Gamma Knife radiosurgery to the surgical cavity following resection of brain metastases

Clinical article

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Object

This study evaluated the efficacy of postoperative Gamma Knife surgery (GKS) to the tumor cavity following gross-total resection of a brain metastasis.

Methods

A retrospective review was conducted of 700 patients who were treated for brain metastases using GKS. Forty-seven patients with pathologically confirmed metastatic disease underwent GKS to the postoperative resection cavity following gross-total resection of the tumor. Patients who underwent subtotal resection or who had visible tumor in the resection cavity on the postresection neuroimaging study (either CT or MR imaging with and without contrast administration) were excluded. Radiographic and clinical follow-up was assessed using clinic visits and MR imaging. The radiographic end point was defined as tumor growth control (no tumor growth regarding the resection cavity, and stable or decreasing tumor size for the other metastatic targets). Clinical end points were defined as functional status (assessed prospectively using the Karnofsky Performance Scale) and survival. Primary tumor pathology was consistent with lung cancer in 19 cases (40%), melanoma in 10 cases (21%), renal cell carcinoma in 7 cases (15%), breast cancer in 7 cases (15%), and gastrointestinal malignancies in 4 cases (9%). The mean duration between resection and radiosurgery was 15 days (range 2–115 days). The mean volume of the treated cavity was 10.5 cm3 (range 1.75–35.45 cm3), and the mean dose to the cavity margin was 19 Gy. In addition to the resection cavity, 34 patients (72%) underwent GKS for 116 synchronous metastases observed at the time of the initial radiosurgery.

Results

The mean radiographic follow-up duration was 14 months (median 10 months, range 4–37 months). Local tumor control at the site of the surgical cavity was achieved in 44 patients (94%), and tumor recurrence at the surgical site was statistically related to the volume of the surgical cavity (p = 0.04). During follow-up, 34 patients (72%) underwent additional radiosurgery for 140 new (metachronous) metastases. At the most recent follow-up evaluation, 11 patients (23%) were alive, whereas 36 patients had died (mean duration until death 12 months, median 10 months). Patients who showed good systemic control of their primary tumor tended to have longer survival durations than those who did not (p = 0.004). At the last clinical follow-up evaluation, the mean Karnofsky Performance Scale score for the overall group was 78 (median 80, range 40–100).

Conclusion:

Radiosurgery appears to be effective in terms of providing local tumor control at the resection cavity following resection of a brain metastasis, and in the treatment of synchronous and metachronous tumors. These data suggest that radiosurgery can be used to prevent recurrence following gross-total resection of a brain metastasis.

Abbreviations used in this paper: GKS = Gamma Knife surgery; KPS = Karnofsky Performance Scale; WBRT = whole brain radiation therapy.
Article Information

Contributor Notes

Address correspondence to: Jason P. Sheehan, M.D., Ph.D., Department of Neurological Surgery, University of Virginia Health Sciences Center, Box 800212, Charlottesville, Virginia 22908. email: jps2f@hscmail.mcc.virginia.edu.Please include this information when citing this paper: published online April 10, 2009; DOI: 10.3171/2008.11.JNS08818.
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References
  • 1

    Andrews RJGluck DSKonchingeri RH: Surgical resection of brain metastases from lung cancer. Acta Neurochir (Wien) 138:3823891996

    • Search Google Scholar
    • Export Citation
  • 2

    Batchelor TDeAngelis LM: Medical management of cerebral metastases. Neurosurg Clin N Am 7:4354461996

  • 3

    Bindal RKSawaya RLeavens MELee JJ: Surgical treatment of multiple brain metastases. J Neurosurg 79:2102161993

  • 4

    Chang ELWefel JSMaor MHHassenbusch SJ IIIMahajan ALang FF: A pilot study of neurocognitive function in patients with one to three new brain metastases initially treated with stereotactic radiosurgery alone. Neurosurgery 60:2772842007

    • Search Google Scholar
    • Export Citation
  • 5

    Coia LRAaronson NLinggood RLoeffler JPriestman TJ: A report of the consensus workshop panel on the treatment of brain metastases. Int J Radiat Oncol Biol Phys 23:2232271992

    • Search Google Scholar
    • Export Citation
  • 6

    Cooper JSSteinfeld ADLerch IA: Cerebral metastases: value of reirradiation in selected patients. Radiology 174:8838851990

  • 7

    Dagnew EKanski JMcDermott MWSneed PKMcPherson CBreneman JC: Management of newly diagnosed single brain metastasis using resection and permanent iodine-125 seeds without initial whole-brain radiotherapy: a two institution experience. Neurosurg Focus 22:3E32007

