“Effective and often curative care—not just palliative care—can be provided for a brain tumor. Radiosurgery can be an effective approach for such patients, together with their systemic cancer management.” Douglas Kondziolka, M.D., M.Sc.

Long-Term Survival Possible After Radiosurgery for Brain Cancer

Some people with brain metastases can live much longer than expected if managed aggressively with radiosurgery, according to new research.

Douglas Kondziolka, M.D., M.Sc.

“It is difficult to pick the best candidates at the beginning,” said study author Douglas Kondziolka, M.D., M.Sc., of the Department of Neurological Surgery at the University of Pittsburgh Medical Center. He and co-author L. Dade Lunsford, M.D., serve as consultants for Elekta Instruments, Inc., manufacturer of the Gamma Knife. Their study appeared in the December 15, 2005, issue of the journal Cancer.

Over the last decade, more and more institutions have begun treating brain metastases with radiosurgery, powerful focused radiation administered in a single session to the tumor, with or without additional whole-brain radiation.

Dr. Kondziolka and colleagues conducted their study to find out why some brain tumor patients who underwent radiosurgery were doing much better than anyone would have expected.

“Through the 1990s, the general expectation for patients with brain metastases who were managed aggressively was an average survival of about a year,” said Dr. Kondziolka. “And yet, there were people who were clearly living many years longer than this. We wanted to understand why. Who were these people? Why were they beating the odds, so to speak?”

The researchers studied 677 patients with brain metastases who underwent radiosurgery procedures between 1988 and 2000. They reported that 44 of the patients (6.5 percent) were still alive four or more years after radiosurgery.

“I think the most surprising finding was that for many of these people, one would not have initially predicted that they would have been in this long-term survivor group,” said Dr. Kondziolka. “That’s because the extent of their cancer was more than just to the brain.”

Survivors included patients with primary cancers of the lung, breast, kidney, skin and other sites. Eighteen of the surviving patients had cancer in two or more organs outside the brain. “People in that group, one would predict, would do the worst,” Dr. Kondziolka said. “But almost half of the entire long-term survivor group included people who had multiple organs involved. At the beginning one would have been fairly nihilistic and not predicted that they would have done very well.”

David H. Hussey, M.D., 2005 RSNA president and a clinical professor in the Department of Radiation Oncology at the University of Texas Health Science Center at San Antonio, said he was impressed that a fair number of the survivors had advanced cancers. “Fifteen of the patients that were long-term survivors had lung cancers,” Dr. Hussey said.

Compared with patients who died within the first three months after radiosurgery, those who lived more than four years showed no differences in age, gender, percentage of lung carcinoma, melanoma or renal cell carcinoma, radiosurgery margin dose, use of prior whole-brain radiation therapy, volume of the largest tumor or total tumor volume.

The patients who beat the odds had higher pre-radiosurgery Karnofsky performance scores, fewer metastases and less extracranial disease burden than those who died in the early months after radiosurgery.

“For the vast majority of people, we were able to get the brain tumor under control, but most were dying because of their systemic cancers,” Dr. Kondziolka says. “Obviously, for the people who lived, we learned that the reason they lived was because we were able to bring the brain burden under control and the body cancer was also brought under control.”

The median survival of the patients was 68 months. Sixteen patients remained alive at the time of last follow-up, with a maximum survival of 156 months so far.

“I was impressed,” Dr. Hussey said. “I probably wouldn’t have wanted to go to the expense and difficulty of having radiosurgery if I personally had a metastasis in my brain. After reading this paper, maybe I would.”

The researchers concluded that while the expected survival of patients with brain metastases may be limited, select patients with effective intracranial and extracranial treatment for malignant disease can have prolonged, good-quality survival.

 Dr. Kondziolka said radiosurgery is just starting to move to spinal applications, with some additional reports regarding the use of focused radiation in lung tumors.

“For other organs, such as the pancreas and liver, there’s a potential opportunity, but it’s just beginning,” Dr. Kondziolka added.

He said an American College of Surgeons study is focusing not only on survival, but also on quality of life, in patients who undergo radiosurgery or whole-brain radiation.

“There have been significant gains made in the management of brain metastases over the last decade,” he said. “Effective and often curative care—not just palliative care—can be provided for a brain tumor. Radiosurgery can be an effective approach for such patients, together with their systemic cancer management.”

To read the abstract for Dr. Kondziolka’s study, “Long-Term Survivors After Gamma Knife Radiosurgery for Brain Metastases, go to www3.interscience.wiley.com/cgi-bin/abstract/112142382/ABSTRACT.