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Posterior fossa metastases: risk of
leptomeningeal disease when treated with stereotactic radiosurgery compared to
surgery
Vitaly E. Siomin, Michael
A. Vogelbaum, Andrew A. Kanner, Shih-Yuan Lee, John
H. Suh and Gene H. Barnett
Department of Neurosurgery
(V.E.S., M.A.V., A.A.K., S.-Y.L., G.H.B.), Department of Radiation Oncology
(J.H.S.), Brain Tumor Institute, Cleveland Clinic Foundation, Cleveland, Ohio,
USA
Introduction. Leptomeningeal disease (LMD) represents a diffuse form
of central nervous system metastatic disease that is often associated with poor
quality of life and prognosis.
Our objective was to compare the incidence of LMD in patients with posterior
fossa metastases (PFM) following stereotactic radiosurgery (SRS) versus surgical
resection.
Methods. The medical records of 93 patients aged 57.9 +/- 10.8 years
(mean +/- SD) with PFM treated at the Cleveland Clinic from 1995 to 2001 were
analyzed retrospectively.
Treatments consisted of surgery with whole brain radiation therapy (WBRT) or SRS
with or without WBRT.
The impact of age, Karnofsky performance status (KPS) at presentation, Radiation
Therapy Oncology Group, recursive partitioning analysis (RPA) class, status of
extracranial disease, number, size, volume, pathology of brain metastases and
steroid use were studied using univariate and multivariate analyses.
Results. There were 80 evaluable patients (10 lost to follow-up and three
excluded for supratentorial surgery with subsequent LMD).
LMD occurred after the surgical removal of the PFM in 9 of 18 patients (50%),
whereas LMD occurred after SRS in 4 of 62 patients (6.5%) (p = 0.0028).
Multivariate analysis also showed that patients who had surgery were more likely
to develop LMD compared to patients treated with SRS (p = 0.0024).
Patients had a median KPS decline of 30 points after LMD was diagnosed.
There was no statistically significant difference in survival of patients with
LMD and the rest of the patients (13.5 vs. 11.7 months, p = 0.7659).
Patients treated surgically had significantly larger lesions (3.43 +/- 0.74 vs.
1.96 +/- 0.95 cm maximum diameter, p < 0.0001).
All surgical patients belonged to RPA class II at diagnosis.
Their survival was not different from the RPA class II patients in the SRS
group.
Surgery and SRS had comparable complication rates (8.1% vs. 5.6%, p = 0.99),
although the surgical complications were more serious (e.g. hemorrhage, CSF
leak).
The duration of steroid use was longer after SRS compared to surgery (2.1 +/-
3.6 vs. 1.3 +/- 2.4 months); however, the difference was not statistically
significant.
Myopathy and psychosis in one patient after SRS, were the only steroid-related
complications.
There was no statistically significant association between the primary tumor
type and the presence of LMD.
Conclusions. In this retrospective analysis of patients with PFM, SRS was
associated with a lower incidence of LMD than was surgery.
Although LMD was associated with rapid and considerable decline in the quality
of life, it did not influence the overall survival.
SRS was associated with less serious complications than surgery.
Surgery in this study was performed on patients with larger lesion sizes and a
trend toward poorer initial performance status, which could bias these
results.
A prospective study directly comparing surgery and SRS and further evaluating
the significance of LMD in PFM is warranted.
PMID: 15072456 [PubMed - indexed for
MEDLINE]
Source: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15072456
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