Comparative risk of leptomeningeal disease after resection or stereotactic radiosurgery for solid tumor metastasis to the posterior fossa

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Object

The authors tested the hypothesis that patients with metastatic posterior fossa lesions (MPFLs) treated with resection have a higher risk of leptomeningeal disease (LMD) than those with MPFLs treated with stereotactic radiosurgery (SRS).

Methods

Between 1993 and 2004, 379 patients with MPFLs were treated with resection or SRS at The University of Texas M. D. Anderson Cancer Center. The authors' primary study outcome was the incidence of LMD, as diagnosed with cerebrospinal fluid cytological analysis and/or neuroimaging.

Results

Resection was performed in 260 patients, whereas 119 patients underwent SRS. The median patient age was 56 years, 51% of patients were male, and 93% had a Karnofsky Performance Scale score $ 70. The most common primary cancers were those of the lung, breast, and kidney, as well as melanoma. Leptomeningeal dissemination of cancer occurred in 33 patients: 26 in the resection group and 7 in the SRS group (resection group: rate ratio [RR] 2.06, 95% confidence interval [CI] 0.89–4.75, p = 0.09). Piecemeal tumor resection (137 cases) was associated with a significantly higher risk of LMD than en bloc resection (123 cases; RR 3.4, 95% CI 1.43–8.12, p = 0.006) or SRS (RR 3.37, 95% CI 1.41–8.04, p = 0.006), and there was no significant difference in the risk for LMD between en bloc resection and SRS (en bloc resection: RR 0.98, 95% CI 0.34–2.81, p = 0.98). The multivariate RR and significance associated with piecemeal resection, however, were consistent, with a strong effect (RR 2.45, 95% CI 1.19–5.02, p = 0.02) and no indication of biases associated with tumor size, location, or cystic/necrotic appearance.

Conclusions

There is an increased risk of LMD after piecemeal resection of an MPFL. This increase, although clinically and statistically significant, is not as alarming as previously reported and is absent when en bloc removal is achieved. Further assessment of the role of resection in a controlled prospective setting is warranted.

Abbreviations used in this paper: CI = confidence interval; CNS = central nervous system; CSF = cerebrospinal fluid; KPS = Karnofsky Performance Scale; LMD = leptomeningeal disease; MPFL = metastatic posterior fossa lesion; RPA = recursive partitioning analysis; RR = rate ratio; SRS = stereotactic radiosurgery; WBRT = whole-brain radiation therapy.

Article Information

Address correspondence to: Dima Suki, Ph.D., Department of Neurosurgery, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 442, Houston, Texas 77030-4009. email: dsuki@mdanderson.org.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Bar graph showing the incidence of LMD in patients with MPFLs who had undergone treatment with SRS, en bloc resection, or piecemeal resection.

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    Graph depicting the proportion of patients with LMD after piecemeal resection of posterior fossa tumor(s) (137 patients) or an alternative treatment methodologies (en bloc resection [123 patients] or SRS [119 patients]). Plot was based on a multivariate Cox proportional hazards model analysis. The line representing en bloc resection lies on top of the line representing SRS.

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