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Reviewed by: Vasthi Christensen, MD
The Abramson Cancer Center of the University of Pennsylvania
Ultima Vez Modificado: 17 de diciembre del 2004
Authors: Hasegawa T, Kondziolka D, Flickinger JC, Germanwala A, Lunsford LD
Source: Neurosurgery June 2003; 52(6): 1318-26
The incidence of brain metastases as a result of systemic cancer is 20-40%. Many cases are identified in asymptomatic patients by screening neuroimaging. Whole brain radiotherapy (WBRT) extends survival in these patients by 3-5 months, but is associated with morbidity including alopecia, fatigue, long-term cognitive problems, and it may delay delivery of other treatments for extracranial cancer. Stereotactic radiosurgery (SRS) in combination with WBRT has become an important approach to treat patients with a few small brain metastases. However, some have questioned the added value of WBRT after SRS. SRS is a minimally invasive alternative to surgical resection. The authors present a retrospective study of their experience with SRS alone to treat brain metastases.
According to most reports, patient survival after radiosurgery alone was not different from that in patients who had combined SRS and WBRT (because patients died from progression of extracranial disease rather than brain metastases). These results are confirmed in this study. Initial avoidance of WBRT may lead to improved patient quality of life. However, information on quality of life is not available in this study. These results are not a product of a randomized study, and therefore there may be a selection bias for patients who had better prognostic factors and it may not be appropriate to compare their median survival to historical standards. In addition, 30% of patients were lost to follow up. This subgroup may have had less favorable outcomes and the intracranial control rate may not be as good as reported. In addition, most intracranial recurrences were remote recurrences (38% were remote tumor recurrence whereas 17% were local recurrence). These recurrences were not in the radiation field, and they probably would have been decreased with WBRT.
In conclusion, this article demonstrates that SRS may be a reasonable alternative to surgical resection. Patients treated using SRS may have improved quality of life when contrasted with patients treated using WBRT. A reasonable future study would be SRS vs SRS + WBRT with improved quality of life as primary outcome goal. However, at the current time, WBRT remains a part of standard of care treatment in patients with brain metastases.
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