Outcome predictors of Gamma Knife surgery for melanoma brain metastases

Clinical article

View More View Less
  • 1 Departments of Neurological Surgery,
  • 2 Radiation Oncology, and
  • 3 the Center for Image-Guided Neurosurgery, Department of Medicine; and
  • 4 Division of Hematology/Oncology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
  • 5 Department of Neurological Surgery, Université de Sherbrooke, Quebec, Canada
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

Object

To evaluate the role of stereotactic radiosurgery (SRS) in the management of brain metastases from melanoma, the authors assessed clinical outcomes and prognostic factors for survival and tumor control.

Methods

The authors reviewed 333 consecutive patients with melanoma who underwent SRS for 1570 brain metastases from cutaneous and mucosal/acral melanoma. The patient population consisted of 109 female and 224 male patients with a median age of 53 years. Two hundred eleven patients (63%) had multiple metastases. One hundred eighteen patients (35%) underwent whole-brain radiation therapy (WBRT). The target volume ranged from 0.1 cm3 to 37.2 cm3. The median marginal dose was 18 Gy.

Results

Actuarial survival rates were 70% at 3 months, 47% at 6 months, 25% at 12 months, and 10% at 24 months after radiosurgery. Factors associated with longer survival included controlled extracranial disease, better Karnofsky Performance Scale score, fewer brain metastases, no prior WBRT, no prior chemotherapy, administration of immunotherapy, and no intratumoral hemorrhage before radiosurgery. The median survival for patients with a solitary brain metastasis, controlled extracranial disease, and administration of immunotherapy after radiosurgery was 22 months. Sustained local tumor control was achieved in 73% of the patients. Sixty-four (25%) of 259 patients who had follow-up imaging after SRS had evidence of delayed intratumoral hemorrhage. Sixteen patients underwent a craniotomy due to intratumoral hemorrhage. Seventeen patients (6%) had asymptomatic and 21 patients (7%) had symptomatic radiation effects. Patients with ≤ 8 brain metastases, no prior WBRT, and the recursive partitioning analysis Class I had extended survivals (median 54.3 months).

Conclusions

Stereotactic radiosurgery is an especially valuable option for patients with controlled systemic disease even if they have multiple metastatic brain tumors.

Abbreviations used in this paper: HFS = hemorrhage-free survival; HR = hazard ratio; KPS = Karnofsky Performance Scale; OS = overall survival; PFS = progression-free survival; RPA = recursive partitioning analysis; SIR = score index of radiosurgery; SRS = stereotactic radiosurgery; WBRT = whole-brain radiation therapy.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

* Drs. Liew and Kano contributed equally to this work.

Address correspondence to: L. Dade Lunsford, M.D., Department of Neurological Surgery, University of Pittsburgh, Suite B-400, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, Pennsylvania 15213. email: lunsfordld@upmc.edu.

Please include this information when citing this paper: published online June 4, 2010; DOI: 10.3171/2010.5.JNS1014.

  • 1

    Atkins MB, , Sosman JA, , Agarwala S, , Logan T, , Clark JI, & Ernstoff MS, : Temozolomide, thalidomide, and whole brain radiation therapy for patients with brain metastasis from metastatic melanoma: a phase II Cytokine Working Group study. Cancer 113:21392145, 2008

    • Search Google Scholar
    • Export Citation
  • 2

    Bafaloukos D, & Gogas H: The treatment of brain metastases in melanoma patients. Cancer Treat Rev 30:515520, 2004

  • 3

    Bamias A, , Aravantinos G, , Deliveliotis C, , Bafaloukos D, , Kalofonos C, & Xiros N, : Docetaxel and cisplatin with granulocyte colony-stimulating factor (G-CSF) versus MVAC with G-CSF in advanced urothelial carcinoma: a multicenter, randomized, phase III study from the Hellenic Cooperative Oncology Group. J Clin Oncol 22:220228, 2004

    • Search Google Scholar
    • Export Citation
  • 4

    Bhatnagar AK, , Flickinger JC, , Kondziolka D, & Lunsford LD: Stereotactic radiosurgery for four or more intracranial metastases. Int J Radiat Oncol Biol Phys 64:898903, 2006

    • Search Google Scholar
    • Export Citation
  • 5

    Brown PD, , Brown CA, , Pollock BE, , Gorman DA, & Foote RL: Stereotactic radiosurgery for patients with “radioresistant” brain metastases. Neurosurgery 62:Suppl 2 790801, 2008

    • Search Google Scholar
    • Export Citation
  • 6

    Buchsbaum JC, , Suh JH, , Lee SY, , Chidel MA, , Greskovich JF, & Barnett GH: Survival by radiation therapy oncology group recursive partitioning analysis class and treatment modality in patients with brain metastases from malignant melanoma: a retrospective study. Cancer 94:22652272, 2002

