Resection Of Solitary Brain Metastasis Research Articles

Stereotactic radiosurgery versus whole-brain radiotherapy after resection of solitary brain metastasis: A systematic review and meta-analysis

ObjectiveThe standard of care in patients with solitary brain metastasis involves surgical resection and postoperative whole-brain radiotherapy (WBRT). However, WBRT is associated with adverse effects, mainly neurocognitive deterioration. Stereotactic radiosurgery (SRS) is a more targeted form of radiation therapy that could be as effective as WBRT without the detrimental neurocognitive decline. MethodsWe performed the first systematic review and meta-analysis comparing postoperative SRS versus postoperative WBRT in patients with one resected brain metastasis. PubMed, Scopus, and Cochrane library were systematically searched for studies comparing the efficacy of the two radiation modalities in terms of local and distant brain control, leptomeningeal disease control, and overall survival. Additionally, we extracted patients’ neurocognitive function and quality of life after each postoperative radiation form. ResultsFour studies with 248 patients (128: WBRT, 120: SRS) were included in our analysis. There was no difference between SRS and WBRT in the risk of local recurrence (RR = 0.92, CI = 0.51–1.66, p = 0.78, I2 = 0%) and leptomeningeal disease (RR = 1.21, CI = 0.49–2.98, p = 0.67, I2 = 18%), neither in the patients’ overall survival (HR = 1.06, CI = 0.61–1.85, p = 0.83, I2 = 63%). Nevertheless, SRS appeared to increase the risk of distant brain failure (RR = 2.03, CI = 0.94–4.40, p = 0.07, I2 = 61%). Neurocognitive function and quality of life in the SRS group were equal or superior to the WBRT group. ConclusionsAlthough SRS may increase the risk of distant brain failure, it appears to be as effective as WBRT in terms of local control, risk of leptomeningeal disease, and overall survival while sparing the patients of the detrimental, WBRT-associated cognitive deterioration.

Survival and prognostic factors in patients undergoing the resection of solitary brain metastasis from non-small cell lung cancer: a retrospective cohort study.

Neurosurgery is the standard of care for resectable solitary brain metastasis (BM) from non-small cell lung cancer (NSCLC), but still with a poor outcome. Postoperative whole-brain radiotherapy (WBRT) was reported to reduce local recurrence, whether it could prolong survival was uncertain. In this study, we attempted to evaluate WBRT and other prognostic for overall survival (OS) in these patients. In this retrospective study, NSCLC patients with a solitary BM and controlled primary tumor who underwent neurosurgical resection were selected from the medical records database between January 2014 and December 2018. Clinical data, disease control/progression results and survival outcomes were obtained from the medical records, regular outpatient follow-up and telephone interviews. Univariable and multivariable Cox analyses of potential prognostic factors including patients' characteristics, BM features, tissue-based parameters and postoperative treatments were conducted. OS was illustrated using Kaplan-Meier curves, and group differences were assessed using the log-rank test. The subgroup analysis compared each variable between the WBRT group and the untreated control by the hazard ratio and its 95% confidence interval (CI). A total of 94 patients were included, with a median OS of 812 days. Univariable analysis showed that postoperative WBRT and targeted therapy were associated with OS. Multivariable analysis demonstrated that postoperative WBRT [P<0.001, hazard ratio (HR) 0.357], chemotherapy (P=0.008, HR 0.512), targeted therapy (P<0.001, HR 0.265), and smaller tumor size (P=0.018, HR 0.553) were independent prognostic factors for prolonged OS. However, tissue-based parameters (Ki67 tumor cell proliferation index, epidermal growth factor receptor, and checkpoint levels) were identified as statistically insignificant factors. In the subgroup analysis, the beneficial effect of WBRT was only observed in patients that did not receive systematic treatments. Postoperative WBRT and systematic treatments after solitary BM resection improve the prognosis of NSCLC patients with a controlled primary tumor. Postoperative WBRT could be considered, especially for those who not receive systematic chemotherapy or targeted therapy treatments, as they might be more likely to benefit from it.