    • Search Google Scholar
    • Export Citation
  • 8

    Davis PCHudgins PAPeterman SBHoffman JC Jr: Diagnosis of cerebral metastases: double-dose delayed CT vs contrast-enhanced MR imaging. AJNR Am J Neuroradiol 12:2933001991

    • Search Google Scholar
    • Export Citation
  • 9

    DeAngelis LMDelattre JYPosner JB: Radiation-induced dementia in patients cured of brain metastases. Neurology 39:7897961989

  • 10

    Eichler AFLoeffler JS: Multidisciplinary management of brain metastases. Oncologist 12:8848982007

  • 11

    Gaspar LScott CRotman MAsbell SPhillips TWasserman T: Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy Oncology Group (RTOG) brain metastases trials. Int J Radiat Oncol Biol Phys 37:7457511997

    • Search Google Scholar
    • Export Citation
  • 12

    Gutierrez ANWesterly DCTome WAJaradat HAMackie TRBentzen SM: Whole brain radiotherapy with hippocampal avoidance and simultaneously integrated brain metastases boost: a planning study. Int J Radiat Oncol Biol Phys 69:5895972007

    • Search Google Scholar
    • Export Citation
  • 13

    Halpern JKishel SPPark JTsukada YJohnson RJAmbrus JL: Radiation induced brain edema in primates, studied with sequential brain cat scanning and histopathology. Protective effect of sodium meclofenamate A preliminary report. Res Commun Chem Pathol Pharmacol 45:4634701984

    • Search Google Scholar
    • Export Citation
  • 14

    Jagannathan JPetit JHBalsara KHudes RChin LS: Long-term survival after gamma knife radiosurgery for primary and metastatic brain tumors. Am J Clin Oncol 27:4414442004

    • Search Google Scholar
    • Export Citation
  • 15

    Jagannathan JSherman JHMehta GUChin LS: Radiobiology of brain metastasis: applications in stereotactic radiosurgery. Neurosurg Focus 22:3E42007

    • Search Google Scholar
    • Export Citation
  • 16

    Kased NHuang KNakamura JLSahgal ALarson DAMcDermott MW: Gamma Knife radiosurgery for brainstem metastases: the UCSF experience. J Neurooncol 2007

    • Search Google Scholar
    • Export Citation
  • 17

    Kresl JPueschel JPorter RYan EMcDermott MSneed P: Surgical resection and postoperative radiosurgery for single brain metastases. Neuro Oncol 5:3382003. (Abstract)

    • Search Google Scholar
    • Export Citation
  • 18

    Lang FFSawaya R: Surgical management of cerebral metastases. Neurosurg Clin N Am 7:4594841996

  • 19

    Lang FFSawaya R: Surgical treatment of metastatic brain tumors. Semin Surg Oncol 14:53631998

  • 20

    Leksell L: The stereotaxic method and radiosurgery of the brain. Acta Chir Scand 102:3163191951

  • 21

    Loeffler JSKooy HMWen PYFine HACheng CWMannarino EG: The treatment of recurrent brain metastases with stereotactic radiosurgery. J Clin Oncol 8:5765821990

    • Search Google Scholar
    • Export Citation
  • 22

    Lunsford LDFlickinger JC: Radiosurgery plus or minus whole brain radiation therapy for the treatment of brain metastases. An editorial comment. Surg Neurol 66:4614622006

    • Search Google Scholar
    • Export Citation
  • 23

    Mathieu DKondziolka DFlickinger JCFortin DKenny BMichaud K: Tumor bed radiosurgery after resection of cerebral metastases. Neurosurgery [epub ahead of print]2008

    • Search Google Scholar
    • Export Citation
  • 24

    Mehta MPRodrigus PTerhaard CHRao ASuh JRoa W: Survival and neurologic outcomes in a randomized trial of motexafin gadolinium and whole-brain radiation therapy in brain metastases. J Clin Oncol 21:252925362003

    • Search Google Scholar
    • Export Citation
  • 25

    Mehta MPShapiro WRGlantz MJPatchell RAWeitzner MAMeyers CA: Lead-in phase to randomized trial of motexafin gadolinium and whole-brain radiation for patients with brain metastases: centralized assessment of magnetic resonance imaging, neurocognitive, and neurologic end points. J Clin Oncol 20:344534532002

    • Search Google Scholar
    • Export Citation
  • 26

    Meyers CASmith JABezjak AMehta MPLiebmann JIllidge T: Neurocognitive function and progression in patients with brain metastases treated with whole-brain radiation and motexafin gadolinium: results of a randomized phase III trial. J Clin Oncol 22:1571652004