    • Search Google Scholar
    • Export Citation
  • 7

    Chang EL, , Selek U, , Hassenbusch SJ III, , Maor MH, , Allen PK, & Mahajan A, : Outcome variation among “radioresistant” brain metastases treated with stereotactic radiosurgery. Neurosurgery 56:936945, 2005

    • Search Google Scholar
    • Export Citation
  • 8

    Christopoulou A, , Retsas S, , Kingsley D, , Paddick I, & Lindquist C: Integration of gamma knife surgery in the management of cerebral metastases from melanoma. Melanoma Res 16:5157, 2006

    • Search Google Scholar
    • Export Citation
  • 9

    DiLuna ML, , King JT Jr, , Knisely JP, & Chiang VL: Prognostic factors for survival after stereotactic radiosurgery vary with the number of cerebral metastases. Cancer 109:135145, 2007

    • Search Google Scholar
    • Export Citation
  • 10

    Doss LL, & Memula N: The radioresponsiveness of melanoma. Int J Radiat Oncol Biol Phys 8:11311134, 1982

  • 11

    Eisenhauer EA, , Therasse P, , Bogaerts J, , Schwartz LH, , Sargent D, & Ford R, : New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer 45:228247, 2009

    • Search Google Scholar
    • Export Citation
  • 12

    Ellerhorst J, , Strom E, , Nardone E, & McCutcheon I: Whole brain irradiation for patients with metastatic melanoma: a review of 87 cases. Int J Radiat Oncol Biol Phys 49:9397, 2001

    • Search Google Scholar
    • Export Citation
  • 13

    Fife KM, , Colman MH, , Stevens GN, , Firth IC, , Moon D, & Shannon KF, : Determinants of outcome in melanoma patients with cerebral metastases. J Clin Oncol 22:12931300, 2004

    • Search Google Scholar
    • Export Citation
  • 14

    Gaudy-Marqueste C, , Regis JM, , Muracciole X, , Laurans R, , Richard MA, & Bonerandi JJ, : Gamma-Knife radiosurgery in the management of melanoma patients with brain metastases: a series of 106 patients without whole-brain radiotherapy. Int J Radiat Oncol Biol Phys 65:809816, 2006

    • Search Google Scholar
    • Export Citation
  • 15

    Geara FB, & Ang KK: Radiation therapy for malignant melanoma. Surg Clin North Am 76:13831398, 1996

  • 16

    Gieger M, , Wu JK, , Ling MN, , Wazer D, , Tsai JS, & Engler MJ: Response of intracranial melanoma metastases to stereotactic radiosurgery. Radiat Oncol Investig 5:7280, 1997

    • Search Google Scholar
    • Export Citation
  • 17

    Grooms GA, , Eilber FR, & Morton DL: Failure of adjuvant immunotherapy to prevent central nervous system metastases in malignant melanoma patients. J Surg Oncol 9:147153, 1977

    • Search Google Scholar
    • Export Citation
  • 18

    Guirguis LM, , Yang JC, , White DE, , Steinberg SM, , Liewehr DJ, & Rosenberg SA, : Safety and efficacy of high-dose interleukin-2 therapy in patients with brain metastases. J Immunother 25:8287, 2002

    • Search Google Scholar
    • Export Citation
  • 19

    Hara W, , Tran P, , Li G, , Su Z, , Puataweepong P, & Adler JR Jr, : Cyberknife for brain metastases of malignant melanoma and renal cell carcinoma. Neurosurgery 64:2 Suppl A26A32, 2009

    • Search Google Scholar
    • Export Citation
  • 20

    Herfarth KK, , Izwekowa O, , Thilmann C, , Pirzkall A, , Delorme S, & Hofmann U, : Linac-based radiosurgery of cerebral melanoma metastases. Analysis of 122 metastases treated in 64 patients. Strahlenther Onkol 179:366371, 2003

    • Search Google Scholar
    • Export Citation
  • 21

    Jensen RL, , Shrieve AF, , Samlowski W, & Shrieve DC: Outcomes of patients with brain metastases from melanoma and renal cell carcinoma after primary stereotactic radiosurgery. Clin Neurosurg 55:150159, 2008

    • Search Google Scholar
    • Export Citation
  • 22

    Koc M, , McGregor J, , Grecula J, , Bauer CJ, , Gupta N, & Gahbauer RA: Gamma Knife radiosurgery for intracranial metastatic melanoma: an analysis of survival and prognostic factors. J Neurooncol 71:307313, 2005

    • Search Google Scholar
    • Export Citation
  • 23

    Kondziolka D, , Bernstein M, , Resch L, , Tator CH, , Fleming JF, & Vanderlinden RG, : Significance of hemorrhage into brain tumors: clinicopathological study. J Neurosurg 67:852857, 1987

