Abstract
BackgroundBrainstem metastases represent an uncommon clinical presentation that is associated with a poor prognosis. Treatment options are limited given the unacceptable risks associated with surgical resection in this location. However, without local control, symptoms including progressive cranial nerve dysfunction are frequently observed. The objective of this study was to determine the outcomes associated with linear accelerator-based stereotactic radiotherapy or radiosurgery (SRT/SRS) of brainstem metastases.MethodsWe retrospectively reviewed 38 tumors in 36 patients treated with SRT/SRS between February 2003 and December 2011. Treatment was delivered with the Cyberknife™ or Trilogy™ radiosurgical systems. The median age of patients was 62 (range: 28–89). Primary pathologies included 14 lung, 7 breast, 4 colon and 11 others. Sixteen patients (44%) had received whole brain radiation therapy (WBRT) prior to SRT/SRS; ten had received prior SRT/SRS at a different site (28%). The median tumor volume was 0.94 cm3 (range: 0.01-4.2) with a median prescription dose of 17 Gy (range: 12–24) delivered in 1–5 fractions.ResultsMedian follow-up for the cohort was 3.2 months (range: 0.4-20.6). Nineteen patients (52%) had an MRI follow-up available for review. Of these, one patient experienced local failure corresponding to an actuarial 6-month local control of 93%. Fifteen of the patients with available follow-up imaging (79%) experienced intracranial failure outside of the treatment volume. The median time to distant intracranial failure was 2.1 months. Six of the 15 patients with distant intracranial failure (40%) had received previous WBRT. The actuarial overall survival rates at 6- and 12-months were 27% and 8%, respectively. Predictors of survival included Graded Prognostic Assessment (GPA) score, greater number of treatment fractions, and higher prescription dose. Three patients experienced acute treatment-related toxicity consisting of nausea (n = 1) and headaches (n = 2) that resolved with a short-course of dexamethasone.ConclusionSRT/SRS for brainstem metastases is safe and achieves a high rate of local control. We found higher GPA as well as greater number of treatment fractions and higher prescription dose to be correlated with improved overall survival. Despite this approach, prognosis remains poor and distant intracranial control remains an issue, even in patients previously treated with WBRT.
Highlights
Brainstem metastases represent an uncommon clinical presentation that is associated with a poor prognosis
Toxicity Three patients experienced acute treatment-related toxicity consisting of nausea (n = 1) and headaches (n = 2) that resolved with a short-course of dexamethasone
In this study, we have assessed the efficacy of linac-based Stereotactic radiotherapy (SRT)/Stereotactic radiosurgery (SRS) for the treatment of metastases located in the brainstem and determined rates of local control, intracranial control and overall survival
Summary
Brainstem metastases represent an uncommon clinical presentation that is associated with a poor prognosis. Brain metastases develop in 20-40% of cancer patients representing the most common manifestation of intracranial malignancy [1]. These lesions can result in devastating clinical consequences, when they involve brainstem structures. Options for management of brainstem metastases include whole brain radiation therapy (WBRT) or SRT/SRS [2,3,4]. The safety of SRT/SRS for brainstem metastases remains an important question given the proximity to critical structures and potential for treatment-related toxicity [5]. We analyze our institution’s experience using linac-based SRT/SRS for the treatment of brainstem metastases to determine the safety and efficacy of this treatment approach
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