Stereotactic radiosurgery for patients with brain metastases

We read with interest the Article by Masaaki Yamamoto and colleagues 1 Yamamoto M Serizawa T Shuto T et al. Stereotactic radiosurgery for patients with multiple brain metastases (JLGK0901): a multi-institutional prospective observational study. Lancet Oncol. 2014; 15: 387-395 Summary Full Text Full Text PDF PubMed Scopus (819) Google Scholar about the use of stereotactic radiosurgery in patients with one to ten brain metastases. Their prospective, observational study was well designed and they enrolled many patients (n=1194); nevertheless, their findings raise several relevant questions about stereotactic radiosurgery and whole-brain radiotherapy. We have several concerns about the study. First, overall survival is not an appropriate primary endpoint to assess the effectiveness of a local therapy such as brain stereotactic radiosurgery. To the best of our knowledge, no randomised trials have shown an increase in overall survival after stereotactic radiosurgery. 2 Aoyama H Shirato H Tago M et al. Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial. JAMA. 2006; 295: 2483-2491 Crossref PubMed Scopus (1661) Google Scholar In fact in Yamamoto and colleagues' study, 92% of patients died from extracerebral disease, but only 71 (8%) had a neurological death. Overall survival can be affected by several factors—eg, histological changes, extracranial disease, chemotherapy after stereotactic radiosurgery, and biological therapy—and therefore should not be used as the only, or primary, endpoint. Stereotactic radiosurgery for patients with multiple brain metastases (JLGK0901): a multi-institutional prospective observational studyOur results suggest that stereotactic radiosurgery without WBRT in patients with five to ten brain metastases is non-inferior to that in patients with two to four brain metastases. Considering the minimal invasiveness of stereotactic radiosurgery and the fewer side-effects than with WBRT, stereotactic radiosurgery might be a suitable alternative for patients with up to ten brain metastases. Full-Text PDF Stereotactic radiosurgery for patients with brain metastases – Authors' replyWe thank Filippo Alongi and colleagues for their interest in our work.1 We are aware that there has been a debate for more than 20 years as to whether it is meaningful to calculate survival after stereotactic radiosurgery in a cohort, because about 90% of patients died in our study due to extracerebral disease progression after stereotactic radiosurgery for brain metastases. However, overall survival is still the most certain endpoint, as reported by Korn and colleagues,2 and the majority of previous studies have used overall survival to assess results after stereotactic radiosurgery. Full-Text PDF