    • Search Google Scholar
    • Export Citation
  • 24

    Korn EL, , Liu PY, , Lee SJ, , Chapman JA, , Niedzwiecki D, & Suman VJ, : Meta-analysis of phase II cooperative group trials in metastatic stage IV melanoma to determine progression-free and overall survival benchmarks for future phase II trials. J Clin Oncol 26:527534, 2008

    • Search Google Scholar
    • Export Citation
  • 25

    Kouvaris JR, , Miliadou A, , Kouloulias VE, , Kolokouris D, , Balafouta MJ, & Papacharalampous XN, : Phase II study of temozolomide and concomitant whole-brain radiotherapy in patients with brain metastases from solid tumors. Onkologie 30:361366, 2007

    • Search Google Scholar
    • Export Citation
  • 26

    Lagerwaard FJ, , Levendag PC, , Nowak PJ, , Eijkenboom WM, , Hanssens PE, & Schmitz PI: Identification of prognostic factors in patients with brain metastases: a review of 1292 patients. Int J Radiat Oncol Biol Phys 43:795803, 1999

    • Search Google Scholar
    • Export Citation
  • 27

    Lavine SD, , Petrovich Z, , Cohen-Gadol AA, , Masri LS, , Morton DL, & O'Day SJ, : Gamma knife radiosurgery for metastatic melanoma: an analysis of survival, outcome, and complications. Neurosurgery 44:5966, 1999

    • Search Google Scholar
    • Export Citation
  • 28

    Lorenzoni J, , Devriendt D, , Massager N, , David P, , Ruíz S, & Vanderlinden B, : Radiosurgery for treatment of brain metastases: estimation of patient eligibility using three stratification systems. Int J Radiat Oncol Biol Phys 60:218224, 2004

    • Search Google Scholar
    • Export Citation
  • 29

    Manon R, , O'Neill A, , Knisely J, , Werner-Wasik M, , Lazarus HM, & Wagner H, : Phase II trial of radiosurgery for one to three newly diagnosed brain metastases from renal cell carcinoma, melanoma, and sarcoma: an Eastern Cooperative Oncology Group study (E 6397). J Clin Oncol 23:88708876, 2005

    • Search Google Scholar
    • Export Citation
  • 30

    Mathieu D, , Kondziolka D, , Cooper PB, , Flickinger JC, , Niranjan A, & Agarwala S, : Gamma knife radiosurgery in the management of malignant melanoma brain metastases. Neurosurgery 60:471482, 2007

    • Search Google Scholar
    • Export Citation
  • 31

    Meier S, , Baumert BG, , Maier T, , Wellis G, , Burg G, & Seifert B, : Survival and prognostic factors in patients with brain metastases from malignant melanoma. Onkologie 27:145149, 2004

    • Search Google Scholar
    • Export Citation
  • 32

    Mingione V, , Oliveira M, , Prasad D, , Steiner M, & Steiner L: Gamma surgery for melanoma metastases in the brain. J Neurosurg 96:544551, 2002

    • Search Google Scholar
    • Export Citation
  • 33

    Mori Y, , Kondziolka D, , Flickinger JC, , Kirkwood JM, , Agarwala S, & Lunsford LD: Stereotactic radiosurgery for cerebral metastatic melanoma: factors affecting local disease control and survival. Int J Radiat Oncol Biol Phys 42:581589, 1998

    • Search Google Scholar
    • Export Citation
  • 34

    Noël G, , Simon JM, , Valery CA, , Cornu P, , Boisserie G, & Ledu D, : Linac radiosurgery for brain metastasis of melanoma. Stereotact Funct Neurosurg 79:245255, 2002

    • Search Google Scholar
    • Export Citation
  • 35

    Ott PA, , Chang JL, , Oratz R, , Jones A, , Farrell K, & Muggia F, : Phase II trial of dacarbazine and thalidomide for the treatment of metastatic melanoma. Chemotherapy 55:221227, 2009

    • Search Google Scholar
    • Export Citation
  • 36

    Powell JW, , Chung CT, , Shah HR, , Canute GW, , Hodge CJ, & Bassano DA, : Gamma Knife surgery in the management of radioresistant brain metastases in high-risk patients with melanoma, renal cell carcinoma, and sarcoma. J Neurosurg 109:Suppl 122128, 2008

    • Search Google Scholar
    • Export Citation
  • 37

    Radbill AE, , Fiveash JF, , Falkenberg ET, , Guthrie BL, , Young PE, & Meleth S, : Initial treatment of melanoma brain metastases using gamma knife radiosurgery: an evaluation of efficacy and toxicity. Cancer 101:825833, 2004

