Treatment of Large Brain Metastases With Stereotactic Radiosurgery

Zimmerman, Amy L.; Murphy, Erin S.; Suh, John H.; Vogelbaum, Michael A.; Barnett, Gene H.; Angelov, Lilyana; Ahluwalia, Manmeet; Reddy, Chandana A.; Chao, Samuel T.

doi:10.1177/1533034614568097

Cited by 24 publications

(12 citation statements)

References 40 publications

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“…However, elderly cancer patients and those in a poor clinical condition often prefer less invasive SRS to control tumor progression. Some studies have found that SR plus SRS or WBRT achieves better survival and local control than SRS [26, 27], while others have found no significant difference, for both large (>3 cm diameter) and small (≤3 cm diameter) BMs [8, 20, 24]. The most direct evidence of clinical effect is local control, due to the confounding factors that affect OS in all clinical studies.…”

Section: Discussionmentioning

confidence: 99%

“…However, the optimal treatment regimen is under debate, especially regarding the selection of SRS or SR for the initial local treatment. Although several studies have found that SRS alone achieves better local control than SR (including SR plus WBRT and SR plus SRS) [4][5][6], others have found that SR results in longer overall survival (OS) and better local control [7,8]. High-quality clinical data are lacking; only 2 randomized controlled trials (RCTs) have compared SR and SRS as initial treatment.…”

Section: Surgical Resection Vs Srs For Bm 405mentioning

confidence: 99%

“…Distant control did not significantly differ between the SR and SRS groups overall (HR 0.78, 95% CI 0.38-1.60, p = 0.49; I 2 = 61, p = 0.03), or in the subgroup analyses of SR plus SRS versus SRS alone (HR 0.86, 95% CI 0.35-2.11, p = 0.74; I 2 = 79%, p = 0.008) and SR plus WBRT versus SRS alone (HR 0.48, 95% CI 0.11-2, p = 0.31, I 2 = 0, p = 0.77). Zimmerman et al [8] increased the heterogeneity due to their inclusion of patients with BM > 3 cm in diameter; the other 4 studies all included solitary BM, most of which were < 3 cm. The analysis after excluding their study showed that distant intracranial control was significantly better in the SR group than in the SRS group overall (HR 0.59, 95% CI 0.38-0.92, p = 0.02; I 2 = 0, p = 0.74).…”

Section: Local Recurrence and Distant Progressionmentioning

confidence: 99%

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Comparison of Surgical Resection and Stereotactic Radiosurgery in the Initial Treatment of Brain Metastasis

Liu

Liang

2020

Stereotact Funct Neurosurg

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Background: Brain metastasis (BM) is the most common brain malignancy and a common cause of death in cancer patients. However, the relative outcome-related advantages and disadvantages of surgical resection (SR) and stereotactic radiosurgery (SRS) in the initial treatment of BM are controversial. Method: We systematically reviewed the English language literature up to March 2020 to compare the efficacy of SR and SRS in the initial treatment of BM. We identified cohort studies from the Cochrane Library, PubMed, and EM-BASE databases and conducted a meta-analysis following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Twenty cohort studies involving 1,809 patients were included. Local control did not significantly differ between the SR and SRS groups overall (hazard ratio [HR] 1.02, 95% confidence interval (CI) 0.64-1.64, p = 0.92; I 2 = 54%, p = 0.03) or in subgroup analyses of SR plus SRS vs. SRS alone, SR plus whole brain radiation therapy (WBRT) versus SRS plus WBRT, or SR plus WBRT versus SRS alone. Distant intracranial control did not significantly differ between the SR and SRS groups overall (HR 0.78, 95% CI 0.38-1.60, p = 0.49; I 2 = 61%, p = 0.03) or in subgroup analyses of SR plus SRS versus SRS alone or SR plus WBRT versus SRS alone. In addition, overall survival (OS) did not significantly differ in the SR and SRS groups (HR 0.91, 95% CI 0.65-1.27, p = 0.57; I 2 = 47%, p = 0.09) or in subgroup analyses of SR plus SRS versus SRS alone, SR plus WBRT versus SRS alone or SR plus WBRT versus SRS plus WBRT. Conclusion: Initial treatment of BM with SRS may offer comparable local and distant intracranial control to SR in patients with single or solitary BM. OS did not significantly differ between the SR and SRS groups in people with single or solitary BM.

