M.D. Johnson

Utility of graded prognostic assessment in evaluation of patients with brainstem metastases treated with radiosurgery

OBJECTIVES Prospective data regarding the safety and efficacy of stereotactic radiosurgery (SRS) for patients with metastatic disease involving the brainstem are lacking. The aim of this study was to assess the efficacy and toxicity of SRS for patients with brainstem metastases treated at our institution. PATIENTS AND METHODS From September 2007 to October 2015, patients treated with SRS for brain metastases were prospectively entered into an institutional database. Forty eight patients with 51 lesions involving the brainstem with clinical follow-up were identified. Local control (LC), elsewhere brain failure (EBF) and overall survival (OS) were assessed from the date of radiosurgery using the Kaplan-Meier method. Univariate and multivariate analyses of factors related to OS were performed using a Cox proportional hazards model. RESULTS Median clinical follow-up was 4.8 months. Median patient age was 62 (range: 28-87); non-small cell lung and breast cancer were the most common primaries at 54% and 21% respectively. Median brainstem lesion volume was 0.12cm(3) (range: 0.01-3.67cm(3)). Whole brain radiotherapy was previously utilized in 19 patients (40%). The median OS was 7.6 months and the 12 month LC rate was 89%. Only 2 patients (4%) experienced grade 3 motor toxicity secondary to SRS. 11 of the 16 patients (69%) initially presenting with symptoms related to brainstem metastases had symptom improvement or resolution following SRS. On multivariate analysis, graded prognostic assessment (GPA) score>2 was predictive of improved survival (p<0.01) while prior chemotherapy use predicted decreased survival (p=0.049). CONCLUSIONS SRS is associated with high LC rates and low toxicity for brainstem metastases. Improved OS was seen for patients with GPA score>2. GPA appears to be a useful tool for assessing prognosis in patients with brainstem metastases. Small volume lesions were safely treated with or without prior whole brain radiotherapy.

Matched-Pair Analysis of High Dose Versus Standard Dose Definitive Chemoradiation for Locally Advanced Non–Small-Cell Lung Cancer

Background Recent data have called into question the use of dose‐escalated radiotherapy for locally advanced non–small‐cell lung cancer and the effect of cardiac radiotherapy doses. We compared the outcomes after chemoradiation using standard‐dose (SD; ≤ 64 Gy) or high‐dose (HD; > 64 Gy) radiotherapy. Patients and Methods A matched‐pair analysis was performed of 178 patients with stage IIB‐IIIB non–small‐cell lung cancer for SD versus HD groups using age ± 5 years, gender, stage, tumor size ± 2 cm, yielding 86 patients. The clinical endpoints were estimated using the Kaplan‐Meier method. Univariate and multivariate analyses were performed using the Cox regression method. Results The median follow‐up was 16.8 months for the entire cohort (HD, 21.6 months; SD, 12.1 months; P = .06). No significant differences were found in disease stage, histologic type, age, performance status, gender, or tumor size between the 2 groups. The median overall survival was 23.1 months for the HD group (95% confidence interval, 20.6‐25.5) versus 13.6 months for the SD group (95% confidence interval, 9.6‐17.5; P = .03). The 2‐year freedom from locoregional recurrence was 48.7% for the SD and 65.3% for the HD groups (P = .07). The 2‐year freedom from distant metastasis was 46.7% for the SD and 70.3% for the HD groups (P = .05). A higher cardiac V30 dose (P = .03) was the strongest predictor of survival besides clinical stage (P = .02). Conclusion Dose‐escalated radiotherapy resulted in improved survival and recurrence rates. A higher cardiac dose was a significant predictor of decreased survival. Micro‐Abstract Recent data have shown a survival detriment with dose‐escalated radiation for locally advanced non–small‐cell lung cancer with concurrent chemotherapy. Using data from a single institution, a matched‐pair analysis comparing patients treated with standard versus dose escalation was performed, yielding 86 patients. Higher dose radiotherapy was associated with improved outcomes, but a lower cardiac dose was a significant predictor of survival.