Cases Of Brain Metastases Research Articles

SU-E-J-08: Research the Feasibility of High Dose Radiotherapy for Brain Metastases Guided by the Contrasted Cone Beam CT

Purpose: To research the feasibility of high doseradiotherapy for brain metastases guided by the contrasted cone beam CT through studying how to implement and improve the contrasted cone‐beam CT scanning and image registration in the progress of CBCT guided brainmetastasisradiotherapy. Methods: 8 brain metastases cases were selected (lung cancer 3cases, liver cancer 1 cases, breast cancer 2 cases and nasopharyngeal carcinoma 2 cases), and achieved the CBCT scanning, in 20 minutes, 30 minutes, 40 minutes after contrasted stimulation CT scanning.Analyzed the CBCTimage quality and the demonstration capability of the tumor on CBCTimages comparing with the simulation CT.Radiotherapy plans were designed quickly with the Prescription dose 5Gy/fraction and the image registration work were completed online, and analyze the potential role of the contrasted CBCT in radiotherapy for brain metastasis.Results: The contrasted CBCT could improve the image resolution, the tumor area and the location relationship between tumor and normal brain tissue were showed clearly. The demonstration capability of tumor on CBCT in 30 minutes was bigger than in 20 minutes and 40 minutes. The setup errors were 3.0±0.8mm in z‐axial, 2.8±0.6mm in y‐axial and 2.0±0.5mm in x‐axial. Conclusions: The contrasted CBCTimage can display the tumor and location relationship between tumor and normal tissue clearly, it can exhibit the result of adjustment for setup error directly, it could become an effective way to ensure the security in high doseradiotherapy for brain metastases.

An innovative iterative thresholding algorithm for tumour segmentation and volumetric quantification on SPECT images: Monte Carlo-based methodology and validation

Positron emission tomography (PET) and single-photon emission computed tomography (SPECT) imaging play an important role in the segmentation of functioning parts of organs or tumours, but an accurate and reproducible delineation is still a challenging task. In this work, an innovative iterative thresholding method for tumour segmentation has been proposed and implemented for a SPECT system. This method, which is based on experimental threshold-volume calibrations, implements also the recovery coefficients (RC) of the imaging system, so it has been called recovering iterative thresholding method (RIThM). The possibility to employ Monte Carlo (MC) simulations for system calibration was also investigated. The RIThM is an iterative algorithm coded using MATLAB: after an initial rough estimate of the volume of interest, the following calculations are repeated: (i) the corresponding source-to-background ratio (SBR) is measured and corrected by means of the RC curve; (ii) the threshold corresponding to the amended SBR value and the volume estimate is then found using threshold-volume data; (iii) new volume estimate is obtained by image thresholding. The process goes on until convergence. The RIThM was implemented for an Infinia Hawkeye 4 (GE Healthcare) SPECT/CT system, using a Jaszczak phantom and several test objects. Two MC codes were tested to simulate the calibration images: SIMIND and SimSet. For validation, test images consisting of hot spheres and some anatomical structures of the Zubal head phantom were simulated with SIMIND code. Additional test objects (flasks and vials) were also imaged experimentally. Finally, the RIThM was applied to evaluate three cases of brain metastases and two cases of high grade gliomas. Comparing experimental thresholds and those obtained by MC simulations, a maximum difference of about 4% was found, within the errors (+/- 2% and +/- 5%, for volumes > or = 5 ml or < 5 ml, respectively). Also for the RC data, the comparison showed differences (up to 8%) within the assigned error (+/- 6%). ANOVA test demonstrated that the calibration results (in terms of thresholds or RCs at various volumes) obtained by MC simulations were indistinguishable from those obtained experimentally. The accuracy in volume determination for the simulated hot spheres was between -9% and 15% in the range 4-270 ml, whereas for volumes less than 4 ml (in the range 1-3 ml) the difference increased abruptly reaching values greater than 100%. For the Zubal head phantom, errors ranged between 9% and 18%. For the experimental test images, the accuracy level was within +/- 10%, for volumes in the range 20-110 ml. The preliminary test of application on patients evidenced the suitability of the method in a clinical setting. The MC-guided delineation of tumor volume may reduce the acquisition time required for the experimental calibration. Analysis of images of several simulated and experimental test objects, Zubal head phantom and clinical cases demonstrated the robustness, suitability, accuracy, and speed of the proposed method. Nevertheless, studies concerning tumors of irregular shape and/or nonuniform distribution of the background activity are still in progress.

