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The role of stereotactic radiosurgery for multiple brain metastases in stable systemic disease: a review of the literature

Acta Neurochirurgica volume 155, pages 1321–1328 (2013)Cite this article

Abstract

Background

Cancer patients with brain metastases display a median survival of only 1 to 2 months if left untreated. Although whole-brain radiation therapy (WBRT) has lengthened median patient survival, the long-term neurotoxic effects of WBRT have become a deterrent to its use in the context of stable systemic disease. Therefore, it is important to identify patients who might benefit from stereotactic radiosurgery (SRS) in order to delay or avoid WBRT. Here we present a review of the literature to elucidate the role of SRS in patients with multiple brain metastases.

Methods

MEDLINE search for English-language articles from 1998 to 2012 describing survival or neurocognitive functioning of patients with multiple brain metastases treated with SRS, WBRT, or a combination.

Results

SRS monotherapy yields an equivalent survival with low risk of long-term neurotoxicity, but higher rate of recurrence, compared to WBRT or combined radiotherapy. Patients with ≤4 brain metastases or KPS ≥ 80 are expected to survive significantly longer than the onset time of prominent WBRT-induced neurocognitive decline.

Conclusions

SRS, administered alone or adjuvant to surgical resection of symptomatic metastases, is preferred for patients with ≤4 brain metastases or KPS ≥ 80 to delay or avoid WBRT. WBRT can then be employed in the event of recurrence. WBRT with or without resection is preferred for patients with ≥5 brain metastases and KPS < 80, due to these patients’ shorter survival and increased recurrence risk. SRS boost treatments can then be used in the event of poor tumor response or progression.

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Conflicts of interest

None.

Author information

Affiliations

  1. George Washington University School of Medicine and Health Sciences, Washington, DC, USA

    Siri Sahib S. Khalsa, Moshe Chinn & Max Krucoff

  2. Department of Neurological Surgery, George Washington University, Washington, DC, USA

    Jonathan H. Sherman

  3. Department of Neurological Surgery, George Washington University Medical Center, 2150 Pennsylvania Ave, NW Suite 7420, Washington, DC, 20037, USA

    Jonathan H. Sherman

Authors
  1. Siri Sahib S. Khalsa
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  2. Moshe Chinn
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  3. Max Krucoff
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  4. Jonathan H. Sherman
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Corresponding author

Correspondence to Jonathan H. Sherman.

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Comment

This is an important and well-done analysis of the sometimes confusing and still shifting literature on stereotactic radiosurgery (SRS) for multiple brain metastases. The authors have managed to filter out those patients who may profit from SRS monotherapy according to the literature. Figure 1 illustrates very well the dilemma of choosing the best treatment option for a given patient. As the authors point out, there are patients in whom the onset of neurotoxicity as early as 4 months following WBRT must be considered a worse outcome than potential tumor recurrence following stand alone SRS. Modern management of patients with brain metastases should be done keeping this in mind. The tendency in the treatment of patients with multiple brain metastases should therefore be to delay WBRT as much as possible or even to avoid it entirely. This can be done best by treating focal disease with focal therapy such as stand alone SRS in select patients. As opposed to WBRT, such a treatment strategy requires a tighter follow up regime. In that sense, focal treatment regimes require a paradigm shift in terms of patient follow-up. Serial MRIs should be performed in those patients in order to detect tumor recurrence early enough for focal or whole-brain retreatment. Most probably, this is done best by the neurosurgeon responsible for the SRS. A dedicated neurosurgeon with a broad knowledge of SRS for brain metastases and its follow-up is most likely to manage those patients to their advantage. In that context, it is not surprising that important publications on the follow-up after SRS for brain metastases have come from neurosurgeons and not from oncologists, radiation oncologists, or radiologists (1). Many centers go even one step further. Instead of treating brain metastases with SRS to be followed by WBRT in case of tumor recurrence, they apply successfully stand alone SRS followed by repeat or even serial SRS in case of local or distant tumor recurrence (2, 3). This allows to avoid WBRT altogether in select patients. This publication helps in selecting patients properly for such novel and focal treatment regimes.

References

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Thomas Mindermann,

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Khalsa, S.S.S., Chinn, M., Krucoff, M. et al. The role of stereotactic radiosurgery for multiple brain metastases in stable systemic disease: a review of the literature. Acta Neurochir 155, 1321–1328 (2013). https://doi.org/10.1007/s00701-013-1701-5

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  • DOI: https://doi.org/10.1007/s00701-013-1701-5

Keywords

  • Brain metastases
  • Stereotactic radiosurgery
  • Whole-brain radiation therapy
  • KPS