Multiple Metastatic Brain Tumors Research Articles

Assessing the impact of distortion correction on Gamma Knife radiosurgery for multiple metastasis: Volumetric and dosimetric analysis

IntroductionMagnetic resonance imaging (MRI) is a robust neuroimaging technique and is the preferred method for stereotactic radiosurgery (SRS) planning. However, MRI data always contain distortions caused by hardware and patient factors. Research questionCan these distortions potentially compromise the effectiveness and safety of SRS treatments? Material and methodsTwenty-six MR datasets with multiple metastatic brain tumors (METs) used for Gamma Knife radiosurgery (GKRS) were retrospectively evaluated. A commercially available software was used for distortion correction. Geometrical agreement between corrected and uncorrected tumor volumes was evaluated using MacDonald criteria, Euclidian distance, and Dice similarity coefficient (DSC). SRS plans were generated using uncorrected tumor volumes, which were assessed to determine their coverage of the corrected tumor volumes. ResultsThe median target volume was 0.38 cm3 (range,0.01–12.38 cm3). A maximum displacement of METs of up to 2.87 mm and a median displacement of 0.55 mm (range,0.1–2.87 mm) were noted. The median DSC between uncorrected and corrected MRI was 0.92, and the most concerning case had a DSC of 0.46. Although all plans met the optimization criterion of at least 98% of the uncorrected tumor volume (median 99.55%, range 98.1–100%) receiving at least 100% of the prescription dose, the percent of the corrected tumor volume receiving the total prescription dose was a median of 95.45% (range,23.1–99.5%). Discussion and conclusionMRI distortion, though visually subtle, has significant implications for SRS planning. Regular utilization of corrected MRI is recommended for SRS planning as distortion is sometimes enough to cause a volumetric miss of SRS targets.

Brain metastasis: Recent treatment modalities and future-perspectives.

With the advent of novel systemic therapies, such as molecular targeted therapy and immune checkpoint inhibitors, the treatment of advanced-stage cancer is markedly transitioning. The treatment for brain metastasis is influenced by these new therapies. Moreover, the frequency of brain metastasis is associated with cancer genetics. Since conventional cytotoxic chemotherapeutic drugs cannot easily cross the brain-blood barrier, radiotherapy plays a major role in the management of brain metastasis. Whole-brain radiotherapy (WBRT) has been frequently used, especially for multiple metastatic brain tumors; however, late adverse effects on cognitive function are a significant clinical problem of WBRT in patients with an otherwise good prognosis and overall survival rate. Some novel systemic agents are effective against brain metastasis. Moreover, advances in radiotherapy technology have made it possible to deliver optimal radiation doses to patients with brain metastasis, with fewer adverse events. Brain metastasis has a significant impact on the quality of life of patients with advanced-stage cancer; therefore, its appropriate management is an important factor in the comprehensive treatment of cancer.

ML-4 A case of primary CNS lymphoma diagnosed 5 years after stereotactic radiosurgery

Central nervous system primary malignant lymphoma (PCNSL) is rarely diagnosed as multiple metastatic brain tumors. Almost tumors recure early after receiving stereotactic radiosurgery (SRS). Regardless of the fact, the following case report displays PCNSL, diagnosed five years after the initial treatment with SRS as brain metastases of unknown primary origin. This extraordinal case suggests long-term follow-up regarding PCNCL. The case was a 55-year-old woman with a history of a total hysterectomy for cervical cancer. She developed left paralysis. Brain MRI confirmed a 27 mm contrast-enhanced lesion in the right frontal lobe and three other lesions. SRS was performed as a diagnosis of multiple brain metastases for urgent symptom relief. No extra-cranial cancerous lesions were found. Unknown primary cancer was a probable diagnosis at that time. Two years after SRS, local regrowth of tumor of the right frontal primary motor area was discovered. Re-irradiation was performed. Cerebral edema, contrast enhancement, and left paralysis progressed following five months, taking an oral corticosteroid. Craniotomy and debulk. The pathological diagnosis was brain radiation necrosis due to no viable tumor cells. New lesions in the left temporal lobe and basal ganglia appeared three years after surgery. Awake craniotomy was performed for the left temporal lobe lesion. Histopathology showed diffuse growth of tumor cells with a high nucleo-cytoplasmic ratio and irregular nuclear shape. Immunohistochemistry revealed positive CD10, CD20, CD45 (LCA), MUM1, and negative CD3, CD5. The Ki- 67 labeling rate was as high as almost 100% to diagnose diffuse large B-cell lymphoma, PCNSL. Multidrug chemotherapy consisting of rituximab, high-dose methotrexate, procarbazine, and vincristine were performed. Complete remission was obtained without any serious adverse events. Considering the residual radiation necrosis, whole-brain irradiation was avoided. Moreover, consolidation therapy was performed only with high-dose cytarabine therapy.