Primary and Metastatic Central Nervous System Malignancies

About 13,000 deaths each year in the United States are attributed to primary central nervous system (CNS) malignancies. An estimated 20% of patients with cancer eventually develop clinically apparent CNS metastases, and an estimated 170,000 cases of brain metastases are diagnosed in the United States yearly. Autopsy studies suggest that as many as 50% of patients dying from advanced cancer may have metastasis to the CNS. This chapter provides an overview of primary and metastatic CNS malignancies with in-depth discussion of gliomas, primary CNS lymphoma, meningioma, brain metastases, leptomeningeal metastases, and metastatic epidural spinal cord compression. Discussions cover epidemiology, etiology, diagnosis, and treatment of gliomas, including surgery, radiotherapy, and chemotherapy for both newly diagnosed gliomas and recurrent gliomas. The epidemiology, diagnosis, treatment and prognosis for primary CNS lymphomas are reviewed, as well as the epidemiology, etiology, diagnosis, treatment, and prognosis for meningiomas. Epidemiology, diagnosis, and prognosis for brain metastases are briefly discussed, and the section on treatment includes surgery, stereotactic radiosurgery, and whole-brain radiotherapy for patients with three or fewer brain metastases. The sections on leptomeningeal metastases and metastatic epidural spinal cord compression cover diagnosis, treatment, and prognosis. This chapter contains 126 references.

Brain metastases from hepatocellular carcinoma after hepatectomy

Hepatocellular carcinoma is a highly malignant neoplasm and frequently involves extrahepatic organs but decidedly rarely occurs in brain. We describe 3 cases of brain metastases in patients suffering from post-HBV hepatocarcinoma. The “stroke-like” presentation of the cerebral localization of the disease can be explained by both the important vascularization of the tumor and the frequent hemocoagulative alterations caused by the cirrhosis. The importance of diagnostic neuroradiology is briefly addressed, with reference to the fundamental role played by MRI. Surgery of these lesions does not present any particular technical problems as long as they are located in accessible areas and the patient's general and neurological conditions allow it. Postoperative radiotherapy seems to improve the quality and quantity of residual life, although the number of patients described in the literature was too small to draw any definite conclusion in this regard.

NGAL immunohistochemical expression in brain primary and metastatic tumors

A significant association has been recently shown between the expression of neutrophil gelatinase-associated lipocalin (NGAL) in tumors and its urinary levels. Thus NGAL urinary detection has been proposed as a method for the early diagnosis of brain tumors. In view of this, the objective of this study was to investigate whether NGAL expression differs according to brain tumor type or in primary vs. metastatic brain neolasias. 42 surgically resected formalin fixed and paraffin embedded neoplasias, including 15 cases of brain metastasis and 27 cases of primary central nervous system (CNS) tumors (11 meningiomas; 1 pilocytic astrocytoma, 2 diffuse astrocytomas, 2 oligoastrocytomas, 2 oligodendrogliomas, 1 anaplastic oligoastrocytoma, 7 glioblastomas, 1 ependymoma) were submitted to the immunohistochemical procedure. Sections were incubated overnight with the primary antibody against NGAL. NGAL staining was found in all the analyzed glioblastomas and in the anaplastic oligoastrocytoma. No NGAL immuno-expression was evidenced in all the other cases. A statistically significant correlation was demonstrated between NGAL presence and high proliferation index in the primary tumors. In conclusion, our findings suggest that NGAL expression is restricted to high grade gliomas among primary brain tumors, and that brain metastases do not express this protein. Considering the correlation between NGAL expression in tumors and its urinary levels, if our observations will be further validated, NGAL urinary detection might be used as an additional tool in the pre-surgical definition of brain lesions involving difficult differential diagnosis.

