International Journal of Radiation Oncology*Biology*Physics
Clinical investigation: central nervous systemMetastatic melanoma to the brain: prognostic factors after gamma knife radiosurgery
Introduction
For the past few decades, there has been a steady increase in the incidence and mortality of patients with melanoma 1, 2. Melanoma is of major importance for the development of brain metastases, because it represents the third most common cause of this disease after primary tumors of the lung and breast 3, 4, 5. Melanoma metastasis to the brain is a serious problem, because affected patients experience a sharp decrease in quality of life and poor survival 2, 3, 6, 7, 8. Rapid deterioration and death resulting from progressive central nervous system disease is a norm in untreated patients. In one report, median survival for patients with untreated intracranial melanoma was <1 month (8). Various treatment modalities have been used individually and in combination in the management of patients with melanoma metastatic to the brain. These treatment modalities include the following: surgical resection with and without whole-brain irradiation (WBI) 9, 10, 11, 12, 13, 14, 15, 16, WBI 17, 18, 19, 20, chemotherapy (2), immunotherapy (21), and stereotactic radiosurgery 22, 23, 24, 25, 26. Despite earlier detection of frequently asymptomatic metastatic disease with the use of contemporary imaging modalities, the prognosis in patients with intracranial metastatic melanoma remains poor. The reported median survival ranges from 2 to 8 months 2, 4, 5, 6, 8, 27.
In this report, we have assessed the influence of multiple prognostic factors on survival and freedom from progression (FFP) in a series of consecutive patients treated with stereotactic radiosurgery in a single medical center during a 5-year period.
Section snippets
Patients
Between August 1994 and October 1999, a total of 122 consecutive patients with metastatic intracranial melanomaunderwent gamma knife stereotactic radiosurgery (GK) at the University of Southern California Keck School of Medicine. There were 167 radiosurgery sessions used to treat 332 brain metastases. Most (70%) patients were males, with a median age of 55 years. A total of 61 (50%) patients presented with a solitary lesion, whereas 26 (21%) had two lesions at diagnosis (Table 1). Median tumor
Results
Overall median survival was 7 months, and the 1-year survival was 26% (Fig. 1). The median survival from the onset of brain metastasis was 9.1 months and from the original diagnosis of melanoma was 46.7 months. At the end of this study, 107 (88%) patients were known to have died, 10 (8%) were alive, and 5 (4%) were lost to follow-up. The cause of death could be determined in 86 of the patients known to have died during the data capture period. Death from systemic disease occurred in 49 (46%)
Discussion
Fractionated radiotherapy has been widely accepted as a treatment of choice for patients with brain metastases since the reports of its effectiveness in the early 1950s (18). The reported median survival after WBI for patients with tumors such as melanoma metastatic to the brain was only 10–14 weeks (30). Several retrospective studies evaluating treatment efficacy in patients with this disease showed an improvement in median survival from 3.3 to 8.4 months after surgical resection followed by
Conclusion
Stereotactic radiosurgery is a safe, minimally invasive, and effective treatment modality for patients with intracranial metastatic melanoma. Total intracranial tumor volume was the most important predictor of survival, local tumor control, and freedom from subsequent brain metastasis. A routine screening for brain metastasis in asymptomatic, high-risk patients with melanoma may be of relevance. Application of early therapy for lower-volume lesions should be expected to result in improved
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