Re-irradiation of multiple brain metastases using CyberKnife stereotactic radiotherapy: Case report.

Introduction:Brain metastasis (BM) is the commonest adult intracranial malignancy and many patients with brain metastases require two course radiotherapy. Re-irradiation is frequently performed in Radiotherapy (RT) departments for multiple brain metastases.Patient concerns:We present a case of a 55-year-old male patient suffering from brain metastases, who had previously received whole-brain radiotherapy (WBRT) and first CyberKnife Stereotactic Radiotherapy (CKSRT) for metastases, presented with a recurrence of metastasis and new lesions in the brain.Diagnoses:An enhanced computed tomography (CT) scan of the brain revealed abnormalities with double-dosing of intravenous contrast that identified >10 lesions scattered in the whole brain.Interventions:Re-irradiation was performed using CKSRT. The patient was treated with 30 Gy in 5 fractions for new lesions and 25 Gy in 5 fractions for lesion that were locally recurrent and close to brainstem lesions.Outcome:The lesions were well-controlled, and the headache of the patient was significantly relieved one month after radiotherapy. The total survival time of the patients was 17 months from the beginning of the Cyberknife treatment.Conclusion:The present case report demonstrates that CyberKnife therapy plays a significant role in the repeated radiotherapy for multiple metastatic brain tumors. CKSRT can be used as a salvage method in recurrent multiple brain metastases.

SURG-04. SIMULTANEOUS CRANIOTOMIES FOR MULTIPLE BRAIN METASTASES

BACKGROUND: It is well known that for patients with solitary metastatic disease in the brain, aggressive surgical treatment can prolong survival. However, there is a paucity of literature focusing on simultaneous resection of multiple metastatic brain tumors. METHODS: We analyzed 13 patients and 26 tumors between 2005–2019 who had simultaneous resection of at least 2 metastatic brain tumors via either one or two craniotomies. We independently analyzed those patients with simultaneous resection of metastatic disease in both the supra- and infratentorial compartments. RESULTS: Overall, 26 tumors were resected in a simultaneous fashion. There were 7 females (53.8%) and 6 males (46.2%) total. 5/13 (38.5%) patients had previously known brain metastases in which all 5 had previous adjuvant radiation. All 13 patients had 2 metastatic lesions resected during one operation. Gross total resection rate reached 88.5% with a median post-operative stay of 3 days. Complications presented in only 3 out of 13 cases (grade 2 and 3 according to CTCAE). Primary sites of metastatic disease were lung, breast, skin and renal. 12/13 (92.3%) had two distinct craniotomies and 23/26 (88.5%) tumors had gross total resection of both lesions. There were 11 frontal (42.3%), 7 parietal (26.9%), 2 temporal (7.7%), 1 occipital (3.8%) and 5 cerebellar (19.2%) tumors. There were three patients with both supra- and intratentorial tumors with simultaneous resection. All three patients had two craniotomies and two separate incisions. 1 of the 3 had pre-operative SRS. Overall, average local progression since surgery to at least one resected tumor bed was 88.3 days. CONCLUSIONS: Our results suggest that patients with multiple metastatic brain lesions have comparable outcomes and similar rates of surgical risk to those with solitary brain lesions. In patients with simultaneous supra- and infratentorial brain metastatic disease and indications for decompression, safe resection is feasible.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on Treatment Options for Adults With Multiple Metastatic Brain Tumors.