Anal cancer with cerebral metastasis: a case report

Carcinoma of the anal canal is a relatively rare cancer with a low propensity for metastasis. A literature review identifies two cases of brain metastases from anal cancer. The authors present the case of a 63-year-old female with poorly differentiated squamous cell carcinoma of the anal canal who presented with a solitary dural-based enhancing lesion of the right parietal area. The patient underwent craniectomy and tumor resection. Histopathology confirmed the cerebral lesion to be a poorly differentiated squamous cell carcinoma, consistent with the known primary tumor of the anal canal. Although exceptionally rare, the presence of a cerebral lesion in a patient with carcinoma of the anal canal should raise the possibility of metastatic disease. Treatment decisions in patients with newly diagnosed dural-based enhancing lesions and known anal cancer should bear in mind the possibility of metastatic disease.

Sarcoma metastatic to the brain: a series of 35 cases and considerations from 27 years of experience

The authors report their 27-year experience regarding 35 cases of supratentorial brain metastasis from sarcoma treated in a single institution: these included ten osteosarcomas, seven leiomyosarcomas, five Ewing sarcomas, four malignant fibrous histiocytomas, three alveolar soft-part sarcomas (ASPS), two rhabdomyosarcomas, one liposarcoma, and three unclassified sarcomas. The first 15 cases of the series have already been described in a previous publication. Median survival after craniotomy was 9.8 months (range: 4-24). In patients with preoperative Karnofsky performance score (KPS) > 60 it was 12.8 months (range: 6.5-24 months) versus 5.4 months for those patients with a KPS < or = 60 (P = 0.01). Eight patients had more than one lesion, six of which were treated in the last ten years. Of the three patients with ASPS, the first two were alive at 15 and 20 months (before being lost to follow-up) whereas the third patient is alive at 24 month follow-up. The authors conclude that surgery is more effective in treating selected patients with sarcoma metastatic to the brain, and that patients with metastasis from ASPS have good prognosis when submitted to surgical treatment. The complete removal of all brain metastases "en bloc" and a KPS > 60 are associated with the best prognosis. Finally, it seems that surgical indications for multiple brain metastases from sarcoma have increased during the last ten years.

Control of brain metastases using frameless image-guided radiosurgery

Radiosurgery is an important and well-accepted method in the management of brain metastases. Using conventional frame-based techniques, high lesional control rates are expected. The introduction of image-guided techniques allows for improved patient comfort and workflow. Some controversy exists as to the accuracy of imageguided techniques and consequently the impact they might have on control of brain metastases (as opposed to the level of control achieved with frame-based methods). The authors describe their initial 15-month experience with image-guided radiosurgery (IGRS) using Novalis with ExacTrac for management of brain metastases. The authors reviewed the cases of brain metastasis treated by means of IGRS in their tertiary regional radiation oncology service over a 15-month period. During the study period 54 patients (median age 57.9 years) harboring 108 metastases were treated with IGRS. The median time from cancer diagnosis to development of brain metastasis was 12 months (range 0-144 months). The median tumor volume was 0.98 cm(3) (range 0.03-19.07 cm(3)). The median prescribed dose was 18 Gy to the 80% isodose line (range 14-20 Gy). Lesions were followed with postradiosurgery MR imaging every 2-3 months following treatment. The median follow-up period was 9 months (range 0-20 months). Median actuarial survival was 8.6 months following IGRS. Eight patients with 18 lesions died within the first 2 months after the procedure, before scheduled follow-up imaging. Thus 90 lesions (in 46 patients) were followed up with imaging studies. Lesions that were unchanged or reduced in size were considered to be under control. The 6-month actuarial lesion control rate was 88%. Smaller lesions (< 1 cm(3)) had a statistically improved likelihood of complete imaging response (loss of all contrast-enhancement p = 0.01). Image-guided radiosurgical treatment of brain metastases resulted in high rates of tumor control comparable to control rates reported for frame-based methods. High control rates were seen for small lesions in which spatial precision in dose delivery is critical. These data suggests that in regard to lesion control, IGRS using Novalis with ExacTrac is equivalent to frame-based radiosurgery methods.