Resection of isolated brain metastases in non-small cell lung cancer (NSCLC) patients - evaluation of outcome and prognostic factors: A retrospective multicenter study.

Background and objectivesBrain metastases occur in about 30% of all patients with non-small cell lung cancer (NSCLC). In selected patients, long-term survival can be achieved by resection of brain metastases. In this retrospective study, we investigate the prognosis of NSCLC patients with resected brain metastases and possible prognostic factors.MethodsIn 119 patients with NSCLC and resected brain metastases, we report the following parameters: extent of resection, resection status, postoperative complications and overall survival (OS). We used the log-rank test to compare unadjusted survival probabilities and multivariable Cox regression to investigate potential prognostic factors with respect to OS.ResultsA total of 146 brain metastases were resected in 119 patients. The median survival was 18.0 months. Postoperative cerebral radiotherapy was performed in 86% of patients. Patients with postoperative radiotherapy had significantly longer survival (median OS 20.2 vs. 9.0 months, p = 0.002). The presence of multiple brain metastases was a negative prognostic factor (median OS 13.5 vs. 19.5 months, p = 0.006). Survival of patients with extracerebral metastases of NSCLC was significantly shorter than in patients who had exclusively brain metastases (median OS 14.0 vs. 23.1 months, p = 0.005). Both of the latter factors were independent prognostic factors for worse outcome in multivariate analysis.ConclusionsBased on these data, resection of solitary brain metastases in patients with NSCLC and controlled extracerebral tumor disease is safe and leads to an overall favorable outcome. Postoperative radiotherapy is recommended to improve prognosis.

Intracranial relapse rates and patterns, and survival trends following post-resection cavity radiosurgery for patients with single intracranial metastases

The objective of this study is to evaluate the patterns of relapse and survival trends in patients with single brain metastases treated with post-operative adjuvant Gamma knife stereotactic radiosurgery (GKS) without whole brain radiotherapy (WBRT). Retrospective analysis of all consecutive patients who underwent GKS to the tumor cavity following resection of solitary brain metastasis was performed at a single institution. Between March 2001 and June 2010, 56 patients underwent GKS to the resection cavity following resection of intracranial metastases; no patient received pre- or post-operative WBRT as an adjuvant (salvage WBRT was permissible). The mean marginal dose was 17.1 Gy (range 14-20 Gy). The mean follow-up period was 24 months (range 3-99 months). Five patients (8.9%) had local recurrence in the immediate vicinity of the resection cavity, qualifying as "local failures", and 21 (37.5%) recurred at distant intracranial sites. Median intracranial recurrence free survival was 13 months. Median overall survival was 20.5 months. Salvage interventions were required in 26 patients, and included repeat radiosurgery in 17 patients, further surgery in two patients, and salvage WBRT in eight (14.3%; two of whom had also been locally salvaged with repeat radiosurgery) patients. As expected, avoidance of WBRT results in a high rate of intracranial failure (26/56 patients, 46%), even in well-selected patients with only single brain metastases. As anticipated, the majority of failures (21, 37.5%) are "distant intracranial", and in this well-selected cohort the local failure rate is low (5/56 patients, <9%). All patients failing intracranially (46%) are potential candidates for salvage therapies, but WBRT as salvage was utilized in only 14.3% of patients. The median intracranial relapse-free was 13 months and overall survival was 20.5 months.