These recommendations apply to adult patients newly diagnosed with multiple (more than 1) brain metastases. In what circumstances should whole brain radiation therapy be recommended to improve tumor control and survival in patients with multiple brain metastases? Level 2: It is recommended that whole brain radiation therapy can be added to stereotactic radiosurgery to improve local and distant control keeping in mind the potential for worsened neurocognitive outcomes and that there is unlikely to be a significant impact on overall survival. In what circumstances should stereotactic radiosurgery be recommended to improve tumor control and survival in patients with multiple brain metastases? Level 1: In patients with 2 to 3 brain metastases not amenable to surgery, the addition of stereotactic radiosurgery to whole brain radiation therapy is not recommended to improve survival beyond that obtained with whole brain radiation therapy alone. Level 3: The use of stereotactic radiosurgery alone is recommended to improve median overall survival for patients with more than 4 metastases having a cumulative volume <7 cc. In what circumstances should surgery be recommended to improve tumor control and survival in patients with multiple brain metastases? Level 3: In patients with multiple brain metastases, tumor resection is recommended in patients with lesions inducing symptoms from mass effect that can be reached without inducing new neurological deficit and who have control of their cancer outside the nervous system.The full guideline can be found at https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_6.

Commentary: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on Treatment Options for Adults With Multiple Metastatic Brain Tumors.

Commentary: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on Treatment Options for Adults With Multiple Metastatic Brain Tumors.

Commentary: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on Treatment Options for Adults With Multiple Metastatic Brain Tumors.

Target population These recommendations apply to adult patients newly diagnosed with multiple (more than 1) brain metastases. Question 1 In what circumstances should whole brain radiation therapy be recommended to improve tumor control and survival in patients with multiple brain metastases? Recommendation Level 2: It is recommended that whole brain radiation therapy can be added to stereotactic radiosurgery to improve local and distant control keeping in mind the potential for worsened neurocognitive outcomes and that there is unlikely to be a significant impact on overall survival. Question 2 In what circumstances should stereotactic radiosurgery be recommended to improve tumor control and survival in patients with multiple brain metastases? Recommendations Level 1: In patients with 2 to 3 brain metastases not amenable to surgery, the addition of stereotactic radiosurgery to whole brain radiation therapy is not recommended to improve survival beyond that obtained with whole brain radiation therapy alone. Level 3: The use of stereotactic radiosurgery alone is recommended to improve median overall survival for patients with more than 4 metastases having a cumulative volume Question 3 In what circumstances should surgery be recommended to improve tumor control and survival in patients with multiple brain metastases? Recommendation Level 3: In patients with multiple brain metastases, tumor resection is recommended in patients with lesions inducing symptoms from mass effect that can be reached without inducing new neurological deficit and who have control of their cancer outside the nervous system.The full guideline can be found at https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_6.

Commentary: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on Treatment Options for Adults With Multiple Metastatic Brain Tumors.

Commentary: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on Treatment Options for Adults With Multiple Metastatic Brain Tumors.

CyberKnife therapy of 24 multiple brain metastases from lung cancer: A case report

Brain metastasis is a significant cause of morbidity and mortality and a critical complication of non-central nervous system primary carcinoma. The present study describes the clinical case of a 46-year-old male with lung cancer and life-threatening brain metastases. The patient was diagnosed with lung cancer with a clinical stage of T2N0M1 (stage IV). Six months after the initial diagnosis and administration of conformal radiotherapy combined with three cycles of chemotherapy, an enhanced computed tomography (CT) scan of the brain revealed abnormalities with double-dosing of intravenous contrast. The CT scan identified >24 lesions scattered in the whole brain. The patient was treated with three-fraction Cyberknife radiotherapy at 22 Gy, delivered to the brain metastases at the Center for Tumor Treatment of People’s Liberation Army 107th Hospital. Following CyberKnife therapy, a CT scan of the brain revealed that most of the tumors had disappeared with almost no residual traces. The stereotactic radiosurgery (SRS) conducted using CyberKnife, an image-guided frameless robotic technology for whole-body radiosurgery, had produced a marked response. The present case report demonstrates that CyberKnife therapy plays a significant role in the management of multiple meta-static brain tumors.