Brain metastasis treated with Cyberknife.

Cyberknife can greatly raise the fractional dose of stereotactic radiosurgery, thus improving its clinical efficacy. We retrospectively analyzed clinical outcomes of brain metastasis treated with Cyberknife. We analyzed 40 cases of brain metastases treated with Cyberknife in the Tianjin Cancer Hospital from August 1, 2006 to August 1, 2007, for a total of 68 lesions with maximal diameter of 0.4 - 7.5 cm (average 1.88 cm). Total hypofractional radiated dosage was 18 - 36 Gy (5 - 25 Gy/F, 1 - 5 F) by Cyberknife. We evaluated the remission rate of clinical symptoms, correlation factors to new foci, 3-month local control rates, and 3-month and 1-year survival rates. All patients were followed up for more than 14 months. After 1 week, clinical remission was 90.0% (36/40). After 3 months, the local control rate and therapeutic effective rate were 77.9% (53/68) and 94.1% (64/68), respectively, as observed by cranium augmentation CT or MRI. The three-month, six-month and 1-year survival rates were 97.5% (39/40), 82.5% (33/40) and 67.5% (27/40), respectively. Fourteen patients had neopathy outside the original lesion after 3 months. Neopathy was not correlated with age, whole-brain radiotherapy, number of original lesions, maximum diameter of the original lesion, therapeutic dose per fraction, therapeutic frequency or total therapeutic dose. Cyberknife got perfect clinical outcomes by higher dosage per fraction. It is an appropriate and valid treatment shortcut for brain metastasis.

Gamma Knife radiosurgery as a primary treatment option for solitary brain metastases from ovarian carcinoma

We present three patients with brain metastasis cases from ovarian carcinoma (BMOC) treated at William Beaumont Hospital with a median follwow-up of 77 months and a mean survival after brain involvement of 23.66 months (range 5-44). Clinical and physical aspects are presented. Between December 2006 and August 2008, three cases of BMOC were treated using Gamma Knife (GK) radiosurgery. All patients had FIGO Stage III primary disease at initial diagnosis. Treatment sequences and features are described. GK achieves excellent local control of BMOC. Other parameters could be considered as biologically effective.

Neuroimaging and quality-of-life outcomes in patients with brain metastasis and peritumoral edema who undergo Gamma Knife surgery