Current Dosing Paradigm For Stereotactic Radiosurgery Alone Following Surgical Resection of Brain Metastases Needs To Be Optimized For Improved Local Control

Current Dosing Paradigm For Stereotactic Radiosurgery Alone Following Surgical Resection of Brain Metastases Needs To Be Optimized For Improved Local Control

Frameless hypofractionated stereotactic radiosurgery to the tumor bed after resection of solitary brain metastases.

e12542 Background: Conventional tx of a solitary brain met consists of surgical resection followed by postop whole-brain radiotherapy (WBRT). For pts with controllable systemic dz this tx regimen has been shown to improve overall survival and functional independence. An alt tx modality for small, discrete mets is stereotactic radiosurgery (SRS). SRS, with or without WBRT, provides adequate local control (LC), preserves performance status, and improves length of survival (LOS). To date, no studies have looked at the role of post-op SRS. This study will analyze the role of SRS to the postop tumor bed following gross total surgical resection (GTR) of brain mets. Methods: Retrospective chart review on 23 pts (1 pt received similar tx to a separate brain lesion: 24 sites tx) who underwent hypofractionated frameless SRS following GTR of a newly diagnosed cerebral met. All pts underwent a craniotomy for GTR. Post op, each pts resection bed was tx using a frameless, image-guided 6 MV linear accelerator. Tx was divided into 5 fx in each case. Total delivered dose: 25 Gy to the 78-85% (median 81%) isodose line. Target vols were tx non- isocentrically, allowing conformality of RT to the tumor cavity. Variables analyzed were LOS, LC, regional control, and major post-RT complications. Results: Mean fu for 23 pts: 6.3 mos post SRS. Mean LOS: 9.5 mos. LC rate: 92% (22 of 24 tx sites). Local recurrence: 2 pts. 1 required add'l surgical resection, the other was tx with add'l SRS. Distant cerebral recurrence: 4 pts (2 pts developed lesions distant from the original site that were successfully tx with add'l SRS; 2 pts developed diffuse intracranial dz and received WBRT). No major complications as a result of SRS were noted. 8 of the 23 pts are still alive, mean LOS 15.3 mos. Conclusions: SRS is typically viewed as an alt to surgery in the mgmt of cerebral met dz, rather than an adjunct tx option. The isocentric, homogeneous dose delivery provided by frameless robotic SRS allows for the tx of GTR cavity beds. Unfortunately, no studies have investigated the role of post-GTR SRS to the tumor bed in place of WBRT. This data suggests that GTR followed by SRS to the residual cavity may be as efficacious as surgery followed by WBRT. A large prospective trial is ongoing. Author Disclosure Employment or Leadership Position Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Central Illinois Neuro Health Sciences

Whole-brain radiotherapy and tumor bed radiosurgery following resection of solitary brain metastases

A standard approach to solitary brain metastases is resection followed by whole-brain radiation therapy (WBRT). Despite WBRT, the tumor bed remains a common site of failure. We reviewed outcomes following adjuvant WBRT with tumor bed radiosurgery (SRS). We retrospectively identified patients having undergone neurosurgical resection of a single brain metastasis followed by adjuvant WBRT and tumor bed SRS. SRS dose selection was independent of target volume (10 Gy peripheral dose). Outcomes were calculated actuarially. Patients were censured for local control at the time of last imaging. From 2005 to 2008, 27 patients were treated with WBRT and tumor bed SRS. Median age was 58.7 years, median KPS 80%. The primary malignancy was non-small cell lung cancer in 70%. Median follow-up was 9.7 months. Following the combination of surgery, WBRT and SRS the median overall survival was 17.6 months. Actuarial 2-year local control was 94%. The SRS boost was well tolerated with one patient (4%) requiring reoperation for symptomatic radiation necrosis 16 months post treatment. Radiosurgery can be safely added to WBRT as an adjuvant treatment following resection of a single brain metastasis. In our retrospective series, this combination treatment produced a high rate of local control.