Outcome predictors of Gamma Knife surgery for melanoma brain metastases

To evaluate the role of stereotactic radiosurgery (SRS) in the management of brain metastases from melanoma, the authors assessed clinical outcomes and prognostic factors for survival and tumor control. The authors reviewed 333 consecutive patients with melanoma who underwent SRS for 1570 brain metastases from cutaneous and mucosal/acral melanoma. The patient population consisted of 109 female and 224 male patients with a median age of 53 years. Two hundred eleven patients (63%) had multiple metastases. One hundred eighteen patients (35%) underwent whole-brain radiation therapy (WBRT). The target volume ranged from 0.1 cm(3) to 37.2 cm(3). The median marginal dose was 18 Gy. Actuarial survival rates were 70% at 3 months, 47% at 6 months, 25% at 12 months, and 10% at 24 months after radiosurgery. Factors associated with longer survival included controlled extracranial disease, better Karnofsky Performance Scale score, fewer brain metastases, no prior WBRT, no prior chemotherapy, administration of immunotherapy, and no intratumoral hemorrhage before radiosurgery. The median survival for patients with a solitary brain metastasis, controlled extracranial disease, and administration of immunotherapy after radiosurgery was 22 months. Sustained local tumor control was achieved in 73% of the patients. Sixty-four (25%) of 259 patients who had follow-up imaging after SRS had evidence of delayed intratumoral hemorrhage. Sixteen patients underwent a craniotomy due to intratumoral hemorrhage. Seventeen patients (6%) had asymptomatic and 21 patients (7%) had symptomatic radiation effects. Patients with ≤ 8 brain metastases, no prior WBRT, and the recursive partitioning analysis Class I had extended survivals (median 54.3 months). Stereotactic radiosurgery is an especially valuable option for patients with controlled systemic disease even if they have multiple metastatic brain tumors.

Prescription Dose Guideline Based on Physical Criterion for Multiple Metastatic Brain Tumors Treated With Stereotactic Radiosurgery

Existing dose guidelines for intracranial stereotactic radiosurgery (SRS) are primarily based on single-target treatment data. This study investigated dose guidelines for multiple targets treated with SRS. A physical model was developed to relate the peripheral isodose volume dependence on an increasing number of targets and prescription dose per target. The model was derived from simulated and clinical multiple brain metastatic cases treated with the Leksell Gamma Knife Perfexion at several institutions, where the total number of targets ranged from 2 to 60. The relative increase in peripheral isodose volumes, such as the 12-Gy volume, was studied in the multitarget treatment setting based on Radiation Therapy Oncology Group 90-05 study dose levels. A significant increase in the 12-Gy peripheral isodose volumes was found in comparing multiple target SRS to single-target SRS. This increase strongly correlated (R(2) = 0.92) with the total number of targets but not the total target volumes (R(2) = 0.06). On the basis of the correlated curve, the 12-Gy volume for multiple target treatment was found to increase by approximately 1% per target when a low target dose such as 15 Gy was used, but approximately 4% per target when a high dose such as 20-24 Gy was used. Reduction in the prescription dose was quantified for each prescription level in maintaining the 12-Gy volume. Normal brain dose increases predictably with increasing number of targets for multitarget SRS. A reduction of approximately 1-2 Gy in the prescribed dose is needed compared with single target radiosurgery.