Gamma Knife surgery (GKS) has been shown to be effective for treating many patients with brain metastasis. Some brain metastases demonstrate significant peritumoral edema; radiation may induce cerebral edema or worsening preexisting edema. This study was conducted to evaluate the imaging and neurobehavioral outcomes in patients with preexisting peritumoral edema who then undergo GKS. Between August 2003 and January 2008, 63 cases of brain metastasis with significant peritumoral edema (> 20 cm(3)) were prospectively studied. The study inclusion criteria were as follows: 1) a single metastatic lesion with significant edema (perilesional edema signal volume on FLAIR > 20 cm(3)); and 2) inclusion of only 1 lesion > 20 cm(3) in the study (in cases of multiple lesions noted on FLAIR images). All patients received MR imaging with pulse sequences including T1-weighted imaging and FLAIR with or without contrast and T2-weighted imaging at an interval of 3 months. A neurological assessment and Brain Cancer Module (BCM-20) questionnaire were obtained every 2-3 months. Kaplan-Meier, Cox regression, and logistic regression were used for analysis of survival and associated factors. At the time of GKS, the median Karnofsky Performance Scale (KPS) score was 70 (range 50-90), and the mean BCM-20 score was 45.5 +/- 6.1. The mean tumor volume (+/- standard deviation) was 5.2 +/- 4.6 cm(3) with corresponding T2-weighted imaging and FLAIR volumes of 59.25 +/- 37.3 and 62.1 +/- 38.8 cm(3), respectively (R(2) = 0.977, p < 0.001). The mean edema index (volume of peritumoral edema/tumor volume) was 17.5 +/- 14.5. The mean peripheral and maximum GKS doses were 17.4 +/- 2.3 and 35 +/- 4.7 Gy, respectively. The median survival was 11 months. The longer survival was related to KPS scores >or= 70 (p = 0.008), age < 65 years (p = 0.022), and a reduction of > 6 in BCM-20 score (p = 0.007), but survival was not related to preexisting edema or tumor volume. A reduction in BCM-20 score of > 6 was related to decreased volume in T1-weighted and FLAIR imaging (p < 0.001). Thirty-eight (79.2%) of 48 patients demonstrated decreased tumor volume and accompanied by decreased T2-weighted imaging and FLAIR volume. Eight (16.7%) of the 48 patients exhibited increased or stable tumor volume. A margin dose > 18 Gy was more likely to afford tumor reduction and resolution of peritumoral edema (p = 0.005 and p = 0.006, respectively). However, prior external-beam radiation therapy correlated with worsened preexisting peritumoral edema (p = 0.013) and longer maintenance of corticosteroids (p < 0.001). Patients demonstrating a reduction in the BCM-20 score > 6, age < 65 years, and KPS score >or= 70 exhibited longer survival. Significant preexisting edema did not influence the tumor response or clinical outcome. The resolution of edema was related to better quality of life but not to longer survival.

Erlotinib e metástases cerebrais

We report two cases of brain metastases in context of non small cell lung cancer (NSCLC). After having progressed to chemotherapy they received erlotinib 150mg/m2 orally daily, with complete response of brain metastasis and partial response of thoracic lesions.Brain metastases are both prevalent and a major cause of mortality in NSCLC, with few systemic treatment options. Median survival after whole brain radiotherapy is 4-6 months and the role of systemic therapy for brain metastases is limited with the most drugs use to stage IV disease ineffective in this setting.This case demonstrates that brain metastases may be sensitive to erlotinib and give to us growing body of evidence that EGFR-associated tyrosine kinase inhibition is a feasible strategy in the management of NSCLC patients with brain metastasesWe propose further study into the continued use of this drug in the situation where there is a differential response.Rev Port Pneumol 2008; XIV (Supl 3): S35-S42

Human primary brain tumor cell growth inhibition in serum-free medium optimized for neuron survival

Glioblastoma is the most common primary brain tumor in adults from which about 15,000 patients die each year in the United States. Despite aggressive surgery, radiotherapy and chemotherapy, median survival remains only 1 year. Here we evaluate growth of primary human brain tumor cells in a defined nutrient culture medium (Neuregen) that was optimized for neuron regeneration. We hypothesized that Neuregen would inhibit tumor cell growth because of its ability to inhibit gliosis in rat brain. Tumor tissue was collected from 18 patients including 10 males and 8 females (mean age 60 ± 12 years) who underwent craniotomy for newly diagnosed, histologically confirmed brain tumors. The tissue was shipped overnight in Hibernate transport medium. Tumor cells were isolated and plated in Neurobasal/serum or Neuregen on culture plastic. After 1 week, growth in Neuregen was significantly less in 9/10 glioblastoma multiforme cases, 5/5 meningioma cases and 3/3 cases of brain metastasis. Analysis of deficient formulations of Neuregen and formulations to which selected components were added back implicate no single active component. However, individual cases were sensitive to corticosterone, selenium, ethanolamine, fatty acids and/or antioxidants. Therefore, a defined culture medium that promotes neuron regeneration inhibits the growth of human primary glioblastoma, meningioma and metastatic tumor cells in culture. The possible in vivo efficacy of Neuregen for treatment of brain tumor resections remains to be determined.

