Whole brain radiation does not improve on stereotactic radiation

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Whole brain radiation does not improve on stereotactic radiation
Reuters Health

Last Updated: 2006-06-07 14:36:49 -0400 (Reuters Health)

NEW YORK (Reuters Health) - Adding whole-brain radiation therapy (WBRT) to
stereotactic radiosurgery (SRS) does not seem to improve survival for
patients with one to four metastatic lesions in the brain, physicians in
Japan report.

Skipping WBRT, however, leads to increased brain tumor recurrence. Even
so, salvage therapy is still possible in the event of a relapse, and
omission of WBRT could circumvent long-term neurotoxic effects.

"There is not yet a general consensus regarding the risks and benefits of
omitting up-front WBRT," Dr. Hidefumi Aoyama and colleagues note in their
paper, published in the June 7 issue of the Journal of the American
Medical Association.

Dr. Aoyama, from Hokkaido University Graduate School of Medicine in
Sapporo, and associates conducted a multicenter, prospective study in
which 132 patients with one to four brain metastases were randomized to
SRS alone or SRS plus WBRT.

Patients with metastases from small cell carcinoma, lymphoma, germinoma
and multiple myeloma were excluded, as were patients with Karnofsky
Performance Status scores of < 70. Cases were recruited between 1999 and
2003.

For SRS alone, doses of 22 to 25 Gy were delivered to metastases of up to
2 cm, while larger lesions were treated with doses of 18 to 20 Gy. When
WBRT was added, the SRS dose was cut by 30%, and WBRT was delivered as 30
Gy in 10 fractions over 2 to 2.5 weeks, with SRS delivered upon completion
of WBRT.

There was no significant difference between groups in mortality over 2
years of follow-up or for deaths attributed to neurological causes.
Treatment allocation also did not affect median survival time,
posttreatment neurologic toxicity, functional maintenance, neurologic
deterioration or improvement or neurocognitive function after 12 months.

However, 12-month brain tumor recurrence was 46.8% in the dual-treatment
group and 76.4% in the monotherapy group (p < 0.001). New brain metastases
at distant sites were also more frequent in the SRS group, as was the
number of patients in the SRS group given salvage treatment for
progression of brain tumors.

As to how this study and other recent trials should be interpreted,
editorialist Dr. Jeffrey Raizer suggests that patients with more than four
brain metastases should be treated with WBRT. For those with fewer than
four, "either mode is a reasonable first choice."

For patients with a single brain metastasis, non-small cell lung cancer,
or recursive partitioning analysis classification for brain metastasis
class 1, SRS should be added to WBRT, Dr. Raizer, of the Feinberg School
of Medicine at Northwestern University, Chicago, adds.

"Whether overall quality of life is positively or negatively affected is
unknown, but for patients who might be cured of their cancer, omitting
WBRT could avoid long-term neurotoxic effects," he concludes.

JAMA 2006;295:2483-2491,2535-2536.

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