Long-term survivors of more than 5 years in advanced non-small cell lung cancer

Background The aim of this study is to evaluate the rate of long-term survival of more than 5 years in advanced non-small cell lung cancer (NSCLC). Methods One-hundred and twenty-four patients with advanced NSCLC treated with chemotherapy from September 2002 to October 2003 were reviewed. Results Ten (8%) patients survived for more than 5 years. The median survival time (MST) for the 10 patients was 61.5 months, ranging from 60.1 to 81.0 months. All of the 10 patients had performance status (PS) 0 or 1 and adenocarcinoma. As the initial treatment, 9 patients were treated with a platinum-containing chemotherapy [median progressive free survival (PFS), 10.7 months] and 8 patients received gefitinib as the second or third line chemotherapy (median PFS, 28.7 months). Nine patients received cytotoxic agents after first line chemotherapy (median duration of the chemotherapy, 22.4 months). A mean regimen of chemotherapy was three (range, 1–8). Re-challenge of gefitinib was performed in 2 patients, and surgical resection of solitary brain metastasis was performed as the initial treatment in 2 patients. Conclusion Our results suggest that good performance status, adenocarcinoma and EGFR-TKI therapy play an important role in the long-term survivors of more than 5 years.

Brain metastases in breast cancer: prognostic factors and management

The purpose of this retrospective study was to analyze the overall survival of patients with brain metastases due to breast cancer and to identify prognostic factors that affect clinical outcome. Of the 7,872 breast cancer patients histologically diagnosed with breast cancer between January 1990 and July 2006 at the Asan Medical Center, 198 patients with solitary or multiple brain metastases were included in this retrospective study. Central nervous system (CNS) lesions were diagnosed by computed tomography (CT) or magnetic resonance imaging (MRI). Patients with leptomeningeal or dural metastases without co-existent parenchymal metastatic lesions were excluded in this study. We reviewed the medical records and pathologic data of these 198 patients to characterize the clinical features and outcomes. The median age of the patients at the diagnosis of brain metastases was 45 years (range 26-78 years). Fifty-five patients (28%) had a single brain metastasis, whereas 143 (72%) had more than two metastases. A total of 157 (79.2%) patients received whole-brain radiation therapy (WBRT). A total of 7 (3.6%) patients underwent resection of solitary brain metastases, 22 (11%) patients underwent gamma-knife surgery, three patients underwent intrathecal chemotherapy (1.5%) and 9 (4.6%) patients received no treatment. The overall median survival time was 5.6 months (95% confidence interval (CI), 4.7-6.5 months) and 23.1% of the patients survived for more than 1 year. The median overall survival time was 5.4 months for patients treated with WBRT, 14.9 months for patients treated with surgery or gamma-knife surgery only, and 2.1 months for patients who received no treatment (P < 0.001). Multivariate analysis demonstrated that Eastern Cooperative Oncology Group (ECOG) performance status (relative risk (RR) = 0.704, 95% CI 0.482-1.028, P = 0.069), number of brain metastases (RR = 0.682, 95% CI 0.459-1.014, P = 0.058), treatment modalities (RR = 1.686, 95% CI 1.022-2.781, P = 0.041), and systemic chemotherapy after brain metastases (RR = 1.871, 95% CI 1.353-2.586, P < 0.001) were independent factors associated with survival. Although survival of breast cancer patients with brain metastases was generally short, the performance status, number of brain metastases, treatment modalities and systemic chemotherapy after brain metastases were significantly associated with survival. Patients with single-brain metastasis and good performance status deserve aggressive treatment. The characteristics of initial primary breast lesions did not affect survival after brain metastasis.

A phase II trial of stereotactic radiosurgery boost following surgical resection for solitary brain metastases