Brain Metastases from Endometrial Carcinoma: Report of Three Cases and Review of the Literature

Endometrial carcinoma is a rare cause of brain metastases, accounting for less than 1% of all metastatic lesions to the brain. This report aims to review our experience in the treatment of patients with brain metastases from endometrial carcinoma in order to establish the characteristics of these patients and evaluate the results and efficacy of whole-brain radiation therapy as a palliative measure. Three cases of brain metastases from endometrial carcinoma treated with radiotherapy were identified in the files of the Division of Radiotherapy at the A. Businco Regional Oncological Hospital of Cagliari between 1999 and 2005. All patients had brain metastases as the only sign of systemic disease (a single lesion in 2 patients and 2 lesions in 1 patient). Two patients were classified as RTOG RPA class I and 1 patient as class III. Radiotherapy to the brain was delivered after surgical resection in the first 2 patients and as the only method of palliation in the third patient. The delivered radiation dose was 3000 cGy in 10 fractions over 2 weeks in the postoperative setting and 2000 cGy in 5 fractions over 1 week to the patient treated with irradiation alone. The 2 surgically treated patients are alive and well after 16 and 64 months, respectively. The patient treated with palliative intent died 2 months after irradiation. The combination of surgery and postoperative whole-brain irradiation in selected patients with solitary brain metastases from endometrial carcinoma is an effective method of palliation.

Predisposing factors of blood brain barrier penetration from docetaxel during lung cancer treatment: Preliminary study

17102 Background: Patients with lung cancer account for approximately 50% of brain metastasis cases. On the other hand the majority of active cytotoxic agents (like taxanes) in lung cancer treatment, are unable to penetrate blood brain barrier (BBB) so the role of chemotherapy in management of brain metastasis from lung cancer remain controversial. To investigate predisposing factors (if any) of penetration of BBB from cytotoxic agents we measured concentation levels of Docetaxel in serum and cerebrospinal fluid (CSF) during first line chemotherapy. Methods: Twelve lung cancer patients receiving chemotherapy consisted of Docetaxel (100 mg/m2) and Carboplatin AUC 6 were included in this study. CSF and plasma samples were withdrawn half an hour after termination of chemotherapy infusion. Measurements were performed with high performance liquid chromatography and UV detection was at 227 nm. Results: Mean levels of docetaxel in blood was 2,5530 ± 0,53 mg/l and in CSF 0,7397 ± 0,22 mg/l. Three out of twelve patient had SCLC (2 with ED and 1 with LD) and 9 with NSCLC (2 stage IIIB and 7 stage IV). In three patients without metastasis no detectible level of docetaxel was measured. We were also unable to detect Docetaxel in CSF of the patient with NSCLC and metastasis in the ipsilateral lung. On the other hand in 9 patients with metastatic disease (4 brain metastasis 2 with bone metastasis 1 with metastasis in liver and adrenal and 2 with liver and bone metastasis) had detectable levels of docetaxel in CSF. There was not statistically significant correlation of docetaxel in plasma and CSF. Only one patient without any evidence of metastasis had a detectable level of Docetaxel in CSF (0,33229) but in 6 weeks a brain metastasis was apparent in brain MRI. Conclusions: Metastasis development seems to be associated with a modification of BBB penetration. If Docetaxel penetrates BBB (especially in the presence of brain metastasis) it would be probable to accelerate radiotherapy sensitivity of brain metastasis. No significant financial relationships to disclose.

