRS). Methods For this study, we used our database, which included 804 patients who underwent gamma knife re-SRS during the period 1998–2013. Results There were statistically significant survival differences...
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Last. Patrick W. Elwood (UIC: University of Illinois at Chicago)H-Index: 11
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Object Stereotactic radiosurgery (SRS) alone is increasingly used in patients with newly diagnosed brain metastases. Stereotactic radiosurgery used together with whole-brain radiotherapy (WBRT) reduces intracranial failure rates, but this combination also causes greater neurocognitive toxicity and does not improve survival. Critics of SRS alone contend that deferring WBRT results in an increased need for salvage therapy and in higher costs. The authors compared the cost-effectiveness of treatmen...
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The NCCN Guidelines for Central Nervous System Cancers provide multidisciplinary recommendations for the clinical management of patients with cancers of the central nervous system. These NCCN Guidelines Insights highlight recent updates regarding the management of metastatic brain tumors using radiation therapy. Use of stereotactic radiosurgery (SRS) is no longer limited to patients with 3 or fewer lesions, because data suggest that total disease burden, rather than number of lesions, is predict...
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The median survival for patients with brain metastases has improved significantly over time due to earlier detection,1 better brain-directed2 and systemic therapies.3 With the advent of improved salvage therapies for intracranial metastases including radiosurgery and stereotactic radiotherapy, many patients with intracranial metastases will ultimately die from their systemic disease burden. As patients live longer, there has been an incentive to delay or avoid the neurocognitive toxicities assoc...
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#1David D. Gonda (UCSD: University of California, San Diego)H-Index: 21
#2Teddy Kim (UCSD: University of California, San Diego)H-Index: 5
Last. Clark C. Chen (UCSD: University of California, San Diego)H-Index: 57
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Abstract Introduction Defining key prognostic factors for patients with cerebral metastases who underwent stereotactic radiosurgery (SRS) treatment will greatly facilitate future clinical trial designs. Methods We adopted a two-phase study design where results from one cohort were validated in a second independent cohort. The exploratory analysis reviewed the survival outcomes of 1017 consecutive patients (with 3610 metastases) who underwent Gamma radiosurgery at the University of California, Sa...
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#2Toru SerizawaH-Index: 24
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Summary Background We aimed to examine whether stereotactic radiosurgery without whole-brain radiotherapy (WBRT) as the initial treatment for patients with five to ten brain metastases is non-inferior to that for patients with two to four brain metastases in terms of overall survival. Methods This prospective observational study enrolled patients with one to ten newly diagnosed brain metastases (largest tumour Findings We enrolled 1194 eligible patients between March 1, 2009, and Feb 15, 2012. M...
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The treatment of metastatic brain lesions remains a central challenge in oncology. Because most chemotherapeutic agents do not effectively cross the blood–brain barrier, it is widely accepted that radiation remains the primary modality of treatment. The mode by which radiation should be delivered has, however, become a source of intense controversy in recent years. The controversy involves whether patients with a limited number of brain metastases should undergo whole brain radiation therapy (WB...
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A substantial, but uncertain, number of patients with cancer develop brain metastases. Risk of brain metastasis is recognized to vary with type of primary cancer. Within specific types of primary cancer, prognostic factors for development of brain metastases are being recognized. Recent data suggest that molecular biomarkers that relate to cellular function can predict risk of developing brain metastases. Such information could optimize surveillance standards and/or be used to select patients fo...
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Approximately 25-35% of all cancer patients suffer from brain metastases (BM), and many of them-in particular, those with a limited number of intracranial tumors-are treated with stereotactic radiosurgery (SRS). Accurate prediction of survival remains a key clinical challenge in this population. Several prognostic scales have been developed to facilitate this prognostication, including the Recursive Partitioning Analysis (RPA) classification, the modified Recursive Partitioning Analysis (mRPA) s...
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Background Stereotactic radiosurgery (SRS) remains a mainstay therapy in the treatment of melanoma brain metastases (BM). While prognostic scales have been developed for melanoma patients who underwent SRS treatment for BM, the pertinence of these scales in the context of molecularly targeted therapies remains unclear. Methods Through a multi-institutional collaboration, we collated the survival patterns of 331 melanoma BM patients with known BRAF mutation status treated with SRS. We established...
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#1Greg BowdenH-Index: 7
#2Andrew FaramandH-Index: 12
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Background The number of metastases that can be treated safely and effectively with Gamma Knife stereotactic radiosurgery (SRS) remains controversial despite continuing evidence to support its expanded utilization. We endeavored to elucidate the survival outcomes for patients who presented with ≥15 brain metastases at the time of initial SRS. Methods This retrospective analysis reviewed patients treated for ≥15 brain metastases originating from breast cancer, lung cancer, or melanoma. Ninety-thr...
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#1Rushikesh S. Joshi (UCSD: University of California, San Diego)H-Index: 6
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Background The disease-specific Graded Prognostic Assessment (ds-GPA) for patients with gastrointestinal (GI) tract cancer brain metastases (BM) suggests Karnofsky Performance Status (KPS) as the only pertinent prognostic factor. We evaluated the prognostic importance of cumulative intracranial tumor volume (CITV). Methods KPS, CITV, and overall survival were collected from consecutive patients with stereotactic radiosurgery–treated GI BM. Patients were grouped into 2 independent cohorts for dev...
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#1Ke Ye (ZJU: Zhejiang University)H-Index: 1
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Objective To report on our experience with the Elekta Extend system, a relocatable frame system used in patients with brain metastases for single-session, hypofractionated, or staged hypofractionated Gamma Knife radiosurgery (GKRS); and the evaluation of its efficacy. Methods From March 2014 to September 2016, 856 patients with brain metastases underwent GKRS at our hospital. Of them, 35 patients who were retrospectively investigated, were selected for treatment with GKRS using the relocatable f...
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#1Brian R. Hirshman (UCSD: University of California, San Diego)H-Index: 13
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#7Roukoz B. Chamoun (KU: University of Kansas)H-Index: 13
Background The incidence of brain metastases is rising. To our knowledge, no published study focuses exclusively on brain metastases larger than 4 cm. We present our surgical outcomes for patients with brain metastases larger than 4 cm. Methods This is a retrospective chart review of inpatient data at our institution from January 2006 to September 2015. Primary end points included overall survival, progression-free survival, and local recurrence rate. Results Sixty-one patients had a total of 67...
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#1Brian R. Hirshman (UCSD: University of California, San Diego)H-Index: 13
#2Bayard Wilson (UCSD: University of California, San Diego)H-Index: 10
Last. Clark C. Chen (UCSD: University of California, San Diego)H-Index: 57
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BACKGROUND: Two intracranial tumor volume variables have been shown to prognosticate survival of stereotactic-radiosurgery-treated brain metastasis patients: the largest intracranial tumor volume (LITV) and the cumulative intracranial tumor volume (CITV). OBJECTIVE: To determine whether the prognostic value of the Scored Index for Radiosurgery (SIR) model can be improved by replacing one of its components-LITV-with CITV. METHODS: We compared LITV and CITV in terms of their survival prognosticati...
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Background The number of brain metastases (BMs) plays an important role in the decision between stereotactic radiosurgery (SRS) and whole-brain radiation therapy. Methods We analyzed the survival of 5750 SRS-treated patients with BM as a function of BM number. Survival analyses were performed with Kaplan-Meier analysis as well as univariate and multivariate Cox proportional hazards models. Results Patients with BMs were first categorized as those with 1, 2–4, and 5–10 BMs based on the scheme pro...
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