Radiosurgical salvage therapy for patients presenting with recurrence of metastatic disease to the brain

OBJECTIVE: Radiosurgery has emerged as an important modality in the management of metastatic disease to the brain. A number of groups have published results suggesting that high local control rates can be achieved, with improvements in overall survival that rival the results of open surgical treatment. Typically, however, whole-brain radiotherapy has been used in the salvage therapy of patients who have undergone previous craniotomy or radiosurgery. We describe our experience with radiosurgical salvage in this group of patients. METHODS: From August 1994 to February 1999, 190 patients with brain metastasis were treated with gamma unit radiosurgery at our institution. A subset of 45 patients, who underwent radiosurgical salvage for new tumors in a region remote from an initially treated tumor, form the population base for this study. The usual criteria for repeat treatment were recurrence with five or fewer discrete lesions outside of the previously treated radiosurgical volume and Karnofsky Performance Scale score of at least 70, Survival and freedom from progression were measured from the time of radiosurgical treatment and were computed by the Kaplan-Meier product-limit method. Two or more curves were compared using the log-rank method. RESULTS: In this subgroup of patients, a total of 176 tumors were treated. The median time from first radiosurgical procedure to first salvage was 17.4 weeks. Median survival from the second radiosurgical intervention was 28 weeks. Of the 45 study patients, 34 patients underwent a single salvage procedure, 10 patients underwent two salvage procedures, and 1 patient had three salvage procedures. The actuarial freedom from progression for treated tumors at 52 weeks was 92.4%. Patients undergoing upfront whole-brain irradiation were less likely to require salvage therapy (P = 0.008). There were 33 deaths after salvage radiosurgery during the reporting period. Central nervous system causes accounted for 13 deaths, whereas 19 deaths resulted from systemic disease. The cause of death in one patient could not be determined. No statistically significant advantage in overall survival could be demonstrated in patients treated with whole-brain irradiation. CONCLUSION: Radiosurgical salvage represents a valuable means of treatment for central nervous system recurrence for patients who have undergone previous treatment for metastatic disease to the brain. Whole-brain irradiation may reduce the need for salvage therapy, but no advantage in overall survival could be demonstrated in this subgroup.