TU‐C‐330A‐02: Patterns of Brain Tumor Recurrence Predicted From DTI Tractography

Purpose: Approximately 170,000 new cases of brain metastases and 17,000 cases of primary brain cancer are diagnosed in the United States each year. Stereotactic Radiotherapy (SRT) is fast becoming the method of choice for treatment of non‐superficial brain lesions. SRT treatment plans of malignant and metastatic brain tumors typically incorporate a 2 cm margin to account for microscopic tumor spread, however, distant and/or recurrent tumors sometimes occur. Our hypothesis is that paths of elevated water diffusion may provide a preferred route for transport or migration of cancer cells through an unknown mechanism. If our hypothesis is correct then future SRT treatment would be modified to provide elongated treatment margins along the paths of elevated water diffusion leading from the primary tumor site; thereby reducing the incidence of recurrence and improving clinical outcomes. Method and Materials: MR diffusion tensor imaging datasets were acquired in patient subjects treated with SRT of malignant and/or metastatic brain tumors. DTI was performed using an EPI sequence on a 1.5T clinical GE scanner with 20 serial axial images of voxel dimensions 0.976×0.976×6 mm; TR 10s; TE 89.4 ms; 25 diffusion gradient directions plus 3 reference (b=0) scans. Following SRT, patients were given repeated MRI follow‐ups at regular intervals to identify early tumor recurrence. When recurrent tumors were detected, DTIstudio and FSL software was used to compute paths of preferred water diffusion through the primary tumor site and the site of recurrence. Results: There exists an apparent correlation between patterns of recurrence in the brain and paths of elevated diffusion leading from the primary brain tumor. Conclusions: Our preliminary results on a small number of patient datasets suggest that this hypothesis is correct and further investigation is warranted. Future work will employ a more sophisticated fiber analysis on additional patient images and verification with animal models.

Surgical Treatment of Non-Small Cell Lung Cancer with Isolated Synchronous Brain Metastases

This study is a retrospective examination of our experiences with patients who underwent treatment of isolated synchronous brain metastases coupled with primary non-small cell lung cancer. From January 1995 to June 2004, 12 patients presented with isolated synchronous brain metastases coupled with primary non-small cell lung cancer. The patient was comprised of 8 men and 4 women. The median age was 52 yr, in a range of 32 to 75 yr. Median follow-up duration was 10.6 months, in a range of 2 to 55.8 months. Recurrence developed in 7 patients, and the median interval from 1st treatment to recurrence was 4.5 months (2.8-6.5 months). The overall 1-yr survival rate was 61.7%. The 1-yr survival rates for pathologic N0 and N1 cases were 75% and 66.7%, respectively. The median survival duration for pathologic N2 was 6.2 months (95% CI, 4.8-7.5 months). The 1-yr survival rate for cases of single brain metastasis was 75%. Based on our current observations, we could speculate that aggressive management of primary non-small cell lung cancer and isolated synchronous brain metastases was beneficial in a selected group of patients, as long as the brain lesions and pulmonary lesions were limited or resectable.

Non-small cell lung cancer (NSCLCA): Does the size of the tumor and the patient’s age predict brain metastases?

