Study of Fractionated Stereotactic Radiosurgery to Treat Large Brain Metastases

Brain metastases are the most common intracranial tumors and occur in approximately 25% of patients with cancer. In the US, approximately 170,000 cancer patients a year are diagnosed with brain metastases.

The prognosis of patients with brain metastases is variable and depends on several factors, including performance status, age, control of the primary tumor, and extent of extracranial disease. Historically, patients with brain metastases who receive supportive care only have median survival of 1 to 2 months. However, a subgroup of patients with favorable prognosis who undergo treatment can enjoy an extended life expectancy with median survival of 10 to 16 months. Treatment options for brain metastases include medical management, surgery, and radiation therapy (radiotherapy). Both surgery and radiotherapy have an important role in management of brain metastases, and an optimized treatment plan may include both. It is well-established that surgery followed by conventional whole brain radiation (WBRT) decreases local recurrence and improves median survival compared to WBRT alone. Conventional WBRT is administered as radiotherapy to the whole cranium delivered in 10 to 20 daily treatments.

For this study, radiotherapy will be delivered using stereotactic radiosurgery (SRS) to treat individual metastases. SRS has the advantage of sparing normal brain tissue. In SRS, high energy radiation is precisely directed at the target lesion. Due to the steep fall-off of the radiation dose away from the target, the advantage of relative sparing of the normal brain may be realized. The present study is based on a rationale of treating brain metastases with surgical resection followed by adjuvant SRS to the resection cavity, while deferring conventional WBRT for salvage therapy.

WBRT is associated with a short-term decline in quality of life and long-term deficits in neurocognitive function ("late effects"). Late toxicity of WBRT, such as memory impairment and dementia, is usually irreversible and is likely due to demyelination, vascular damage, and necrosis. Following WBRT, the actuarial rate of neurocognitive toxicity at 2 years can be up to 49%. Recipients of WBRT may demonstrate a > 2 standard deviation decline in their performance at 6 months. Compared to SRS alone, WBRT was reported to be associated with a marked decline in learning and memory function at 4 months (49% vs 23%, in favor of SRS).

To minimize the potential late effects of WBRT, investigators have explored the use of SRS alone, deferring the use of WBRT for salvage treatment if needed. Both retrospective analyses and a prospective randomized trial reported no apparent survival benefit to combining WBRT with SRS compared to SRS alone

Primary Objectives: Determine the maximum tolerated dose (MTD) of stereotactic radiosurgery (SRS).

Secondary Objectives:

• Determine the local control rate as assessed on MRI and clinical exam.
• Determine short- and long-term adverse effects.
• Determine the distant intra-cranial control rate.
• Determine the overall survival rate.
• Assess the patient's health related quality of life.

Treatment Group assignment will be by SRS dose level. SRS will be administered as 3 fractions. Radiation dose is administered as "Greys" (or "Grays"; abbreviated Gy), a unit by which radiation is measured. Treatment Groups are as follows: Group 1 = 24 Gy (administered as 8 Gy x 3) Group 2 = 7 Gy (9 Gy x 3); Group 3 = 30 Gy (10 Gy x 3); Group 4 = 33 Gy (11 Gy x 3).

Within each Treatment Group, analysis may be stratified by tumor size and suitability for surgical resection, as below. For those participants eligible for surgical resection, the procedure will be conducted in advance of the SRS treatment.

• Strata A will be those with tumors 4.2 to 14.1 cm³, and suitable for resection.
• Strata B will be those with tumors 4.2 to 14.1 cm³, but not suitable for resection.
• Strata C will be those with tumors 14.2 to 33.5 cm³, and suitable for resection.
• Strata D will be those with tumors 14.2 to 33.5 cm³, but not suitable for resection.

Inclusion criteria

• Age 18 years and older
• Pathologically-proven solid tumor malignancy
• 1 to 4 brain metastases, one of which is 4.2 to 33.5 cm³.
• Prior surgery or SRS is allowed as long as the target metastatic lesion in this study has not previously been treated with SRS.
• Prior cytotoxic systemic therapy must be completed ≥ 5 days prior to radiosurgery. No concurrent cytotoxic systemic therapy along with SRS. Cytotoxic systemic therapy to start ≥ 5 days after the completion of SRS.
• Life expectancy of ≥ 12 weeks.
• Ability to understand and the willingness to sign a written informed consent.

Exclusion criteria

• Previously treated with whole brain irradiation
• Target metastatic lesion previously been treated with SRS.
• > 4 total brain metastases at the time of initial evaluation.
• Pregnant
• Unable to give informed consent.