1552 Background: At present there is no standard of care for adjuvant therapy following resection of solitary brain metastases. The objective of this study was to determine the local control, survival, patterns of relapse and the incidence of brain injury following a surgery-stereotactic radiosurgery (SRS) combined therapy approach while avoiding upfront whole brain radiation therapy (WBRT). Methods: The eligibility criteria included radiologically proven solitary brain metastases, KPS≥70 and a neurologic function score of 0–2. Following the surgical resection, SRS was delivered to the surgical cavity 4–8 weeks later to a dose of 15–22 Gy in a single fraction using the BrainLAB linear accelerator system. Patients were followed with neurological examination and serial MRI images done every 3 months following the procedure. Results: 25 out of 50 patients needed for the study have been accrued since it opened in August 2004. Four patients have failed locally, with a median time to local failure of 9.5 months. The one year local control at the site of original disease was 35%. Two of the four patients who had local recurrence at the time of relapse also had evidence of leptomeningeal disease. Six additional patients developed new brain metastases, resulting in a 1 year brain relapse free survival of 38% following the combined approach. The median overall survival was 12 months. One patient (4%) developed radiation necrosis that required surgical intervention 6 months following the procedure. Six patients (24%) needed WBRT, two patients (8%) needed further SRS and one patient (4%) needed surgery as salvage following development of new brain lesions with this approach. Conclusions: The preliminary results of surgery-SRS approach appear inferior to surgery-WBRT data for solitary brain metastases in terms of local control and development of new brain metastases. However, relapses can be subsequently managed with WBRT without adversely affecting the overall survival and the morbidity. No significant financial relationships to disclose.

Nonsmall cell lung cancer presenting with synchronous solitary brain metastasis

Solitary brain metastases occur in about 50% of patients with brain metastases from nonsmall cell lung cancer (NSCLC). The standard of care is surgical resection of solitary brain metastases, or stereotactic radiosurgery (SRS) plus whole brain radiation therapy (WBRT). However, the optimal treatment for the primary site of newly diagnosed NSCLC with a solitary brain metastasis is not well defined. The goal was to distinguish which patients might benefit from aggressive treatment of their lung primary in patients whose solitary brain metastasis was treated with surgery or SRS. The cases of 84 newly diagnosed NSCLC patients presenting with a solitary brain metastasis and treated from December 1993 through June 2004 were retrospectively reviewed at The University of Texas M. D. Anderson Cancer Center. All patients had undergone either craniotomy (n = 53) or SRS (n = 31) for management of the solitary brain metastasis. Forty-four patients received treatment of their primary lung cancer using thoracic radiation therapy (median dose 45 Gy; n = 8), chemotherapy (n = 23), or both (n = 13). The median Karnofsky performance status score was 80 (range, 60-100). Excluding the presence of the brain metastasis, 12 patients had AJCC Stage I primary cancer, 27 had Stage II disease, and 45 had Stage III disease. The median follow-up was 9.7 months (range, 1-86 months). The 1-, 2-, 3-, and 5-year overall survival rates from time of lung cancer diagnosis were 49.8%, 16.3%, 12.7%, and 7.6%, respectively. The median survival times for patients by thoracic stage (I, II, and III) were 25.6, 9.5, and 9.9 months, respectively (P = .006). By applying American Joint Committee on Cancer staging to only the primary site, the thoracic Stage I patients in our study with solitary brain metastases had a more favorable outcome than would be expected and was comparable to Stage I NSCLC without brain metastases. Aggressive treatment to the lung may be justified for newly diagnosed thoracic Stage I NSCLC patients with a solitary brain metastasis, but not for locally advanced NSCLC patients with a solitary brain metastasis.

Surgical management of cerebral metastases from non-small cell lung cancer.

The objective of the study was to assess the efficacy of surgical resection of solitary brain metastasis in patients with non-small-cell lung cancer. We report a retrospective analysis of 32 patients with single brain metastasis surgically excised at our hospital. All but one patient underwent postoperative whole brain radiation therapy. The median survival of patients was 12.5 months postoperatively (mean, 17 months), and the overall 1-year survival was 53%. Thirteen patients had recurrence of brain metastasis: 6 of 13 underwent reoperation for the recurrent lesion, and 1 of the 6 patients had a third craniotomy. Baseline characteristics, which significantly influenced survival, included age less than 60 years, tumor histology (ie, adenocarcinoma), and treatment of the primary lung cancer. The analysis did not yield any significant differences between treatment modalities. Our findings correspond well with those reported in the literature and suggest that surgical resection of single brain metastasis in patients with non-small cell lung cancer can improve survival over conservative management. Furthermore, surgical treatment of the primary tumor and the single brain metastasis, combined or not with radiotherapy and chemotherapy, represents an approach that merits further investigation with more patients and a prospective longitudinal design.