Medulloblastoma and juvenile pilocytic astrocytoma presenting as synchronous primary brain tumors in a child

Multiple metastatic brain tumors and multifocal primary brain tumors of a single histological type have been published in the adult and pediatric literature. However, the simultaneous occurrence of multiple primary brain tumors with different cell types is rare. Even more rare is the pediatric presentation of multiple primary brain tumors with different cell types. The authors describe the case of an 8-year-old boy who presented with a 2-week history of progressive headache, nausea and vomiting, and imbalance. Brain MR imaging demonstrated a heterogeneously enhancing mixed solid/cystic mass of the left cerebellar hemisphere and a larger, midline, more homogeneously enhancing lesion of the superior vermis. Spinal MR imaging was unremarkable. The patient underwent a suboccipital craniotomy and subsequent gross-total resection of both mass lesions. Pathological examination revealed the left cerebellar and superior vermian lesions to be a juvenile pilocytic astrocytoma and a medulloblastoma, respectively. The patient did well in the immediate postoperative period, was discharged home, and underwent neurooncological follow-up. To the best of the authors' knowledge, they describe the first known pediatric case in which a medulloblastoma and a juvenile pilocytic astrocytoma presented as synchronous primary brain tumors. They review the literature on multiple primary brain tumors with different histological characteristics and rehash potential mechanisms for their development.

Outcomes and cost-effectiveness of gamma knife radiosurgery and whole brain radiotherapy for multiple metastatic brain tumors

We aimed to analyze the outcomes and cost-effectiveness of gamma knife radiosurgery (GKRS) and whole brain radiotherapy (WBRT) for multiple metastatic brain tumors. Over a period of 5 years, 156 patients with multiple metastatic brain tumors were enrolled and freely assigned by the referring doctors to either gamma knife radiosurgery (GKRS, Group A, n = 56), or to whole brain radiotherapy (WBRT, Group B, n = 100). The follow-up time was set at 1200 days (3.3 years) post-treatment. The number of tumors, patient age, extent of systemic disease and Karnofsky performance scale (KPS) score, were recorded and recursive partitioning analysis used. The outcomes analyzed were: mortality, survival time, neurological complications, post-treatment KPS score, quality-adjusted life years (QALY), and cost-effectiveness. A paired t-test was used for statistical analysis. Mortality rates for patients receiving GKRS and WBRT were 81.1% and 93.0%, respectively ( p = 0.05). The mortality rate was lower for GKRS (74.4%) than for WBRT (97.1%) in patients with initial KPS ⩾ 70 ( p = 0.02). The mortality rate was also significantly lower for GKRS (78.9%) than WBRT (95.5%) in patients with 2–5 tumors ( p < 0.05). Post-treatment KPS score (mean ± standard deviation [s.d.] was higher for patients receiving GKRS (73.8 ± 13.2) than for those receiving WBRT (45.5 ± 26.0), p < 0.01. The median survival time for GKRS and WBRT was 9.5 months and 8.3 months, respectively, p = 0.72. The mean (± s.d.) QALY was 0.76 ± 0.23 for GKRS and 0.59 ± 0.18 for WBRT, respectively ( p < 0.05). The cost-effectiveness per unit of QALY was better for the GKRS treatment (US$10,381/QALY) than in the WBRT treatment (US$17,622/QALY), p < 0.05. The cost-effectiveness per KPS score was also higher for the GKRS treatment (US$139/KPS score) than for WBRT (US$229/KPS score), p < 0.01. Thus, the mortality rate for multiple metastatic brain tumors treated by GKRS is significantly better with a good initial KPS score and when the tumor number is 2–5. GKRS results in a better post-treatment KPS score, QALY, and higher cost-effectiveness than WBRT for treating multiple metastatic brain tumors.

