Gamma Knife surgery for the treatment of 5 to 15 metastases to the brain

Clinical article

Restricted access

Object

It has been generally accepted that Gamma Knife surgery (GKS) is an effective primary or adjunct treatment for patients with 1–4 metastases to the brain. The number of studies detailing the use of GKS for 5 or more brain metastases, however, remains minimal. The aim of the current retrospective study was to elucidate the utility of GKS in patients with 5–15 brain metastases.

Methods

Patients were chosen for GKS based on prior MRI of these metastatic lesions and a known primary cancer diagnosis. Magnetic resonance imaging was used post-GKS to assess tumor control; patients were also followed up clinically. Overall survival (OS) from the date of GKS was used as the primary end point. Statistical analysis was performed to identify prognostic factors related to OS.

Results

Between 2003 and 2012, 96 patients were treated for a total of 704 metastatic brain lesions. The histology of these lesions varied among non–small cell lung cancer (NSCLC), breast cancer, melanoma, renal cancer, and other more rare carcinomas. At the initial treatment, 18 of the patients (18.8%) were categorized in Recursive Partitioning Analysis (RPA) Class 1 and 77 (80.2%) in RPA Class 2; none were in RPA Class 3. The median number of treated lesions was 7 (mean 7.13), and the median planned treatment volume was 6.12 cm3 (range 0.42–57.83 cm3) per patient. The median clinical follow-up was 4.1 months (range 0.1–40.70 months). Actuarial tumor control was calculated to be 92.4% at 6 months, 84.8% at 12 months, and 74.9% at 24 months post-GKS. The median OS was found to be 4.73 months (range 0.4–41.8 months). Multivariate analysis demonstrated that RPA class was a significant predictor of death (HR = 2.263, p = 0.038). Number of lesions, tumor histology, Graded Prognostic Assessment score, prior whole-brain radiation therapy, prior resection, prior chemotherapy, patient age, patient sex, controlled primary tumor, extracranial metastases, and planned treatment volume were not significant predictors of OS.

Conclusions

In patients with 5–15 brain metastases at presentation, the number of lesions did not predict survival after GKS; however, the RPA class was predictive of OS in this group of patients. Gamma Knife surgery for such patients offers an excellent rate of local tumor control.

Abbreviations used in this paper:GKS = Gamma Knife surgery; GPA = Graded Prognostic Assessment; JLGK = Japan Leksell Gamma Knife; KPS = Karnofsky Performance Status; NSCLC = non–small cell lung cancer; OS = overall survival; PTV = planned treatment volume; RECIST = Response Evaluation Criteria in Solid Tumors; RPA = Recursive Partitioning Analysis; RTOG = Radiation Therapy Oncology Group; UVA = University of Virginia; WBRT = whole-brain radiation therapy.

Article Information

Address correspondence to: Jason Sheehan, M.D., Ph.D., Box 800212, Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia 22908. email: jsheehan@virginia.edu.

Please include this information when citing this paper: published online March 29, 2013; DOI: 10.3171/2013.2.JNS121213.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Left: Kaplan-Meier curve showing cumulative survival rate stratified by RPA class. Right: Kaplan-Meier curve of local tumor control.

References

1

Andrews DWScott CBSperduto PWFlanders AEGaspar LESchell MC: Whole brain radiation therapy with or without stereotactic radiosurgery boost for patients with one to three brain metastases: phase III results of the RTOG 9508 randomised trial. Lancet 363:166516722004

2

Bhatnagar AKFlickinger JCKondziolka DLunsford LD: Stereotactic radiosurgery for four or more intracranial metastases. Int J Radiat Oncol Biol Phys 64:8989032006

3

Chang WSKim HYChang JWPark YGChang JH: Analysis of radiosurgical results in patients with brain metastases according to the number of brain lesions: is stereotactic radiosurgery effective for multiple brain metastases? Clinical article. J Neurosurg 113:Suppl73782010

4

Eisenhauer EATherasse PBogaerts JSchwartz LHSargent DFord R: New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer 45:2282472009

5

Gerosa MNicolato AForoni RZanotti BTomazzoli LMiscusi M: Gamma knife radiosurgery for brain metastases: a primary therapeutic option. J Neurosurg 97:5 Suppl5155242002

6

Grandhi RKondziolka DPanczykowski DMonaco EA IIIKano HNiranjan A: Stereotactic radiosurgery using the Leksell gamma knife Perfexion unit in the management of patients with 10 or more brain metastases. Clinical article. J Neurosurg 117:2372452012

7

Hunter GKSun JHReuther AMVogelbaum MABarnett GHAngelov L: Treatment of five or more brain metastases with stereotactic radiosurgery. Int J Radiat Oncol Biol Phys 83:139413982012

8

Kim CHIm YSNam DHPark KKim JHLee JI: Gamma knife radiosurgery for ten or more brain metastases. J Korean Neurosurg Soc 44:3583632008

9

Knisely JPYamamoto MGross CPCastrucci WAJokura HChiang VL: Radiosurgery alone for 5 or more brain metastases: expert opinion survey. Clinical article. J Neurosurg 113:Suppl84892010

10

Kondziolka DPatel ALunsford LDKassam AFlickinger JC: Stereotactic radiosurgery plus whole brain radiotherapy versus radiotherapy alone for patients with multiple brain metastases. Int J Radiat Oncol Biol Phys 45:4274341999

11

Lee CKLee SRCho JMYang KAKim SH: Therapeutic effect of gamma knife radiosurgery for multiple brain metastases. J Korean Neurosurg Soc 50:1791842011