    • Search Google Scholar
    • Export Citation
  • 38

    Redmond AJ, , Diluna ML, , Hebert R, , Moliterno JA, , Desai R, & Knisely JP, : Gamma Knife surgery for the treatment of melanoma metastases: the effect of intratumoral hemorrhage on survival. J Neurosurg 109:Suppl 99105, 2008

    • Search Google Scholar
    • Export Citation
  • 39

    Saha S, , Meyer M, , Krementz ET, , Hoda S, , Carter RD, & Muchmore J, : Prognostic evaluation of intracranial metastasis in malignant melanoma. Ann Surg Oncol 1:3844, 1994

    • Search Google Scholar
    • Export Citation
  • 40

    Samlowski WE, , Watson GA, , Wang M, , Rao G, , Klimo P Jr, & Boucher K, : Multimodality treatment of melanoma brain metastases incorporating stereotactic radiosurgery (SRS). Cancer 109:18551862, 2007

    • Search Google Scholar
    • Export Citation
  • 41

    Sampson JH, , Carter JH Jr, , Friedman AH, & Seigler HF: Demographics, prognosis, and therapy in 702 patients with brain metastases from malignant melanoma. J Neurosurg 88:1120, 1998

    • Search Google Scholar
    • Export Citation
  • 42

    Savas B, , Arslan G, , Gelen T, , Karpuzoglu G, & Ozkaynak C: Multidrug resistant malignant melanoma with intracranial metastasis responding to immunotherapy. Anticancer Res 19:5C 44134420, 1999

    • Search Google Scholar
    • Export Citation
  • 43

    Selek U, , Chang EL, , Hassenbusch SJ III, , Shiu AS, , Lang FF, & Allen P, : Stereotactic radiosurgical treatment in 103 patients for 153 cerebral melanoma metastases. Int J Radiat Oncol Biol Phys 59:10971106, 2004

    • Search Google Scholar
    • Export Citation
  • 44

    Seung SK, , Sneed PK, , McDermott MW, , Shu HK, , Leong SP, & Chang S, : Gamma knife radiosurgery for malignant melanoma brain metastases. Cancer J Sci Am 4:103109, 1998

    • Search Google Scholar
    • Export Citation
  • 45

    Sin AH, , Cardenas RJ, , Vannemreddy P, & Nanda A: Gamma Knife stereotactic radiosurgery for intracranial metastases from conventionally radioresistant primary cancers: outcome analysis of survival and control of brain disease. South Med J 102:4244, 2009

    • Search Google Scholar
    • Export Citation
  • 46

    Sloan AE, , Nock CJ, & Einstein DB: Diagnosis and treatment of melanoma brain metastasis: a literature review. Cancer Control 16:248255, 2009

    • Search Google Scholar
    • Export Citation
  • 47

    Somaza S, , Kondziolka D, , Lunsford LD, , Kirkwood JM, & Flickinger JC: Stereotactic radiosurgery for cerebral metastatic melanoma. J Neurosurg 79:661666, 1993

    • Search Google Scholar
    • Export Citation
  • 48

    Tarhini AA, & Agarwala SS: Management of brain metastases in patients with melanoma. Curr Opin Oncol 16:161166, 2004

  • 49

    Tarhini AA, , Kirkwood JM, , Gooding WE, , Moschos S, & Agarwala SS: A phase 2 trial of sequential temozolomide chemotherapy followed by high-dose interleukin 2 immunotherapy for metastatic melanoma. Cancer 113:16321640, 2008

    • Search Google Scholar
    • Export Citation
  • 50

    Tsao H, , Atkins MB, & Sober AJ: Management of cutaneous melanoma. N Engl J Med 351:9981012, 2004

  • 51

    Weltman E, , Salvajoli JV, , Brandt RA, , de Morais Hanriot R, , Prisco FE, & Cruz JC, : Radiosurgery for brain metastases: a score index for predicting prognosis. Int J Radiat Oncol Biol Phys 46:11551161, 2000

    • Search Google Scholar
    • Export Citation
  • 52

    Wroński M, & Arbit E: Surgical treatment of brain metastases from melanoma: a retrospective study of 91 patients. J Neurosurg 93:918, 2000

    • Search Google Scholar
    • Export Citation
  • 53

    Yu C, , Chen JC, , Apuzzo ML, , O'Day S, , Giannotta SL, & Weber JS, : Metastatic melanoma to the brain: prognostic factors after gamma knife radiosurgery. Int J Radiat Oncol Biol Phys 52:12771287, 2002

    • Search Google Scholar
    • Export Citation
  • 54

    Zacest AC, , Besser M, , Stevens G, , Thompson JF, , McCarthy WH, & Culjak G: Surgical management of cerebral metastases from melanoma: outcome in 147 patients treated at a single institution over two decades. J Neurosurg 96:552558, 2002

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 1267 379 30
Full Text Views 267 25 0
PDF Downloads 206 16 0
EPUB Downloads 0 0 0