Double-platinum chemotherapy combined with etoposide in metastatic brain tumor from small cell lung carcinoma

The platinum-based chemotherapeutic agents, such as cisplatin (CDDP) and carboplatin (CBDCA), are effective for small cell lung carcinoma (SCLC). However, high dose treatment of these agents required for advanced-stage SCLC is often associated with severe toxicity. The authors used combination of lower doses of both cisplatin and carboplatin combined with etoposide (VP-16) to minimize side effects of these agents. This goal was accomplished by utilizing the facts that each agent has its own toxicity that can be controlled individually. Two patients (60- and 71-year old men) with multiple metastatic brain tumors from SCLC were treated by our chemotherapeutic regimen. After fourth chemotherapy, remarkable shrinking of brain masses was associated with significant decrease the size of original lung lesions in both cases. The two patients were discharged without any side effects of the treatment, and neurological deficits subsided in both cases. Each course provided the following schedules: carboplatin 200 mg/m2 x 1 day, cisplatin 25 mg/m2 x 2 days (intravenous administration), and etoposide 25 mg oral x 14 days. After second chemotherapy, the patient of Case 1 was irradiated to both brain and chest lesions, and only to brain in Case 2. The authors concluded from our two cases that the combination of these agents extremely effective to treat this malignancy with less toxicity. We named this double platinum chemotherapy as 'PEC', abbreviated from cisplatin, etoposide, and carboplatin. m

Stereotactic radiosurgery (SRS) for multiple metastatic brain tumors: effects of the number of target tumors on exposure dose in normal brain tissues.

This study was carried out to clarify the practical limit of the number of stereotactic radiosurgery (SRS)-targeted tumors based on the irradiation dose of normal brain tissues. Twenty-five patients with multiple brain metastases who received SRS from October 1998 to May 2002 were enrolled in the study. In each patient, the treatment options were thoroughly studied before deciding upon a course of treatment. The number of irradiated targets was increased one by one until all of the targets were included in a treatment plan. Given a surface dose of 25 Gy, we calculated the dose volume histogram (DVH) for the entire brain in each treatment plan and compared it with those of other treatment plans. Ultimately, only 5 of the 25 patients received irradiation for all of their tumors; the others received selective irradiation targeting only those tumors that were causing symptoms. When the number of targets increased, the DVH curve shifted to the right. The volume of the brain irradiated at a dose of 5 Gy or higher was 25.7% or less for 4 or fewer targets, 45.7% for 5-6 targets, 81.0% for 7-8 targets and 100% for 9-11 targets. When the number of the targets exceeded 8, more than 50% of the entire brain was irradiated at levels of at least 8.7 Gy. The dose distribution became very complex as the number of targets increased. Although the survival time of the group in which tumors were selectively targeted was longer than that in the group in which all tumors were irradiated, the difference between the two groups was not statistically significant ( P = 0.2537). In SRS for multiple brain metastases, risks of both acute and late sequelae may increase because the exposure dose to normal brain tissues increases with increased numbers of target tumors. Dose distribution becomes more complex according to the increase in the number of targets. Based on our DVH curves, we conclude that the exposure dose to normal brain tissues is acceptable when the number of targets is less than 7. Importantly, our study also reveals that it may not be necessary or desirable to irradiate all metastatic tumors.

Combination of stereotactic radiosurgery and cytokine gene-transduced tumor cell vaccination: a new strategy against metastatic brain tumors.

