Radiosurgery for patients with brain metastases: a multi-institutional analysis, stratified by the RTOG recursive partitioning analysis method.

PURPOSE: To estimate the potential improvement in survival for patients with brain metastases, stratified by the Radiation Therapy Oncology Group (RTOG) recursive partitioning analysis (RPA) class and treated with radiosurgery (RS) plus whole brain radiotherapy (WBRT). METHODS AND MATERIALS: An analysis of the RS databases of 10 institutions identified patients with brain metastates treated with RS and WBRT. Patients were stratified into 1 of 3 RPA classes. Survival was evaluated using Kaplan-Meier estimates and proportional hazard regression analysis. A comparison of survival by class was carried out with the RTOG results in similar patients receiving WBRT alone. RESULTS: Five hundred two patients were eligible (261 men and 241 women, median age 59 years, range 26-83). The overall median survival was 10.7 months. A higher Karnofsky performance status (p = 0.0001), a controlled primary (median survival = 11.6 vs. 8.8 months, p = 0.0023), absence of extracranial metastases (median survival 13.4 vs. 9.1 months, p = 0.0001), and lower RPA class (median survival 16.1 months for class I vs. 10.3 months for class II vs. 8.7 months for class III, p = 0.000007) predicted for improved survival. Gender, age, primary site, radiosurgery technique, and institution were not prognostic. The addition of RS boosted results in median survival (16.1, 10.3, and 8.7 months for classes I, II, and III, respectively) compared with the median survival (7.1, 4.2, and 2.3 months, p <0.05) observed in the RTOG RPA analysis for patients treated with WBRT alone. CONCLUSION: In the absence of randomized data, these results suggest that RS may improve survival in patients with BM. The improvement in survival does not appear to be restricted by class for well-selected patients.

Salvage treatment for neck recurrence after irradiation alone for head and neck squamous cell carcinoma with clinically positive neck nodes.

BACKGROUND: To analyze the likelihood of salvage for patients with recurrence in the neck after radiotherapy. METHOD: Recurrent disease developed in the neck of 51 patients after primary irradiation for head and neck carcinoma. Salvage was defined as no recurrence of cancer anywhere for at least 1 year after initial salvage treatment and continuously thereafter. RESULTS: Thirty-three patients (65%) did not undergo a salvage attempt: 18 had unresectable disease; 9 were medically unfit, 4 had distant metastasis; and 2 refused treatment. Eighteen patients (35%) underwent salvage treatment with chemotherapy alone (4 patients), chemotherapy and neck dissection (1 patient), neck dissection alone (11 patients), or surgery with radiotherapy (2 patients). After the initial salvage treatment, recurrent local-regional and/or distant disease developed in all patients. Recurrence was in the neck alone in 10 patients (55%); neck and distant sites in 3 patients (17%); neck, primary site, and distant sites in 2 patients (11%); and with distant metastasis alone in 3 patients (17%). Control of neck disease at 5 years was 9% for the 18 patients who underwent a salvage attempt, as well as for all 51 patients. For the overall group, absolute and cause-specific survival rates were both 10% at 5 years. CONCLUSIONS: The likelihood of successful salvage treatment after a neck recurrence following radiotherapy is remote.

Linear accelerator radiosurgery for nonacoustic schwannomas.

PURPOSE: To analyze the results of nonacoustic schwannomas treated with linear accelerator stereotactic radiosurgery. METHODS AND MATERIALS: Between August 1989 and October 1997, 18 patients with nonacoustic schwannomas underwent stereotactic radiosurgery at the University of Florida. Nine patients had schwannomas located in the jugular foramen region, seven in the trigeminal nerve, and two in the facial nerve. Nine patients had initial subtotal resections and nine did not undergo surgical intervention. One of the 9 patients with subtotal resection was treated with radiosurgery for a recurrent tumor. Tumor volumes ranged from 0.7 to 15.4 cm3 with a mean volume of 5.5 cm3. Minimal tumor doses ranged from 10.0 to 15.0 Gy with a mean dose of 13.1 Gy. Treatment dose was specified to the 80% isodose shell in 11 patients (58%) and to the 70% isodose shell in the remaining patients. Ten patients (56%) were treated with a single isocenter, 6 patients (33%) with 2-4 isocenters, and 2 patients (11%) with greater than 5 isocenters. Follow-up ranged from 5 to75 months and the mean follow-up was 32 months. Ten patients (56%) had follow-up beyond 2 years and none were lost to follow-up. Local control was defined as clinically stable neurological status and/or stable or decreased tumor size on yearly follow-up MR imaging. RESULTS: Eighteen evaluable patients (100%) had local control after treatment. All were alive and progression-free at last follow-up. Six of 10 patients with follow-up MRI 2 years or more after treatment had tumor regression and 4 patients had stable disease. Three additional patients with an MRI at 1 year showed no tumor change. Four complications in 3 patients included one worsening of a preexisting VII nerve palsy, 2 patients with new onset of hearing loss, and one with ataxia. No surgical intervention or prolonged steroid use was necessary for any patient with complications. Five patients had improvement in preexisting neurologic deficits. CONCLUSIONS: Excellent preliminary tumor control rates and a favorable toxicity profile support the effectiveness of linear accelerator stereotactic radiosurgery for patients with nonacoustic schwannomas.