International Journal of Radiation Oncology*Biology*Physics
Clinical investigationBrainFive-year survivors of brain metastases: A single-institution report of 32 patients
Introduction
Brain metastasis is the most common neurologic complication of cancer and occurs in 30% of cancer patients (1). The incidence has been increasing as patients are surviving longer from their primary disease. Unfortunately, the diagnosis of brain metastasis still carries a poor prognosis with a median survival of 4 months. Even patients with a single brain metastasis treated aggressively with surgical resection and whole-brain radiation therapy (WBRT) have a median survival of 40 weeks (2). The Radiation Therapy Oncology Group (RTOG) applied a recursive partitioning analysis (RPA) to the data from three randomized trials of brain metastases to group prognostic factors associated with survival (3). RPA Class 1 patients (Karnofsky Performance Status [KPS] of 70 or greater, controlled primary disease, age younger than 65 years old, and no extracranial metastases) have a median survival of 7.1 months, but RPA Class 3 patients (KPS <70) have a median survival of 2.3 months. All other patients are RPA Class 2 (KPS of ≥70, but uncontrolled primary disease, age 65 years or more, or extracranial metastases) and have a median survival of 4.2 months.
Despite advances in surgery, radiation therapy and chemotherapy, long-term survival is very rare. Two percent of patients with brain metastasis live 5 years or more (4, 5). Ten-year survivors are even more rare, with 33 patients described in the literature (5, 6). We reviewed our experience with such long-term patients by querying from a large institutional database of more than 1300 patients for those who had a minimum potential follow-up of 5 years. The goal of this study is to identify factors that contribute to long-term survival.
Section snippets
Methods and materials
The records of 1,316 patients diagnosed with brain metastases between 1973 and 1999 were reviewed and entered into an Institutional Review Board–approved database. The year 1999 was selected as a cutoff point to allow for a minimum potential follow-up of 5 years. Of these, 1275 (97%) patients were known to have expired. Thirteen (1%) were still alive. Twenty-eight (2%) were lost to follow-up; therefore, they were excluded from the analysis. This left 1,288 patients with adequate follow-up to
Results
The characteristics of all brain metastases patients used in this study (n = 1,288) are in Table 1. The characteristics of the 5 years or more survivors are also shown for comparison. The median survival for all brain metastases patients was 6.0 months. Figure 1 shows the Kaplan-Meier survival curve for all brain metastases patients. Various characteristics were compared using the Kaplan-Meier method to determine if any factors influenced survival (Table 2). Age younger than 65 years, control
Discussion
Survival from brain metastasis is poor. The median survival in our group of patients was 6.0 months. Factors that predicted for survival in this study, which confirm the results of other studies, include age younger than 65 years, control of the primary, and lack of systemic disease (3). Other factors that were prognostic for survival include single brain metastasis at diagnosis and longer interval from diagnosis of their primary to diagnosis of their brain metastasis. Patients with single
Conclusion
Long-term survival is rare, but possible from brain metastases. For patients with good prognostic factors such as young age, good RPA characteristics, and single lesions, aggressive treatment that includes upfront surgery and/or SRS may offer the best chance of long-term survival. Female gender also appears to influence long-term survivorship, but the cause of this remains unclear. Further research, particularly in regards to the biology of these tumors, may identify other characteristics that
References (19)
- et al.
Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy Oncology Group (RTOG) brain metastases trials
Int J Radiat Oncol Biol Phys
(1997) - et al.
Prognostic factors in patients who survived more than 10 years after undergoing surgery for metastatic brain tumors: Report of 5 cases and review of the literature
Surg Neurol
(2002) - et al.
Single dose radiosurgical treatment of recurrent previously irradiated primary brain tumors and brain metastases: Final report of RTOG Protocol 90-05
Int J Radiat Oncol Biol Phys
(2000) - et al.
Salvage stereotactic radiosurgery effectively treats recurrences from whole brain radiation therapy [Abstract]
Int J Radiat Oncol Phys
(2005) - et al.
Adjuvant radiation therapy after surgical resection of solitary brain metastasis: Association with pattern of failure and survival
Int J Radiat Oncol Biol Phys
(1987) - et al.
Surgical approach to lung cancer with solitary cerebral metastasis: Twenty-five years’ experience
Ann Thorac Surg
(1986) - et al.
Management of nonsmall cell lung carcinoma with solitary brain metastasis
J Thorac Cardiovasc Surg
(1989) - et al.
Surgical resection of brain metastases from renal cell carcinoma in 50 patients
Urology
(1996) Management of brain metastasis
Rev Neurol
(1992)
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