Researchers from the MD Anderson Cancer Center have reported that patients with one to three brain metastases treated with stereotactic radiosurgery (SRS) plus whole brain radiation therapy (WBRT) have significant neurocognitive losses after treatment, and that treatment with SRS alone is recommended. The details of this randomized study were published early online in Lancet Oncology on October 8, 2009.[1]

Whole brain radiotherapy is the standard treatment of patients with metastases to the brain and extends survival by approximately six months compared with supportive care alone. Stereotactic radiosurgery allows the precise delivery of radiation to a specific site. In the treatment of brain tumors, SRS is often used when surgery is thought to be too dangerous. A previous study performed by the Radiation Therapy Oncology Group (RTOG) reported that WBRT followed by SRS improved treatment of brain metastasis when compared to WBRT alone (see first item of related news). This was a multicenter trial which randomly allocated 231 patients with one to three brain metastases to receive WBRT or WBRT followed by SRS. These authors reported that the median survival was increased from 4.9 to 6.5 months following WBRT plus SRS.  In this study there were no adverse effects of adding SRS to WBRT.

The current study evaluated the effectiveness of SRS alone versus SRS plus WBRT in 58 patients with one to three brain metastases. There were 30 patients in the SRS group and 28 in the SRS plus WBRT group. This study was stopped early due to a decline in learning and memory function in patients receiving SRS plus WBRT at 4 months post-treatment.

• It was estimated that over half of the patients receiving SRS plus WBRT would have significant learning and memory decline compared with a quarter of patients receiving SRS alone.
• At 4 months there were four deaths in the SRS alone group and eight deaths in the SRS plus WBRT group.
• At 6 months the 73% of patients in the SRS plus WBRT group were free of metastases compared with 27% of patient in the SRS alone group.
• At the time of this report 89% of patients in the SRS plus WBRT group had died compared with 67% of patients receiving SRS alone.
• The median survival was 15.2 months for patients in the SRS group and 5.7 months in the SRS plus WBRT group.
• The one-year survival was 63% for the SRS group and 21% for the SRS plus WBRT group.
• Patients in the SRS plus WBRT were 2-2.5 times more likely to die of neurologic or systemic complications than patients receiving SRS alone.

These authors “recommend that initial SRS alone combined with close clinical monitoring should be the preferred treatment strategy for such patients. Surgical salvage should be used for local failures, and SRS or WBRT for distant failures as indicated. This strategy is consistent with the trend towards personalised medicine and tailoring therapies, rather than applying the ‘one size fits all’ approach of giving WBRT to all patients with brain metastasis.”

Comments: This study suggests that SRS should be the initial therapy for patients with one to three brain metastases. This approach would preserve neurologic function in the relatively small number of survivors.

Related News

Stereotactic Radiosurgery Boost Improves Treatment of Brain Metastases (5/24/2004)

High-Volume Hospitals and Surgeons Have Better Results for Resection of Metastatic Brain Cancers (2/24/2004)

Motexafin Gadolinium (Xcytrin®) Improves Results of Whole Brain Radiation Therapy in Patients with Cancer Metastatic to Brain (10/14/2002)

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