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The case for radiosurgery for brainstem metastases

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Abstract

Purpose

To challenge the prevalent pessimism regarding the outcome of patients with metastases in the brainstem resulting in the use of whole brain radiation for palliation rather than stereotactic radiosurgery for definitive control and preservation of quality of life. We present our single institution review of the efficacy and safety of treating brainstem metastases aggressively with GKRS.

Methods

Forty-one patients with 45 total lesions treated with GKRS were included. Mean age was 58.7 years, ranging from 22 to 82. Tumor volumes were objectively calculated, treatment effects assessed on imaging and clinical data collected and correlated to the radiosurgical response.

Results

Mean survival after diagnosis of BSM was 11.6 months, ranging from 1.4 to 58.8 months. Margin dose ranged from 12 to 20 Gy. At first follow up, 11 (27%) patients had complete resolution of the treated lesion. At the second follow up 15 (37%) and third follow up 19 (46%) patients had a complete response. On average, there was a 64% decrease in tumor size at first follow up after treatment. 25 (61%) patients received WBRT in addition to radiosurgery; 16 (39%) received radiosurgery alone. There was no difference in overall survival between the two groups (p = 0.1324). ARE was seen in one patient who received  16 Gy to the margin of a 2.06 cm3 pontine tumor, but without correlative symptoms. One patient was treated with Bevacizumab® for progressive, but asymptomatic, edema following treatment that was not controlled by corticosteroids.

Conclusions

Location in brainstem should not be a deterrent to the use of radiosurgery for these patients. The addition or exclusion of WBRT should be based on the clinical progression of the patient and within the limits of this study does not seem to impact overall survival. With improved survival as a result of better systemic therapy, these patients can benefit from better preservation of cognitive function by this strategy.

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Abbreviations

ARE:

Adverse radiation effect(s)

BM:

Brain metastasis

BSM:

Brainstem metastasis

GI:

Gradient Index

GKRS:

Gamma Knife radio surgery

Gy:

Gray

NSCLC:

Non-small cell lung cancer

PCI:

Paddick Conformity Index

SCLC:

Small cell lung cancer

SD:

Standard deviation

WBRT:

Whole brain radiation therapy

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Acknowledgements

The authors thank W. Fawn Dorr BA and Debra J. Zimmer for editorial assistance.

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Authors and Affiliations

  1. Department of Neurosurgery, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, USA

    Evan Winograd, Robert Fenstermaker, Andrew Fabiano, Robert Plunkett & Dheerendra Prasad

  2. Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, USA

    Charlotte I. Rivers & Dheerendra Prasad

  3. Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA

    Evan Winograd, Robert Fenstermaker, Andrew Fabiano, Robert Plunkett & Dheerendra Prasad

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  1. Evan Winograd
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  2. Charlotte I. Rivers
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Correspondence to Dheerendra Prasad.

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Conflict of interest

DP serves as a consultant for Elekta AB, Sweden on matters unrelated to this work. All other authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required..

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Winograd, E., Rivers, C.I., Fenstermaker, R. et al. The case for radiosurgery for brainstem metastases. J Neurooncol 143, 585–595 (2019). https://doi.org/10.1007/s11060-019-03195-y

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