Surgical resection of solitary brain metastasis from ovarian carcinoma: An analysis of 22 cases

Objective Central nervous system (CNS) involvement is considered an uncommon complication in patients with ovarian carcinoma. The aim of this study was to evaluate prognostic factors for survival following surgical resection of brain metastases in patients with ovarian carcinoma. Methods A retrospective chart review was conducted on 22 patients who had been submitted to neurosurgical resection of a solitary brain metastasis from ovarian carcinoma. Results Eighteen lesions were cerebral, 4 were cerebellar. CNS was the only site of disease in 9 patients, 9 patients had CNS and abdominopelvic disease, and 4 also had concomitant extraperitoneal dissemination. Following surgery, 17 received whole-brain radiotherapy and 5 received systemic chemotherapy. Median survival from diagnosis of cerebral metastasis for the entire series was 16 months (range, 4–41 months). Extracranial disease at the time of CNS metastasis and time interval between diagnosis of ovarian cancer and CNS involvement manifestation were the only factors significantly affecting survival. Conclusions Neurosurgical resection of brain metastasis from ovarian carcinoma is indicated in solitary lesions in the absence of systemic disease. The role of chemotherapy and stereotactic radiosurgery should be investigated.

Prognostic factors in surgical treatment of solitary brain metastasis after resection of non-small-cell lung cancer

Patients with brain metastasis after resection of non-small-cell lung cancer usually have poor prognosis. A few such patients, however, survive for long periods after surgical resection of brain metastases. To evaluate the prognostic factors in resection of solitary brain metastasis from non-small-cell lung cancer, we reviewed 24 cases undergoing resection of solitary brain metastasis after resection of the primary site from 1977 to 1993. The patient population consisted of 20 men and four women ranging in age from 40 to 75 years old (average, 57.8 years old). None of the patients had systemic metastasis except in the brain at the time of brain surgery. The overall survival rates were 12.5% at 3 years and 8.3% at 5 years after brain surgery. The longest survival periods were 11.5 years after brain surgery and 15.4 years after lung surgery. The interval between lung and brain surgery (≤360 days vs. >360 days), differentiation of primary cancer (poor vs. moderate), size of primary site (≤5.0 cm vs. >5.0 cm), and operation of primary site (lobectomy vs. pneumonectomy) significantly affected survival as shown by univariate analysis (P<0.05). Other clinical factors (age, gender, histology, T- and N-status, ‘resectability with curative intent’ of the primary site, location of the brain metastasis and postoperative radiation therapy) did not affect survival. Multivariate analysis using Cox’s proportional hazards model indicated that an interval of more than 360 days between the two surgical procedures (hazard ratio=0.2351, P=0.0136) and lobectomy (hazard ratio=0.5274, P=0.0416) were independent prognostic factors. In conclusion, patients with solitary brain metastasis from non-small-cell lung cancer without other organ metastasis, in whom relapse in the brain occurred more than 1 year after resection of the primary site and in whom lobectomy was performed, should be treated surgically to maximize the chance of prolonged survival.

Radiosurgery for solitary brain metastases using the cobalt-60 gamma unit: methods and results in 24 patients

