Radiosurgery for the treatment of brain metastases

Surgical resection and whole brain radiotherapy (WBRT) have been the mainstays of the treatment of cerebral metastases. This approach results in a median survival of about 10 months. Several recent publications and our own experience suggest that a similar median survival can be achieved with stereotactic radiosurgery using either the Leksell Gamma Knife or the linear accelerator radiosurgical techniques. In addition, radiosurgery can effectively treat metastatic tumors in surgically inaccessible sites, e.g., the brainstem. Radiosurgery can also effectively treat multiple intracranial metastases in widely separated areas of the brain. In fact, we have shown that patients with multiple metastases have similar lengths and qualities of survival as do patients with single metastases treated with stereotactic radiosurgery. The most important predictor of success in radiosurgical treatment of cerebral metastases is the neurological status of the patient, usually expressed as the Karnofsky Performance Status (KPS). The histological type of primary cancer is not an outcome predictor. Even so-called "radioresistant" tumors (e.g., melanoma, renal cell) respond favorable to radiosurgery. A great benefit of radiosurgery is the virtual lack of perioperative complications and the minimal interference with quality of life compared either to surgery or to fractionated whole brain radiotherapy. Long-term complications of radiosurgery are infrequent and primarily relate to failure of local tumor control (10%) and radiation-induced edema or necrosis. The later usually can be controlled with corticosteroids, but occasionally, craniotomy may be required to treat life-threatening mass effects. We believe that radiosurgery is the treatment of choice for most cerebral metastases. Only large lesions (> 3.5-4 cm diameter) and those which require immediate decompression to treat life-threatening mass effects require surgical treatment. Radiosurgery also may be used to treat residual disease after surgical resection. We have shown that WBRT does not increase the efficacy of radiosurgery in the treatment of cerebral metastases, and, therefore, we prefer to avoid both the short- and long-term morbidity of that treatment, if possible.