12

Li BYu JSuntharalingam MKennedy ASAmin PPChen Z: Comparison of three treatment options for single brain metastasis from lung cancer. Int J Cancer 90:37452000

13

Linskey MEAndrews DWAsher ALBurri SHKondziolka DRobinson PD: The role of stereotactic radiosurgery in the management of patients with newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline. J Neurooncol 96:45682010

14

Mingione VOliveira MPrasad DSteiner MSteiner L: Gamma surgery for melanoma metastases in the brain. J Neurosurg 96:5445512002

15

Minniti GSalvati MMuni RLanzetta GOsti MFClarke E: Stereotactic radiosurgery plus whole-brain radiotherapy for treatment of multiple metastases from non-small cell lung cancer. Anticancer Res 30:305530612010

16

Nam TKLee JIJung YJIm YSAn HYNam DH: Gamma knife surgery for brain metastases in patients harboring four or more lesions: survival and prognostic factors. J Neurosurg 102:Suppl1471502005

17

Pan HCSheehan JStroila MSteiner MSteiner L: Gamma knife surgery for brain metastases from lung cancer. J Neurosurg 102:Suppl1281332005

18

Park SHHwang SKKang DHLee SHPark JHwang JH: Gamma knife radiosurgery for multiple brain metastases from lung cancer. J Clin Neurosci 16:6266292009

19

Patil CGPricola KGarg SKBryant ABlack KL: Whole brain radiation therapy (WBRT) alone versus WBRT and radiosurgery for the treatment of brain metastases. Cochrane Database Syst Rev 6CD0061212010

20

Rades DBohlen GPluemer AVeninga THanssens PDunst J: Stereotactic radiosurgery alone versus resection plus whole-brain radiotherapy for 1 or 2 brain metastases in recursive partitioning analysis class 1 and 2 patients. Cancer 109:251525212007

21

Sanghavi SNMiranpuri SSChappell RBuatti JMSneed PKSuh JH: Radiosurgery for patients with brain metastases: a multi-institutional analysis, stratified by the RTOG recursive partitioning analysis method. Int J Radiat Oncol Biol Phys 51:4264342001

22

Sansur CAChin LSAmes JWBanegura ATAggarwal SBallesteros M: Gamma knife radiosurgery for the treatment of brain metastases. Stereotact Funct Neurosurg 74:37512000

23

Schöggl AKitz KReddy MWolfsberger SSchneider BDieckmann K: Defining the role of stereotactic radiosurgery versus microsurgery in the treatment of single brain metastases. Acta Neurochir (Wien) 142:6216262000

24

Serizawa THirai TNagano OHiguchi YMatsuda SOno J: Gamma knife surgery for 1–10 brain metastases without prophylactic whole-brain radiation therapy: analysis of cases meeting the Japanese prospective multi-institute study (JLGK0901) inclusion criteria. J Neurooncol 98:1631672010

25

Serizawa TYamamoto MSato YHiguchi YNagano OKawabe T: Gamma Knife surgery as sole treatment for multiple brain metastases: 2-center retrospective review of 1508 cases meeting the inclusion criteria of the JLGK0901 multi-institutional prospective study. Clinical article. J Neurosurg 113:Suppl48522010

26

Sheehan JPYen CPNguyen JRainey JADassoulas KSchlesinger DJ: Timing and risk factors for new brain metastasis formation in patients initially treated only with Gamma Knife surgery. Clinical article. J Neurosurg 114:7637682011

27

Sneed PKSuh JHGoetsch SJSanghavi SNChappell RBuatti JM: A multi-institutional review of radiosurgery alone vs. radiosurgery with whole brain radiotherapy as the initial management of brain metastases. Int J Radiat Oncol Biol Phys 53:5195262002

28

Sperduto CMWatanabe YMullan JHood TDyste GWatts C: A validation study of a new prognostic index for patients with brain metastases: the Graded Prognostic Assessment. J Neurosurg 109:Suppl87892008

29

Sperduto PWBerkey BGaspar LEMehta MCurran W: A new prognostic index and comparison to three other indices for patients with brain metastases: an analysis of 1,960 patients in the RTOG database. Int J Radiat Oncol Biol Phys 70:5105142008

30

Suzuki SOmagari JNishio SNishiye EFukui M: Gamma knife radiosurgery for simultaneous multiple metastatic brain tumors. J Neurosurg 93:Suppl 330312000

31

Tsao MNLloyd NWong RKChow ERakovitch ELaperriere N: Whole brain radiotherapy for the treatment of newly diagnosed multiple brain metastases. Cochrane Database Syst Rev 4:CD0038692012

32

Tsao MNLloyd NSWong RKRakovitch EChow ELaperriere N: Radiotherapeutic management of brain metastases: a systematic review and meta-analysis. Cancer Treat Rev 31:2562732005

33

Vesagas TSAguilar JAMercado ERMariano MM: Gamma knife radiosurgery and brain metastases: local control, survival, and quality of life. J Neurosurg 97:5 Suppl5075102002

34

Viani GAda Silva LGStefano EJ: Prognostic indexes for brain metastases: which is the most powerful?. Int J Radiat Oncol Biol Phys 83:e325e3302012

35

Yamamoto MSato YSerizawa TKawabe THiguchi YNagano O: Subclassification of recursive partitioning analysis class II patients with brain metastases treated radiosurgically. Int J Radiat Oncol Biol Phys 83:139914052012

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 21 21 20
Full Text Views 125 125 33
PDF Downloads 85 85 30
EPUB Downloads 0 0 0

PubMed

Google Scholar