    • Search Google Scholar
    • Export Citation
  • 27

    Mintz BJTuhrim SAlexander SYang WCShanzer S: Intracranial metastases in the initial staging of bronchogenic carcinoma. Chest 86:8508531984

    • Search Google Scholar
    • Export Citation
  • 28

    Muacevic AKreth FWHorstmann GASchmid-Elsaesser RWowra BSteiger HJ: Surgery and radiotherapy compared with gamma knife radiosurgery in the treatment of solitary cerebral metastases of small diameter. J Neurosurg 91:35431999

    • Search Google Scholar
    • Export Citation
  • 29

    Nieder CSchwerdtfeger KSteudel WISchnabel K: Patterns of relapse and late toxicity after resection and whole-brain radiotherapy for solitary brain metastases. Strahlenther Onkol 174:2752781998

    • Search Google Scholar
    • Export Citation
  • 30

    Packer RJ: Radiation-induced neurocognitive decline: the risks and benefits of reducing the amount of whole-brain irradiation. Curr Neurol Neurosci Rep 2:1311332002

    • Search Google Scholar
    • Export Citation
  • 31

    Patchell RA: The management of brain metastases. Cancer Treat Rev 29:5335402003

  • 32

    Patchell RARegine WF: The rationale for adjuvant whole brain radiation therapy with radiosurgery in the treatment of single brain metastases. Technol Cancer Res Treat 2:1111152003

    • Search Google Scholar
    • Export Citation
  • 33

    Patchell RATibbs PARegine WFDempsey RJMohiuddin MKryscio RJ: Postoperative radiotherapy in the treatment of single metastases to the brain: a randomized trial. JAMA 280:148514891998

    • Search Google Scholar
    • Export Citation
  • 34

    Patchell RATibbs PAWalsh JWDempsey RJMaruyama YKryscio RJ: A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 322:4945001990

    • Search Google Scholar
    • Export Citation
  • 35

    Pollock BE: An evidence-based medicine review of stereotactic radiosurgery. Prog Neurol Surg 19:1521702006

  • 36

    Regine WFRogozinska AKryscio RJTibbs PAYoung ABPatchell RA: Recursive partitioning analysis classifications I and II: applicability evaluated in a randomized trial for resected single brain metastases. Am J Clin Oncol 27:5055092004

    • Search Google Scholar
    • Export Citation
  • 37

    Rogers LRRock JPSills AKVogelbaum MASuh JHEllis TL: Results of a phase II trial of the GliaSite radiation therapy system for the treatment of newly diagnosed, resected single brain metastases. J Neurosurg 105:3753842006

    • Search Google Scholar
    • Export Citation
  • 38

    Schackert GSteinmetz AMeier USobottka SB: Surgical management of single and multiple brain metastases: results of a retrospective study. Onkologie 24:2462552001

    • Search Google Scholar
    • Export Citation
  • 39

    Sheehan JNiranjan AFlickinger JCKondziolka DLunsford LD: The expanding role of neurosurgeons in the management of brain metastases. Surg Neurol 62:32412004

    • Search Google Scholar
    • Export Citation
  • 40

    Shehata MKYoung BReid BPatchell RASt Clair WSims J: Stereotatic radiosurgery of 468 brain metastases < or = 2 cm: implications for SRS dose and whole brain radiation therapy. Int J Radiat Oncol Biol Phys 59:87932004

    • Search Google Scholar
    • Export Citation
  • 41

    Smith MLLee JY: Stereotactic radiosurgery in the management of brain metastasis. Neurosurg Focus 22:3E52007

  • 42

    Soltys SGAdler JRLipani JDJackson PSChoi CYPuataweepong P: Stereotactic radiosurgery of the postoperative resection cavity for brain metastases. Int J Radiat Oncol Biol Phys 70:1871932008

    • Search Google Scholar
    • Export Citation
  • 43

    Sundaresan NGalicich JHBeattie EJ Jr: Surgical treatment of brain metastases from lung cancer. J Neurosurg 58:6666711983

  • 44

    Syk ETorkzad MRBlomqvist LLjungqvist OGlimelius B: Radiological findings do not support lateral residual tumour as a major cause of local recurrence of rectal cancer. Br J Surg 93:1131192006

    • Search Google Scholar
    • Export Citation
  • 45

    Tasdemiroglu EPatchell RAKryscio R: Neurological complications of childhood malignancies. Acta Neurochir (Wien) 141:131313211999

    • Search Google Scholar
    • Export Citation
  • 46

    Vecht CJHaaxma-Reiche HNoordijk EMPadberg GWVoormolen JHHoekstra FH: Treatment of single brain metastasis: radiotherapy alone or combined with neurosurgery?. Ann Neurol 33:5835901993

    • Search Google Scholar
    • Export Citation
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