For patients with brain metastases, long-term survival is possible, but the majority of long-term survivors will still experience intracranial progression and require salvage therapies after initial treatment. While salvage therapies may control disease, the development of new metastasis seems to adversely affect survival. RN risk increases over time and may affect a significant portion of long-term survivors.
Jared R. Robbins, MD, Raphael L. Yechieli, MD, Parag Sevak, MD, M. Salim Siddiqui, MD, PhD; Medical College of Wisconsin; University of Miami; Henry Ford Hospital
PURPOSE/OBJECTIVES: Brain metastases typically portend a poor outcome, but long-term survival is possible. The purpose of this study is to evaluate intracranial progression after initial therapy, the need for salvage treatments, and rates of late toxicity in long-term brain metastases survivors.
MATERIALS AND METHODS: In this institutional review board (IRB)-approved study, we identified 44 patients with brain metastases surviving > 3 years treated at a single institution from 1987 to 2009. All outcomes were calculated starting at the time of initial brain metastases. Univariate and multivariate logistic regression modeling, as well as Kaplan-Meier and log-rank test methods, was used to characterize outcomes.
RESULTS: Median age was 56 years (range: 28–83 yr). Primary sites were lung 52%, breast 23%, melanoma 11.4%, and other 13.6%. Initial treatments were 71% surgery followed by radiosurgery to the cavity (Sx+SRS), 16% whole-brain radiation therapy (WBRT), 9% radiosurgery alone (SRS), and 5% surgery followed by WBRT (Sx+WBRT). The 5-year, 10-year, and 15-year overall survival (OS) was 60%, 34%, and 19%, respectively (range: 3–26.5 yr). Seven failures at the site of initial brain metastasis were observed, with 1-year, 3-year, and 5-year local control of 98%, 93%, and 84%, respectively. Salvage for local failures included Sx (43%), Sx+SRS (29%), SRS (14%), and hospice (14%). New brain metastases developed in 52%, with 1-year, 3-year, and 5-year freedom from new brain metastases rates of 79%, 63%, and 44%, respectively. Initial salvage treatments for new metastases were SRS (45%), WBRT (14%), surgery (14%), Sx+SRS (18%), Sx+WBRT (5%), and hospice (5%). After initial treatment, additional salvage therapies included 20% of patients receiving surgery, 40% receiving SRS, and 25% receiving WBRT. Radiation necrosis (RN) occurred in 27% of patients, with 1-year, 3-year, and 5-year rates of 5%, 19%, and 32%, respectively. The median time to RN was 24 months (range: 7–54 mo), and the median survival after RN was 39 months (range: 2–280 mo). Overall, 41% of patients experienced no intracranial progression, but 22% of them did develop RN. On multivariate analysis, higher initial Karnofsky performance status (KPS) (P = .008; hazard ratio [HR] = 0.943) and freedom from new brain metastases after initial treatment (P ≤.001; HR = 0.183) were associated with improved survival.
CONCLUSIONS: For patients with brain metastases, long-term survival is possible, but the majority of long-term survivors will still experience intracranial progression and require salvage therapies after initial treatment. While salvage therapies may control disease, the development of new metastasis seems to adversely affect survival. RN risk increases over time and may affect a significant portion of long-term survivors.
Proceedings of the 97th Annual Meeting of the American Radium Society - americanradiumsociety.org