for those considerng STS vs whole brain RT 4 1/a few brain mets, a new consideration!

[Lani]

increased risk of leptomeningeal disease---article is not restricted to bcm let alone her2+ bc, which has theadded optio of intrathecal her2 therapy



International Journal of Radiation Oncology, Biology, Physics
International Journal of Radiation Oncology, Biology, Physics
Volume 94, Issue 3

Copyright © 2016 Elsevier Inc.

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Surgical Resection of Brain Metastases and the Risk of Leptomeningeal Recurrence in Patients Treated With Stereotactic Radiosurgery RSS Download PDF Get rights and content

Matthew D. Johnson MD, Vladimir Avkshtol MD, Andrew M. Baschnagel MD, Kurt Meyer MD, PhD, Hong Ye MS, Inga S. Grills MD, Peter Y. Chen MD, Ann Maitz MS, Rick E. Olson MD, Daniel R. Pieper MD and Daniel J. Krauss MD
International Journal of Radiation Oncology, Biology, Physics, 2016-03-01, Volume 94, Issue 3, Pages 537-543, Copyright © 2016 Elsevier Inc.
Purpose

Recent prospective data have shown that patients with solitary or oligometastatic disease to the brain may be treated with upfront stereotactic radiosurgery (SRS) with deferral of whole-brain radiation therapy (WBRT). This has been extrapolated to the treatment of patients with resected lesions. The aim of this study was to assess the risk of leptomeningeal disease (LMD) in patients treated with SRS to the postsurgical resection cavity for brain metastases compared with patients treated with SRS to intact metastases.

Methods and Materials

Four hundred sixty-five patients treated with SRS without upfront WBRT at a single institution were identified; 330 of these with at least 3 months' follow-up were included in this analysis. One hundred twelve patients had undergone surgical resection of at least 1 lesion before SRS compared with 218 treated for intact metastases. Time to LMD and overall survival (OS) time were estimated from date of radiosurgery, and LMD was analyzed by the use of cumulative incidence method with death as a competing risk. Univariate and multivariate analyses were performed with competing risk regression to determine whether various clinical factors predicted for LMD.

Results

With a median follow-up time of 9.0 months, 39 patients (12%) experienced LMD at a median of 6.0 months after SRS. At 1 year, the cumulative incidence of LMD, with death as a competing risk, was 5.2% for the patients without surgical resection versus 16.9% for those treated with surgery (Gray test, P <.01). On multivariate analysis, prior surgical resection ( P <.01) and breast cancer primary ( P =.03) were significant predictors of LMD development. The median OS times for patients undergoing surgery compared with SRS alone were 12.9 and 10.6 months, respectively (log-rank P =.06).

Conclusions

In patients undergoing SRS with deferral of upfront WBRT for intracranial metastatic disease, prior surgical resection and breast cancer primary are associated with an increased risk for the development of LMD.


The use of stereotactic radiosurgery for resected and intact brain metastases with deferral of whole-brain radiation therapy continues to increase. Surgical resection entails disruption of anatomic boundaries, which may result in contamination of meningeal surfaces with malignant cells. Our retrospective review of 330 patients treated with radiosurgery for intact or resected metastases revealed significantly higher rates of leptomeningeal disease in patients with resected lesions compared with intact metastases. This finding should be investigated further in prospective studies.

Summary
Introduction

Patients with diagnoses of brain metastases are surviving longer because of improvements in systemic therapies (1) . This increases the importance of central nervous system (CNS) disease control. For patients with limited brain metastases, prospective data have shown that upfront stereotactic radiosurgery (SRS) allows for deferral of whole-brain radiation therapy (WBRT) without survival decrement (2) . Since WBRT has been associated with decline in neurocognitive function (3) and quality of life (4) , this approach of deferring WBRT has become an attractive option despite increased rates of distant brain failure (2) . The approach of upfront SRS has been extrapolated to use in patients undergoing surgical resection for solitary or oligometastatic disease 5 6 7 .

Whereas increased distant brain failure (DBF) is a known risk in omitting WBRT, the risk of leptomeningeal disease (LMD) is less frequently reported (2 5) . LMD is a devastating and often rapidly fatal condition characterized by metastatic involvement of the leptomeninges and cerebrospinal fluid (CSF). Despite multiple treatment options for LMD including intrathecal chemotherapy, systemic chemotherapy, and radiation, the median survival after a diagnosis of LMD is typically 2 to 4 months in patients receiving treatment (8 9) .

Surgical resection of brain metastases entails disruption of anatomic boundaries that could, theoretically, result in contamination of CSF with malignant cells and potentiate the development of LMD. WBRT could potentially mitigate this risk in the postoperative setting. However, SRS does not; as such, it could potentially result in increased rates of LMD. The goal of this analysis was to determine whether or not the risk of LMD development was increased in patients undergoing SRS after surgery compared with those undergoing SRS to intact lesions.

[agness]

That is what happened to me but, in the case of surgical resection in the posterior fossa area of the skull (low-back of skull, where the cerebellum resides) is actually higher due to restricted flow dynamics from what I have been able to glean.

I would argue that while brain radiation is not necessary but either pre-operative treatment of the tumor area to damage the cancer before surgery (something that is in studies now), adjuvant treatment with IT Herceptin (ommaya ports aren't fun but unlike WBR it is reversible and targeted, adjuvant therapy to prevent LM already happens for melanoma, leukemia and lymphoma in the CNS), and partial brain irradiation instead of WBR are more appropriate than nuking someone's brain with WBR. Why would you irradiate someone with a large tumor's entire brain when it is local disease spread that is an issue? Also, note that they are unable to diagnose LM until months into the progression which further limits the options while promoting disease spread.

The really sad and frustrating part is that this is going to keep on happening because it takes years for doctors to change their practices. They won't learn from anything I have tried for better or worse because only patients are able to read about my profession details, clinically I don't exist.

The standard for monitoring of central nervous system disease need to change to reflect the realities for patients at high risk -- HER2 and TNBC with nodal involvement as the first site of mets for the first two years and I'm sure other criteria could be set for those with systemic disease as well. We shouldn't be forced into a place where craniotomies to remove large tumors is the standard.