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Section: Discussionmentioning

confidence: 99%

Section: Surgical Resection Vs Srs For Bm 405mentioning

confidence: 99%

Section: Local Recurrence and Distant Progressionmentioning

confidence: 99%

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Comparison of Surgical Resection and Stereotactic Radiosurgery in the Initial Treatment of Brain Metastasis

Liu

Liang

2020

Stereotact Funct Neurosurg

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“…22 In addition, studies comparing surgery with adjuvant stereotactic radiation alone have primarily focused on SRS. In patients with limited metastases, surgery with SRS is associated with improved overall survival [23][24][25][26] and in some cases reduced risk of local recurrence. 23,25 Although studies on patients with 1 brain metastasis have reported concordant overall survival trends, local control with surgery has been reported to be similar to local control with SRS alone.…”

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Minimizing Intracranial Disease Before Stereotactic Radiation in Single or Solitary Brain Metastases

et al. 2023

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BACKGROUND AND OBJECTIVES: Stereotactic radiotherapy (SRT) in multiple fractions (typically ≤5) can effectively treat a wide range of brain metastases, including those less suitable for single-fraction stereotactic radiosurgery (SRS). Prior prospective studies on surgical resection with stereotactic radiation have focused exclusively on SRS, and retrospective studies have shown equivocal results regarding whether surgery is associated with improved outcomes compared with SRT alone. We compared resection with postoperative cavity SRT or SRS to SRT alone in patients with 1 brain metastasis, while including patients receiving SRS alone as an additional reference group. METHODS: We studied 716 patients in a retrospective, single-institution cohort diagnosed with single or solitary brain metastases from 2007 to 2020. Patients receiving whole-brain radiotherapy were excluded. Cox proportional hazards models were constructed for overall survival and additional intracranial outcomes. RESULTS: After adjustment for potential confounders, surgery with cavity SRT/SRS was associated with decreased all-cause mortality (hazard ratio [HR]: 0.39, 95% CI [0.27-0.57], P = 1.52 × 10−6) compared with SRT alone, along with lower risk of neurological death attributable to intracranial tumor progression (HR: 0.46, 95% CI [0.22-0.94], P = 3.32 × 10−2) and radiation necrosis (HR: 0.15, 95% CI [0.06-0.36], P = 3.28 × 10−5). Surgery with cavity SRS was also associated with decreased all-cause mortality (HR: 0.52, 95% CI [0.35-0.78], P = 1.46 × 10−3), neurological death (HR: 0.30, 95% CI [0.10-0.88], P = 2.88 × 10−2), and radiation necrosis (HR: 0.14, 95% CI [0.03-0.74], P = 2.07 × 10−2) compared with SRS alone. Surgery was associated with lower risk of all-cause mortality and neurological death in cardinality-matched subsets of the cohort. Among surgical patients, gross total resection was associated with extended overall survival (HR: 0.62, 95% CI [0.40-0.98], P = 4.02 × 10−2) along with lower risk of neurological death (HR: 0.31, 95% CI [0.17-0.57], P = 1.84 × 10−4) and local failure (HR: 0.34, 95% CI [0.16-0.75], P = 7.08 × 10−3). CONCLUSION: In patients with 1 brain metastasis, minimizing intracranial disease specifically before stereotactic radiation is associated with improved oncologic outcomes.

