Brain Metastases

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More than 100,000 patients are diagnosed with brain metastasis annually. The management of brain metastasis patients remains a challenge for oncologists, radiation oncologists, and neurosurgeons. Traditional therapy of single metastasis has been either resection or whole brain radiation (WBRT), with a boost to the affected region, or combined surgery with whole brain radiation. The surgical resection of solitary metastasis with WBRT has been shown to improve survival compared to WBRT alone [7]. The complications of whole brain fractionated radiation include memory loss, alopecia, dementia, and radiation necrosis.

Stereotactic radiosurgery is changing the long-standing management of brain metastasis. Radiosurgery can achieve many of the same goals as resection, (tumor control, reduced mass effect), one of the goals of fractionated radiation therapy (the treatment of multiple lesions), and effectively treat deeply located tumors that are not considered for resection. For patients with solitary metastasis, radiosurgery may allow the avoidance of WBRT and its potential complications. In conjunction with WBRT, radiosurgery can provide rapid improvement in peritumoral edema, local tumor control, and prolonged survival compared with WBRT alone [8]. Radiosurgery provides nearly equivalent tumor control rates for breast, lung, and renal cell carcinoma, as well as melanoma. With control of brain metastasis, the management of systemic disease becomes the survival limiting factor. Radiosur-gery has the additional benefits of 1- to 2-day hospital stays and low costs (Fig. 4).

9 OTHER LESIONS

Stereotactic radiosurgery can be used to manage effectively other intracranial lesions, such as chordomas, chondrosarcomas, gliomas, and cavernous malformations (CM). Stereotactic radiosurgery is an adjuvant therapy, providing a radiation boost to the enhancing component of malignant glial neoplasms. We have also obtained good results in the treatment of juvenile pilocytic astrocytomas in children. Cavernous malformations are treated with radio-surgery after a second symptomatic hemorrhage using the same dose algorithm applied to AVMs. The baseline risk of hemorrhage for CMs is approximately 1% annually; however, the natural history of CMs suggests that those with a second symptomatic hemorrhage have an increased tendency toward hemorrhage (> 30% annually).

10 FUNCTIONAL RADIOSURGERY

Lars Leksell originally designed the Gamma Knife in 1967 to create functional lesions for the treatment of psychiatric disorders. Today, radiosurgery

Figure 4 A 56-year-old woman presented with this solitary metastasis, 2 years after a mastectomy for breast cancer. The dose plan was created with two 14-mm isocenters and three 8-mm isocenters. The maximal dose was 32 Gy. The marginal dose was 16 Gy.

is used to treat trigeminal neuralgia, essential tremor, parkinsonian tremor, and selected psychiatric or epileptic disorders. In trigeminal neuralgia, a maximum dose of 80 Gy is targeted to the proximal trigeminal nerve just anterior to the pons, using a single 4-mm isocenter. Radiosurgical thala-motomy (ventral intermediolateral thalamic nucleus) is performed with anatomical MRI localization. Tremor is improved in most patients after a latency interval of 2 to 6 months.

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