Changes to This Summary (05/14/2013)
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Revised text on factors used to diagnose brain metastases to include diagnostic procedures, including contrast magnetic resonance imaging (MRI) of the brain.
Added text to state that external-beam radiation therapy using either 3-dimensional conformal radiation therapy or intensity-modulated radiation therapy is considered an acceptable technique in radiation therapy delivery. Typically 2- to 3-cm margins on the MRI-based volumes to create the planning target volume are used. Dose escalation using radiosurgery has not improved outcomes.
Added Souhami et al. as reference 15.
Added Leptomeningeal carcinomatosis as a new subsection.
Added text to state that a phase III randomized trial compared adjuvant whole-brain radiation therapy (WBRT) with observation after surgery or radiosurgery for a limited number of brain metastases in patients with stable solid tumors. Added that health-related quality of life was improved in the observation-only arm compared with WBRT and patients in the observation arm had better mean scores in physical, role, and cognitive functioning at 9 months. Also added that In an exploratory analysis, statistically significant worse scores for bladder control, communication deficit, drowsiness, hair loss, motor dysfunction, leg weakness, appetite loss, constipation, nausea/vomiting, pain, and social functioning were observed in patients who underwent WBRT compared with those who underwent observation only (cited Soffietti et al. as reference 48 and level of evidence 1iiC).
Revised text to state that given this body of information, focal therapy plus WBRT or focal therapy alone, with close follow-up with serial MRIs and initiation of salvage therapy when clinically indicated, appear to be reasonsable treatment options.
Revised text to state that patients with multiple brain metastases may be treated with WBRT and that surgery is indicated to obtain tissue from a metastasis with an unknown primary tumor or to decompress a symptomatic dominant lesion causing significant mass effect. Added text to state that a meta-analysis of two trials found no statistically significant difference in overall survival (OS) between the WBRT plus stereotactic radiosurgery (SRS) and WBRT alone groups; patients in the WBRT plus SRS group had decreased local failure compared with patients who received WBRT alone. An unchanged or improved Karnofsky Performance Scale at 6 months was seen in 43% of patients in the combined therapy group versus only 28% in the WBRT group (cited Patil et al. as reference 49 and level of evidence 1iiDiii).
Added text to state that mature results from the phase III, randomized European Organisation for Research and Treatment of Cancer Brain Tumor Group Study 26951 demonstrated increased OS and progression-free survival in patients with anaplastic oligodendroglial tumors with six cycles of adjuvant procarbazine + lomustine + vincristine (PCV) chemotherapy after radiation therapy compared with radiation therapy alone. Also added that the OS was significantly longer in the radiation therapy and PCV arm; the 1p/19q-codeleted tumors derived more benefit from adjuvant PCV chemotherapy compared with non-1p/19q-deleted tumors (cited van den Bent et al. as reference 5 and level of evidence 1iiA).
Added text to state that the Radiation Therapy Oncology Group trial 9402 demonstrated no differences in median survival by treatment arm between an 8-week intensive PCV chemotherapy regimen followed by immediate involved-field-plus-radiation therapy and radiation therapy alone; however, in an unplanned subgroup analysis, patients with 1p/19q codeleted anaplastic oligodendroglioma and mixed anaplastic astrocytoma demonstrated a median survival of 14.7 years versus 7.3 years. Also added that for patients with noncodeleted tumors, there was no difference in median survival by treatment arm (cited Cairncross et al. as reference 6 and level of evidence 1iiA).
Added text to state that based on these data, CODEL, a study that randomly assigned patients to radiation therapy alone, radiation therapy with temozolomide, and temozolomide alone, was halted because radiation therapy alone was no longer considered adequate treatment in patients with anaplastic oligodendroglioma with 1p/19q codeletion (cited Gilbert as reference 7). Also added that a comparison between temozolomide and PCV chemotherapy in anaplastic oligodendroglioma has not been done, although in the setting of grade 3 anaplastic gliomas, no survival difference was seen between PCV chemotherapy and temozolomide (cited Brada et al. as reference 8).
This summary is written and maintained by the PDQ Adult Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ NCI's Comprehensive Cancer Database pages.