To define the role of stereotactic radiosurgery in the treatment of metastatic brain tumors we treated 24 consecutive patients (20 men, 4 women) with the 201-source 60Co gamma unit between May 1988 and March 1990. The primary tumors included malignant melanoma (n = 10), non-small cell lung carcinoma (n = 6), renal cell carcinoma (n = 3), colorectal carcinoma (n = 1), oropharyngeal carcinoma (n = 1), and adenocarcinoma of unknown origin (n = 3). All tumors were ≤3.0 cm in greatest diameter. Twenty patients received a planned combination of 30–40 Gy whole brain fractionated irradiation and a radiosurgical “boost” of 16–20 Gy to the tumor margins; one patient refused conventional fractionated irradiation. Three patients with recurrent, persistent, or new non-small cell lung carcinomas had radiosurgical treatment 12–20 months after receiving 30–42.5 Gy whole-brain external beam irradiation. Stereotactic computed tomographic imaging was used for target coordinate determination and imaging-integrated dose planning. All tumors were enclosed by the 50–90% isodose shell using one (n = 22), two (n = 1), or three (n = 1) irradiation isocenters. During this 23-month period (median follow-up of 7 months) no patient died from progression of a radiosurgically-treated brain metastasis. Ten patients died of systemic disease (n = 8) or remote central nervous system metastasis (n = 2) between 1 week and 10 months after radiosurgery. One patient had tumor progression and underwent craniotomy and tumor excision 5 months after radiosurgery. To date, median survival after radiosurgery has been 10 months; 1-year survival was 33.3%. Stereotactic radiosurgery eliminated the surgical and anesthetic risks associated with craniotomy and resection of solitary brain metastases. Radiosurgery also effectively controlled the growth of tumors considered “resistant” to conventional irradiation.

Surgical Treatment of Primary Lung Cancer and Solitary Intracranial Metastasis

From 1976 through 1986, 12 patients underwent 14 thoracotomies (two patients had a second thoracotomy for recurrence) and 16 craniotomies (two patients had three craniotomies for recurrence) for carcinoma of the lung and solitary intracranial metastasis. Age ranged from 40 to 65 years. Adjuvant therapy (chemotherapy and thoracic irradiation) was employed in three patients prior to thoracotomy and in four patients following thoracotomy. Whole-brain irradiation was used in four patients after craniotomy. Improvement in neurologic symptoms following craniotomy was noted in 15 of 16 instances. There were no operative mortalities. Overall survival from the time of initial diagnosis ranged from 13 to 63 months. Survival following initial craniotomy ranged from 12 to 56 months. Eight patients are currently alive and well with no disabling neurological symptoms. These results support an aggressive approach to the resection of solitary brain metastasis from bronchogenic carcinoma, both for palliation and prolongation of survival.

Adjuvant radiation therapy after surgical resection of solitary brain metastasis: Association with pattern of failure and survival

We reviewed patients treated by resection of solitary cerebral metastasis at the Mayo Clinic from January 1, 1972, to December 1, 1982. Eighty-five patients rendered clinically disease-free and who received intramural follow-up after craniotomy were studied. Adjuvant whole-brain radiation therapy (WBRT) was delivered to 34, and 51 were observed after craniotomy. Pattern-of-failure analysis showed a much smaller incidence of subsequent brain relapse in the adjuvant WBRT group than in the observation group (21% versus 85%, respectively). Multivariate analysis utilizing 17 patient, tumor, and treatment characteristics showed adjuvant WBRT to have the strongest association with brain control ( p < 0.0001). The only other variable which was significant ( p < 0.01) was multilobe involvement of the metastatic lesion, which was associated with a greater likelihood of brain failure. Systemic failures were more frequent (61% versus 37%), and the proportion of patients remaining disease-free (29% versus 4%) was higher in the adjuvant group. Those patients who received adjuvant WBRT to a dose of 39 Gy or greater manifested an 11% rate of subsequent brain failure versus a 31% rate when less than 39 Gy was delivered. The median survival was longer for the adjuvant WBRT group (21 months versus 11.5 months). Multivariate analysis indicated that adjuvant WBRT was one of several variables (including female gender, long disease-free survival, and good neurologic function prior to craniotomy) significantly associated with improved survival. This study suggests that adjuvant cranial irradiation may help prevent clinical recurrence of resected metastatic intracranial disease and that improved control of intracranial disease may be associated with an improved survival in patients without clinical evidence of systemic disease at the time of craniotomy.