7318 Background: Many studies have demonstrated the prognostic importance of tumor size in the early stages of NSCLCA and the effect of age on the outcome; however, no study has looked at the association between brain metastases and the size of the tumor or the age of the patient. Subjects and Methods: We retrospectively analyzed 251 cases that were diagnosed with NSCLCA over a period of five years (1999–2003) in two institutions. We looked at many aspects at the presentation of the disease in an effort to predict brain metastases: age of the patients, size of the tumor, hilar involvement, pleural effusion, and pathology of the tumor. 88 patients (35%) were ≤60 years old. 82 patients (32.7%)had a tumor size ≤3 cm, 146 (58%) had tumor >3 cm, 16 (6.4%) had massive plural effusion, and 7 (2.8%) were presented with lung collapse. Hilar and pleural involvement occurred in 127 (51%) and 83 patients (33%), respectively. Histology showed adenocarcenoma in 194 patients (77%), squamous cell carcinoma in 51 (20%), and large cell carcinoma in 6 (3%). Results: A total of 44 cases of brain metastasis were found at the time of diagnosis, and of these, 24 (55%) were <60 years old. Compared to the patients >60 years old, there was a statistically significant increase in the incidence of brain metastasis by using chi-squar test (p=0.0029), and by using linear regression analysis there was a high significance of age predicting brain metastases (p<0.05). There was no significance when comparing the incidence of brain metastases to a primary tumor size ≤3 cm, (p=0.2668), Hilar involvement (p= 0.2147), or pleural effusion (p=0.3683). However, there was a statistical significance when comparing the incidence of brain mets with the pathology (adenocarcenoma) of the tumor (p=0.01). Conclusion: Our analysis suggests that younger pts. (≤60 years) have a higher chance to present with brain mets then older pts. (>60), the pathology of the tumor (adenocarcenoma) has a high chance to metastasize, and the size of the tumor does not predict brain mets. No significant financial relationships to disclose.

Results of Whole Brain Radiation Therapy in Patients with Brain Metastases from Colorectal Carcinoma

Carcinoma of the colon-rectum is an infrequent cause of brain metastases, constituting 1.5% of all metastatic lesions to the brain. We reviewed our experience in the treatment of brain metastases from colorectal cancer to define the efficacy of whole brain radiation therapy as a palliative measure in this setting of patients. Twenty-three consecutive cases of brain metastasis from colorectal cancer treated between 1999 and 2004 were identified in the files of the Division of Radiotherapy of the A Businco Regional Oncological Hospital, Cagliari. Their records were reviewed for patient and tumor characteristics and categorized according to the RTOG RPA classes. Fifteen patients (65%) had multiple metastases. Twenty-one patients (91%) showed extracranial metastases. Fourteen patients were classified as RTOG RPA class II and 9 class III. The median radiation dose delivered was 2000 cGy in 5 fractions in one week (range, 20-36 Gy). In 14 of 20 assessable patients (70%), symptomatic improvement was observed. The median follow-up and survival time for all the patients, 12 females and 11 males, was 3 months. In 3 patients only the cause of death was the brain metastasis. Despite the disappointing survival time, external radiation therapy to the whole brain proved to be an efficacious palliative treatment for patients with multiple or inoperable brain metastasis from colorectal cancer.

The expanding role of neurosurgeons in the management of brain metastases

Background Brain metastases are the most common type of intracranial tumor. Until recently, whole brain fractionated radiation therapy (WBRT) was the mainstay of treatment, thereby confining the role of neurosurgeons to resection of an occasional solitary, accessible, and symptomatic brain metastasis. Median survival after surgery and radiation typically ranged from 5 to 11 months. Methods We analyzed various demographic incidence reports and our series of brain metastasis patients treated with radiosurgery. During a 15-year interval (1987–2002), radiosurgery was performed on 5,032 patients of whom 1,088 (21.6%) had metastatic brain tumors. Results In the United States, 266,820 to 533,640 new cases of brain metastases will be diagnosed in the year 2003. Evidence to date demonstrates that radiosurgery provides effective local tumor control for brain metastases. Important prognostic factors affecting patient survival include the absence of active systemic disease, the patient's preoperative performance status, age, and the number of metastases. Survival and local tumor control rates attained with radiosurgery are superior to those of either conventional surgery or WBRT. The morbidity associated with radiosurgery of brain metastasis is very low, and the mortality rate approaches zero. Conclusions Compelling evidence indicates that radiosurgery is an effective neurosurgical management strategy for intracranial brain metastases. Quite often, favorable tumor control and survival can be achieved without WBRT. With radiosurgery as a therapeutic option, neurosurgeons now have a vastly expanded armamentarium for treatment of patients with brain metastases. The large number of patients with brain metastases who require care by a neurosurgeon for optimal treatment has significant implications for both the patterns of neurosurgical training and practice in the United States.