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“…4,22,32,42,44,52 Recently, SRS, fractionated stereotactic radiotherapy, or a combination of these modalities with more conventional treatment options has been studied in the management of LBM. 15,18,27,34,42,76 However, optimal treatment paradigms with radiosurgery remain unclear and controversial and are associated with a relatively inferior control rate compared with smaller lesions. 6,16,18,22,32,40,41,44,57,70,76 Furthermore, potential significant treatment-associated toxicities, most notably adverse effects (AEs) of radiation, 1,56,60 and their management remain concerning in patients with LBM.…”

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confidence: 99%

Impact of 2-staged stereotactic radiosurgery for treatment of brain metastases ≥ 2 cm

Angelov

Mohammadi

Bennett

et al. 2018

Journal of Neurosurgery

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OBJECTIVE Stereotactic radiosurgery (SRS) is the primary modality for treating brain metastases. However, effective radiosurgical control of brain metastases ≥ 2 cm in maximum diameter remains challenging and is associated with suboptimal local control (LC) rates of 37%-62% and an increased risk of treatment-related toxicity. To enhance LC while limiting adverse effects (AEs) of radiation in these patients, a dose-dense treatment regimen using 2-staged SRS (2-SSRS) was used. The objective of this study was to evaluate the efficacy and toxicity of this treatment strategy. METHODS Fifty-four patients (with 63 brain metastases ≥ 2 cm) treated with 2-SSRS were evaluated as part of an institutional review board-approved retrospective review. Volumetric measurements at first-stage stereotactic radiosurgery (first SSRS) and second-stage SRS (second SSRS) treatments and on follow-up imaging studies were determined. In addition to patient demographic data and tumor characteristics, the study evaluated 3 primary outcomes: 1) response at first follow-up MRI, 2) time to local progression (TTP), and 3) overall survival (OS) with 2-SSRS. Response was analyzed using methods for binary data, TTP was analyzed using competing-risks methods to account for patients who died without disease progression, and OS was analyzed using conventional time-to-event methods. When needed, analyses accounted for multiple lesions in the same patient. RESULTS Among 54 patients, 46 (85%) had 1 brain metastasis treated with 2-SSRS, 7 patients (13%) had 2 brain metastases concurrently treated with 2-SSRS, and 1 patient underwent 2-SSRS for 3 concurrent brain metastases ≥ 2 cm. The median age was 63 years (range 23-83 years), 23 patients (43%) had non-small cell lung cancer, and 14 patients (26%) had radioresistant tumors (renal or melanoma). The median doses at first and second SSRS were 15 Gy (range 12-18 Gy) and 15 Gy (range 12-15 Gy), respectively. The median duration between stages was 34 days, and median tumor volumes at the first and second SSRS were 10.5 cm (range 2.4-31.3 cm) and 7.0 cm (range 1.0-29.7 cm). Three-month follow-up imaging results were available for 43 lesions; the median volume was 4.0 cm (range 0.1-23.1 cm). The median change in volume compared with baseline was a decrease of 54.9% (range -98.2% to 66.1%; p < 0.001). Overall, 9 lesions (14.3%) demonstrated local progression, with a median of 5.2 months (range 1.3-7.4 months), and 7 (11.1%) demonstrated AEs (6.4% Grade 1 and 2 toxicity; 4.8% Grade 3). The estimated cumulative incidence of local progression at 6 months was 12% ± 4%, corresponding to an LC rate of 88%. Shorter TTP was associated with greater tumor volume at baseline (p = 0.01) and smaller absolute (p = 0.006) and relative (p = 0.05) decreases in tumor volume from baseline to second SSRS. Estimated OS rates at 6 and 12 months were 65% ± 7% and 49% ± 8%, respectively. CONCLUSIONS 2-SSRS is an effective treatment modality that resulted in significant reduction of brain metastases ≥ 2 cm, with excellent 3-month (95%) ...

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Treatment of Large Brain Metastases With Stereotactic Radiosurgery

Cited by 24 publications

References 40 publications

Comparison of Surgical Resection and Stereotactic Radiosurgery in the Initial Treatment of Brain Metastasis

Comparison of Surgical Resection and Stereotactic Radiosurgery in the Initial Treatment of Brain Metastasis

Minimizing Intracranial Disease Before Stereotactic Radiation in Single or Solitary Brain Metastases

Impact of 2-staged stereotactic radiosurgery for treatment of brain metastases ≥ 2 cm

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