Northeast Florida Medicine, Spring 2016

Vol. 67, No. 1 2016

Northeast Florida Medicine

DCMS online

. org

Palliative Care

with one to four brain metastases randomized to SRS alone

versus SRS plusWBRT and found that for patients ≤50 years

old, there was a survival benefit to SRS alone without an

increased risk of distant brain metastases.

Therefore, SRS

alone may become the new standard for this population.

In addition, attempts have been made to sculpt the ra-

diation dose in whole brain out of critical structures. Since

short term memory deficiencies have been seen following

whole brain therapy,

a national study of whole brain ra-

diotherapy sparing the hippocampus was performed. This

so-called ‘hippocampal sparing’ therapy appears in early

analysis to have resulted in a superior neurologic outcome

compared to historical controls.

Current guidelines recommend discussing treatment

options with patients. Patients with the best prognosis and

fewest lesions may be considered for local therapy with or

withoutWBRT.Those withmany lesions are likely to benefit

most from WBRT alone.

Many patients will eventually

receive a combination of both targeted treatments and

WBRT during their disease course. A recent report from

Columbia University revealed in a data set of 528 patients

with multiple primary sites including lung cancer, breast

cancer, melanoma and renal cell cancer the median survival

times of several different approaches toward palliation of a

single brain metastasis. The median survival times were 9.0

months for SRS, 19.1 months for SRS plus WBRT, 25.5

months for SRS and surgical resection and 25.0 months

for SRS, surgery and WBRT. If a patient had more than

one brain metastasis the median survival times were 8.6,

20.4, 20.7 and 24.5 months, suggesting that there remains

a significant role for each component of radiotherapy for

the optimal outcome of the palliative patients.

Spine

Metastatic disease in the spine can present in multiple

ways. Most commonly, progressive pain from a metastatic

lesion in the vertebral column is the presenting symptom.

However, if the lesion progresses to extend into the spinal

canal or neural foramina, then weakness, sensory loss, or

autonomic dysfunction may occur. A pathologic fracture

of an involved vertebral body may lead to rapid onset of

neurologic symptoms from bone impingement upon the

56.7 percent respectively.

More recently the concept of

oligo-recurrence has been explored. It is defined similarly

to an oligo metastases with the assumption that the cancer’s

primary site continues to be controlled.

Brain

Brain metastases are some of the most common tumors

targeted by radiation oncologists. Given the poor penetration

of most targeted agents and chemotherapies through the

blood brain barrier, the standard of care for management

of intracranial lesions became whole brain radiotherapy

(WBRT). A recursive partitioning analysis (RPA) was devel-

oped with prognostic factors that included age, Karnofsky

Performance Status (KPS), controlled primary tumor and

brain as only site of metastasis, and found that even for the

best subset of patients the median survival was 7.1 months.

More recently a diagnosis-specific graded prognostic assess-

ment was created and revealed some groups of patients may

have a median survival as long as 18.7 months, especially

in the setting of controlled systemic disease.

Whole brain radiotherapy is typically delivered with one

of the aforementioned palliative regimens. However,WBRT

can result in both irritating short-term side effects including

fatigue, alopecia, scalp dermatitis and serous otitis. It may

also cause an increased long-term risk of neurocognitive

decline. Over the years, multiple attempts have been made

to improve the quality of life of patients with brain metas-

tases. Local treatment of patients with a limited number

of lesions has been attempted with both surgery and SRS.

For isolated lesions, there is evidence that a local procedure

performed with WBRT may improve survival compared to

patients receiving WBRT alone.

8,9

This survival benefit has

not been proven in patients with multiple brain metastases.

In an attempt to decrease neurocognitive decline associ-

ated with WBRT, multiple studies have attempted to avoid

WBRT following local therapy for one to five metastases.

Individually, these trials found that addingWBRT to a local

therapy improves the local control, distant brain control and

risk of dying from a neurologic death, but has not shown

any difference in overall survival (although none have been

powered to detect a difference).

10,11

However, a recent me-

ta-analysis evaluated individual patient data for patients