Fast track — ArticlesNeurocognition in patients with brain metastases treated with radiosurgery or radiosurgery plus whole-brain irradiation: a randomised controlled trial
Introduction
About 170 000 new brain metastases are diagnosed in the USA each year.1 For over 50 years, whole brain radiotherapy (WBRT) has served as the standard palliative treatment for brain metastases. More recently, randomised trials have established the added survival benefit of either surgery or stereotactic radiosurgery (SRS) combined with WBRT over WBRT alone for patients with single brain metastases,2, 3, 4 raising questions about the role of WBRT and its possible effect on neurocognitive function.
A strategy to preserve neurocognition in patients with one to three newly diagnosed brain metastases is to use SRS alone with clinical monitoring to defer or completely avoid WBRT.5 However, SRS plus WBRT is frequently given to maximise disease control, since the omission of WBRT increases the risk of recurrent brain metastases.6, 7, 8, 9, 10 We did a randomised controlled trial to help clarify whether elective WBRT should be given with SRS, or deferred. We proposed that patients treated with SRS plus WBRT would have inferior neurocognitive function based on the Hopkins Verbal Learning Test–Revised (HVLT–R) compared with patients treated with SRS alone.
Section snippets
Patients
Eligible patients who presented at the Departments of Radiation Oncology, and Neurosurgery, and at the Brain and Spine Center, MD Anderson Cancer Center, Houston, TX, USA, were recruited to the study. Eligibility requirements were: age 18 years or greater; recursive partitioning analysis (RPA) class one or two (Karnofsky Performance Status [KPS] ≥70); one to three newly diagnosed brain metastases eligible for SRS; brain MRI within 1 month of enrolment; and signed written informed consent. A
Results
58 patients were enrolled and randomly assigned to SRS alone (n=30) or SRS plus WBRT (n=28) from Jan 2, 2001, to Sept 14, 2007 (figure 1) before the trial was halted by the data monitoring committe. The date of last follow-up was Oct 20, 2008. Patient characteristics are presented in table 1. The median follow-up was 9·5 months (range 0·3–66) for the entire study. For the SRS alone group, the median SRS tumour margin dose was 19 Gy (range 15–20). For the SRS plus WBRT group, the median SRS
Discussion
Patients randomly assigned to SRS plus WBRT were more likely to show a significant drop in HVLT–R total recall at 4 months than were patients randomly assigned to SRS alone (52% vs 24%, respectively), despite the fact that patients in the SRS alone group showed a higher overall brain tumour recurrence than did those patients in the SRS plus WBRT group. This finding persisted at 6-month follow-up.
We proposed that memory would be likely to be affected by radiation therapy, given the adverse
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