Central Nervous System

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MO_4_2558 - Comparison of Treatment Modalities for Large Brain Metastases

Monday, October 22
10:45 AM - 12:15 PM
Location: Innovation Hub, Exhibit Hall 3

Comparison of Treatment Modalities for Large Brain Metastases
A. E. Dohm1, R. T. Hughes2, W. H. Wheless3, M. C. LeCompte2, C. M. Lanier2, J. Ruiz4, K. Watabe5, J. Su6, C. K. Cramer2, A. Laxton7, and M. D. Chan8; 1Wake Forest University School of Medicine, Winston-Salem, NC, 2Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 3Wake Forest School of Medicine, Winston-Salem, NC, 4W.G. (Bill) Hefner Veteran Administration Medical Center, Cancer Center, Salisbury, NC, 5Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, 6Department of Diagnostic Radiology, Wake Forest School of Medicine, Winston-Salem, NC, 7Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, 8Wake Forest School of Medicine, Winston Salem, NC

Purpose/Objective(s): Treatment options for large brain metastases (BM) include surgical resection followed by stereotactic radiosurgery (SRS) to the surgical cavity, hypofractionated SRS, whole brain radiation, and staged SRS; however, no studies to date have compared postoperative radiation and staged SRS. The purpose of this study was to retrospectively review and compare outcomes of patients with large BM treated with these two treatment strategies.

Materials/Methods: We evaluated the medical records of 78 patients with large BM treated between 2009-2017 with either surgical resection and post-operative SRS within 30 days (surgery+SRS) or staged SRS separated by 1 month. Overall survival (OS) was estimated using the Kaplan Meier method and compared across groups using the log-rank test. Cumulative incidence of neurologic death and local and distant brain failure (LF, DBF) were estimated using competing risk methodology. Changes in treatment volumes were found using GammaPlan.

Results: A total of 40 patients with 40 lesions were treated with surgery+SRS and 39 patients with 47 lesions were treated with staged SRS. Median follow-up was 7.5 months (95% CI 5.8-13.2). Median tumor volume for those treated with surgery+SRS and staged SRS were 14.9 cm3 and 13.5 cm3, respectively; p=0.50). Surgery+SRS patients had 1 lesion each, staged SRS patients had a median 1 lesion (range, 1-3) treated (p=0.02). Median dose to the tumor cavity after surgical resection was 16.5 Gy (IQR 13.9-17.0). Median dose for patients treated with staged SRS was 15 Gy (IQR 14-16) for the first treatment and 13.5 Gy (IQR 12.0-14.5) for the second. Median reduction in treatment volume was 54% (IQR 14-63%) for surgery+SRS and 36% (IQR 11-61%) for staged SRS (p=0.60). Median OS showed showed a trend toward improved survival with staged SRS (13.2 months) compared to surgery+SRS (9.7 months, p=0.53). Cumulative incidence of neurologic death at 1 year was 23% after surgery+SRS, 27% after staged SRS (p=0.69); cumulative incidence of local failure at 1 year was 6% and 8% (p=0.65) and 1 year distant brain failure (DBF) was 59% and 21% (p≤0.01). Overall rates of leptomeningeal failure and radiation necrosis were similar between the groups (p=1.0)

Conclusion: In our retrospective study, patients undergoing surgery+SRS and staged SRS experienced excellent local control with favorable overall and neurologic mortality. While surgical resection followed by postoperative SRS remains a standard for large brain metastases, staged SRS may represent an attractive treatment paradigm without sacrificing local control or survival, and potentially decrease distant brain failure. Prospective studies are needed to validate these findings.

Author Disclosure: A.E. Dohm: None. R.T. Hughes: None. W.H. Wheless: None. M.C. LeCompte: None. J. Ruiz: None. J. Su: None. M.D. Chan: Honoraria; Elekta. Advisory Board; Novocure.

Ammoren Dohm, BS

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