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Case report
peer-reviewed

Efficacy of Stereotactic Radiosurgery in Patients with Multiple Metastases: Importance of Volume Rather Than Number of Lesions



Abstract

The role of stereotactic radiosurgery (SRS) in the treatment of multiple brain metastases is controversial. While whole brain radiation therapy (WBRT) has historically been the mainstay of treatment, its value is increasingly being questioned as emerging data supports that SRS alone can provide comparable therapeutic outcomes for limited (one to three) intracranial metastases with fewer adverse effects, including neurocognitive decline. Multiple recent studies have also demonstrated that patients with multiple (> 3) intracranial metastases with a low overall tumor volume have a favorable therapeutic response to SRS, with no significant difference compared to patients with limited metastases. Herein, we present a patient with previously controlled breast cancer who presented with multiple recurrences of intracranial metastases but low total intracranial tumor volume each time. This patient underwent SRS alone for a total of 40 metastatic lesions over three separate procedures with good local control and without any significant cognitive toxicity. The patient eventually opted for enrollment in the NRG-CC001 clinical trial after multiple cranial recurrences. She received conventional WBRT with six months of memantine and developed significant neurocognitive side effects. This case highlights the growing body of literature supporting the role of SRS alone in the management of multiple brain metastases and the importance of maximizing neurocognition as advances in systemic therapies prolong survival in Stage IV cancer.



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Case report
peer-reviewed

Efficacy of Stereotactic Radiosurgery in Patients with Multiple Metastases: Importance of Volume Rather Than Number of Lesions


Author Information

Basem A. Dahshan Corresponding Author

Department of Radiation Oncology, Marshall University, Joan C. Edwards School of Medicine

Department of Radiation Oncology, West Virginia University School of Medicine

Malcolm D. Mattes

Department of Radiation Oncology, West Virginia University School of Medicine

Sanjay Bhatia

Department of Neurosurgery, West Virginia University School of Medicine

Mary Susan Palek

Department of Radiation Oncology, West Virginia University School of Medicine

Christopher P. Cifarelli

Department of Neurosurgery, West Virginia University School of Medicine

Joshua D. Hack

Department of Radiation Oncology, West Virginia University School of Medicine

John A. Vargo

Department of Radiation Oncology, West Virginia University School of Medicine


Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: Vargo, John A. declare(s) personal fees from Brainlab. Dr. Vargo has previously received speaking honoraria from Brainlab. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.


Case report
peer-reviewed

Efficacy of Stereotactic Radiosurgery in Patients with Multiple Metastases: Importance of Volume Rather Than Number of Lesions


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Case report
peer-reviewed

Efficacy of Stereotactic Radiosurgery in Patients with Multiple Metastases: Importance of Volume Rather Than Number of Lesions

  • Author Information
    Basem A. Dahshan Corresponding Author

    Department of Radiation Oncology, Marshall University, Joan C. Edwards School of Medicine

    Department of Radiation Oncology, West Virginia University School of Medicine

    Malcolm D. Mattes

    Department of Radiation Oncology, West Virginia University School of Medicine

    Sanjay Bhatia

    Department of Neurosurgery, West Virginia University School of Medicine

    Mary Susan Palek

    Department of Radiation Oncology, West Virginia University School of Medicine

    Christopher P. Cifarelli

    Department of Neurosurgery, West Virginia University School of Medicine

    Joshua D. Hack

    Department of Radiation Oncology, West Virginia University School of Medicine

    John A. Vargo

    Department of Radiation Oncology, West Virginia University School of Medicine


    Ethics Statement and Conflict of Interest Disclosures

    Human subjects: Consent was obtained by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: Vargo, John A. declare(s) personal fees from Brainlab. Dr. Vargo has previously received speaking honoraria from Brainlab. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

    Acknowledgements


    Article Information

    Published: December 19, 2017

    DOI

    10.7759/cureus.1966

    Cite this article as:

    Dahshan B A, Mattes M D, Bhatia S, et al. (December 19, 2017) Efficacy of Stereotactic Radiosurgery in Patients with Multiple Metastases: Importance of Volume Rather Than Number of Lesions. Cureus 9(12): e1966. doi:10.7759/cureus.1966

    Publication history

    Received by Cureus: September 22, 2017
    Peer review began: October 12, 2017
    Peer review concluded: December 10, 2017
    Published: December 19, 2017

    Copyright

    © Copyright 2017
    Dahshan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    License

    This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

The role of stereotactic radiosurgery (SRS) in the treatment of multiple brain metastases is controversial. While whole brain radiation therapy (WBRT) has historically been the mainstay of treatment, its value is increasingly being questioned as emerging data supports that SRS alone can provide comparable therapeutic outcomes for limited (one to three) intracranial metastases with fewer adverse effects, including neurocognitive decline. Multiple recent studies have also demonstrated that patients with multiple (> 3) intracranial metastases with a low overall tumor volume have a favorable therapeutic response to SRS, with no significant difference compared to patients with limited metastases. Herein, we present a patient with previously controlled breast cancer who presented with multiple recurrences of intracranial metastases but low total intracranial tumor volume each time. This patient underwent SRS alone for a total of 40 metastatic lesions over three separate procedures with good local control and without any significant cognitive toxicity. The patient eventually opted for enrollment in the NRG-CC001 clinical trial after multiple cranial recurrences. She received conventional WBRT with six months of memantine and developed significant neurocognitive side effects. This case highlights the growing body of literature supporting the role of SRS alone in the management of multiple brain metastases and the importance of maximizing neurocognition as advances in systemic therapies prolong survival in Stage IV cancer.



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Create a free account to continue reading this article.

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Basem A. Dahshan, Medical Student

Department of Radiation Oncology, Marshall University, Joan C. Edwards School of Medicine

For correspondence:
bdahshan94@gmail.com

Malcolm D. Mattes

Department of Radiation Oncology, West Virginia University School of Medicine

Sanjay Bhatia

Department of Neurosurgery, West Virginia University School of Medicine

Mary Susan Palek, R.N.

Department of Radiation Oncology, West Virginia University School of Medicine

Christopher P. Cifarelli

Department of Neurosurgery, West Virginia University School of Medicine

Joshua D. Hack

Department of Radiation Oncology, West Virginia University School of Medicine

John A. Vargo

Department of Radiation Oncology, West Virginia University School of Medicine

Basem A. Dahshan, Medical Student

Department of Radiation Oncology, Marshall University, Joan C. Edwards School of Medicine

For correspondence:
bdahshan94@gmail.com

Malcolm D. Mattes

Department of Radiation Oncology, West Virginia University School of Medicine

Sanjay Bhatia

Department of Neurosurgery, West Virginia University School of Medicine

Mary Susan Palek, R.N.

Department of Radiation Oncology, West Virginia University School of Medicine

Christopher P. Cifarelli

Department of Neurosurgery, West Virginia University School of Medicine

Joshua D. Hack

Department of Radiation Oncology, West Virginia University School of Medicine

John A. Vargo

Department of Radiation Oncology, West Virginia University School of Medicine