To determine if the combination of radiosurgery and tumor cell vaccine would enhance the therapy of metastatic lesions of the central nervous system (CNS), the authors examined the antitumoral effects of radiosurgery and cytokine-transduced tumor cell vaccine. Fifty-five rats underwent intracranial implantation of 5 x 10(3) MADB 106 cells. On Day 3 after tumor implantation, 34 rats were inoculated in the flank with nonirradiated MADB 106 cells that had been retrovirally transduced to express granulocyte-macrophage colony-stimulating factor or interleukin-4. Twenty-seven rats (17 animals that had received the vaccine and 10 that had not) underwent radiosurgery performed using a gamma knife at maximum doses of 32 Gy on Day 5. No animals in the untreated group or in the vaccine-alone groups survived longer than 21 days. Animals treated by ra diosurgery alone displayed prolonged survival in comparison with untreated animals (p < 0.0001), but only one of 10 animals survived longer than 55 days. In contrast, 14 of 17 animals that received the combination therapy of radiosurgery and vaccination survived longer than 55 days (p = 0.0003 compared with animals that underwent radiosurgery alone). On Day 55, the long-term survivors were challenged by parental MADB 106 cells, which were implanted in the contralateral hemisphere. All animals from the combination therapy groups survived longer than 50 days after this challenge, but the single survivor from the radiosurgery-alone group died of tumor growth in 27 days. The combination of radiosurgery and cytokine gene-transduced tumor cell vaccine markedly prolonged animal survival and protected animals from a subsequent challenge by parental tumor cells placed in the CNS. The data provided by this study indicate that this combination therapy represents a strategy that may have clinical applicability for single and/or multiple metastatic brain tumors.

多発性転移性脳腫瘍に対する治療戦略Gamma Knife治療はどこまで予後を改善できるのか?

多発性転移性脳腫瘍に対する治療戦略Gamma Knife治療はどこまで予後を改善できるのか?

Gamma knife treatment for multiple metastatic brain tumors compared with whole-brain radiation therapy

Object. The purpose of this retrospective study was to compare the effectiveness of gamma knife radiosurgery (GKS) for multiple cerebral metastases with that of whole-brain radiation therapy (WBRT). Methods. Ninety-six consecutive patients with cerebral metastases from nonsmall cell lung cancer were treated between 1990 and 1999. The entry criteria were the presence of between one and 10 multiple brain lesions at initial diagnosis, no surgically inaccessible tumors with more than a 30-mm diameter, no carcinomatous meningitis, and more than 2 months of life expectancy. The patients were divided into two groups: the GKS group (62 patients) and the WBRT group (34 patients). In the GKS group, large lesions (&gt; 30 mm) were removed surgically and all other small lesions (≤ 30 mm) were treated by GKS. New distant lesions were treated by repeated GKS without prophylactic WBRT. In the WBRT group, the patients were treated by the traditional combined therapy of WBRT and surgery. In both groups, chemotherapy was administered according to the primary physician's protocol. The two groups did not differ in terms of age, sex, initial Karnofsky Performance Scale (KPS) score, type, lesion number, and size of lesion, systemic control, and chemotherapy. Neurological survival and qualitative survival of the GKS group were longer than those of the WBRT group. In multivariate analysis, significant poor prognostic factors were systemically uncontrolled patients, WBRT group, and poor initial KPS score. Conclusions. Gamma knife radiosurgery without prophylactic WBRT could be a primary choice of treatment for patients with as many as 10 cerebral metastases from nonsmall cell cancer.

Gamma knife radiosurgery for simultaneous multiple metastatic brain tumors

Object. The authors assessed the efficacy of gamma knife radiosurgery (GKS) in the treatment of patients with 10 or more simultaneous metastatic brain tumors. Methods. Gamma knife radiosurgery was performed for the treatment of 10 or more simultaneous metastatic brain tumors in 24 patients. The performance status before and after GKS was expressed using the Karnofsky Performance Scale (KPS). The cumulative survival rate was analyzed using the Kaplan—Meier method. The level of satisfaction with the procedure was assessed by telephone interview. No patient has died due to brain metastasis—related symptoms, and all patients and/or their families were satisfied with the GKS. In 12 patients who had brain metastasis—related symptoms, five improved, six were unchanged, and one deteriorated, as reflected by the KPS scores. The cumulative survival rate calculated by the Kaplan—Meier method was 70.4%, 49.3%, and 12.3% at 12 weeks, 24 weeks, and 36 weeks, respectively. The median survival time was 11 weeks. Conclusions. Single-fraction GKS can achieve acceptable tumor control, low morbidity, and good quality of life in the treatment of multiple metastatic brain tumors even in cases with 10 or more simultaneous metastases.