Portal de Periódicos da CAPES

STEREOTACTIC RADIOSURGERY FOR MALIGNANT MELANOMA TO THE BRAIN

1996; Elsevier BV; Volume: 76; Issue: 6 Linguagem: Inglês

10.1016/s0039-6109(05)70522-3

1558-3171

Steven K. Seung, Hui‐Kuo G. Shu, Michael McDermott, Penny K. Sneed, David A. Larson,

Meningioma and schwannoma management

The development of brain metastases from any primary cancer generally portends a very limited life expectancy. Without treatment, the median length of survival of patients with neurologic symptoms is about 1 month.36 Although pharmacologic therapies aimed at reducing cerebral edema often improve symptoms, these interventions have little impact on patient survival.24, 46 The mainstay of treatment for patients with brain metastases has been fractionated radiation therapy since the first reports of its effectiveness.11, 13 In the early 1970s, the Radiation Therapy Oncology Group (RTOG) conducted randomized trials that helped define optimal dose fractionation schemes for whole-brain radiation therapy (WBRT).4, 5, 31 Although WBRT can alleviate neurologic symptoms, its impact on survival remains modest: Median survival is typically 12 to 24 weeks4, 34, 38 and may approach 30 weeks.18 Other forms of therapy for patients with brain metastases include chemotherapy, which has not been shown to improve patient survival,23, 42 and surgery. The latter has been evaluated in clinical trials in highly selected patients with a single brain metastasis. In one randomized trial, Patchell et al38 observed significantly improved median survival (40 weeks versus 15 weeks) and local control (18/25 patients versus 11/23 patients) with resection followed by WBRT as opposed to WBRT alone. In a similar randomized trial, Noordijk et al37 observed a median survival of 10 months in patients treated with resection followed by WBRT versus 6 months in patients treated with WBRT alone. Although patients with multiple brain metastases usually do not have surgery for each separate gross tumor focus in the brain, Bindal et al3 showed that survival in such surgically treated patients was similar to that of patients with a solitary brain metastasis that was surgically resected. Nonetheless, most patients are not good candidates for gross total resection, either because of tumor location in the brain or because of concomitant medical problems. In addition, patients with recurrent brain metastases who have failed previous WBRT may be ineligible for further fractionated radiation therapy. In all these patients, as well as in patients who may have undergone subtotal resection, radiosurgery has often been recommended, both because it is a noninvasive procedure that requires minimal hospitalization and because retrospective reports have shown improved survival and local control compared with historical results of conventional fractionated radiation therapy.1, 14, 15, 19, 20, 21, 30, 32, 33, 36 However, no randomized studies have sorted out the relative efficacy of WBRT, radiosurgery, and surgery or combinations of these therapies. The existing studies specifically involving melanoma brain metastases are listed in Table 1. Although the role of radiosurgery for melanoma brain metastases has not been defined, it may provide local control rates comparable to those of conventional surgery. This is supported by a small retrospective series by Samoza et al,44 in which 23 patients with melanoma metastases to the brain were treated with WBRT and adjuvant Gamma Knife (Elekta Instruments S.A., Geneva, Switzerland) radiosurgery. They observed a median survival of 28 weeks after radiosurgery and a 97% local tumor control rate. In this article we review patients with single or multiple intracranial melanoma metastases treated at the University of California, San Francisco (UCSF), with Gamma Knife radiosurgery.