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Evidence-Based Surgery

Role of Gamma Knife Surgery in Metastatic Melanoma of the Brain

Sanmugarajah Paramasvaran

9th February 2012

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Clinical Case• 83 year old man

• Previous history of melanoma and prostatic cancer

• Intermittent confusion , gait disturbance and urinary incontinence

• MRI : 6 supratentorial mets

• Craniotomy and excision of largest/symptomatic mets

• HPE : metastatic melanoma

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Clinical Questions:

• Melanoma is a radioresistant tumour

Does addition of GKS to WBRT prolong survival in metastatic melanoma of the brain?

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Search strategy

• P = Patients with metastatic melanoma of the brain

• I = Gamma Knife Surgery and WBRT

• C = WBRT

• O = survival benefit

Search Keywords (exp MESH )

“ Melanoma” “Brain Metas*” “Gamma Knife” “Radiotherapy”

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Search Results

• 71 total

• 5 relevant

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2 relevant papers

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Nil relevant

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Selection Criteria

• Cerebral melanoma metastasis• GKS + WBRT• Retrospective/prospective studies• Last 20 yrs• English Language

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Levels of Evidence (NHMRC)

Class l – nil

Class ll – nil

Class lll – nil

Class lV- 7

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The articles

1. Outcome predictors of Gamma Knife Surgery for Melanoma Brain Metastases

Donald N. Liew, M.D.et al, J Neurosurg 114:769–779, 2011

2. Gamma Knife surgery in the management of radioresistant brain metastases in high-risk patients with melanoma, renal cell carcinoma, and sarcoma

John W. Powell et al, J Neurosurg (Suppl) 109:000–000, 2008

3. Gamma Knife Surgery in Brain Melanomas: Absence of Extracranial Metastases and Tumour Volume Strongest Indicators of Prolonged Survival

Bente Sandvei Skeie, WORLD NEUROSURGERY 75 [5/6]: 684-691, MAY/JUNE 2011

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4. Gamma Knife radiosurgery for intracranial metastatic melanoma: an analysis of survival and prognostic factors

Mehmet Koc et al; Journal of Neuro-Oncology (2005) 71: 307–313

5 Stereotactic radiosurgery for cerebral metastatic melanoma

Salvador Somaza et al, J Neurosurg 79:661-666, 1993

6 Metastatic Melanoma To The Brain: Prognostic Factors After Gamma Knife Surgery

Cheng Yu Ph.D. et al, Int. J. Radiation Oncology Biol. Phys., Vol. 52, No. 5, pp. 1277–1287, 2002

7. Cerebral Metastases from Malignant Melanoma: Current Treatment Strategies, Advances in Novel Therapeutics and Future Directions

Timothy L. Siu and Suyun Huang , Cancers 2010, 2, 364-375

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Summary of findingsYear /Center No Type of

studyMethods Results/Conclusion

1993, Pittsburgh,US

23 Retrosp All pts WBRT + GKS

Median survival 9 months for pts with single mets and 7 months for multiple mets18/19 died due to systemic disease

2002,Los Angeles

122 Retrosp 39 had WBRT + GKS

> Median survival GKS : 7.5 monthsGKS + WBRT : 5 months>Predictors of survivalTumor volume< 3 cm3

Absent systemic diseaseKPS > 80Supratentorial location

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Year /Center No Type Of Study

Methods Result

2005,Ohio,US

26 Retrosp 14 pts had WBRT + GKS, 5 had GKS

Median survival 6 monthsPrognostic factors : KPS>90,Female,Supratentorial mets, absent neurology

WBRT, chemo/immunotherapy,age , no of mets : not significant

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Prognostic Factor Median survival

KPS >90 8 months

KPS< 90 5 months

Supratentorial mets 8 months

Infratentorial mets 3 months

Tumour Volume < 1cm3 20 months

Tumour volume > 1 cm3 5 months

Nil neurology 11 months

Neurology present 4 months

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Year /Center No Type of study

Methods Results/Conclusion

2008,New York

76 Retrosp Melanoma(50),RCC(23),sarcomas(3)

WBRT – 37 pts

Median survival with GKS – 5.1 months

No realtionship with WBRT

Prognostic : Single mets and and KPS score

2011,Pittsburgh

333 Retrospective

WBRT + SRS(87)Surgery + SRS (19)

Surgery + WBRT + SRS (31)

Median SurvivalWBRT + GKS : 4.5 mSRS : 6.4 m

Poor Prognostic factors > 4 mets KPPS < 90 no immunotherapy

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Year /Center No Type of study

Methods Results/Conclusion

2011Bente Sandvei Skeie et al

Norway

77 Retrosp 16 had WBRT

Selection:1) < 4 mets2) <3.5 cm3) No mass

effect4) KPS > 70

Median survival ; 7 months

With WBRTNo additional survival time

Incidence of new brain mets not deceresed

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• GKS compares well with surgery

• WBRT had been routinely given

• Melanoma is under represented

• Randomized control study shows neurocognitive decline with WBRT*

• SRS only for resection bed

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Summary

• No evidence that WBRT + GKS improves survival

• GKS alone would be sufficient

• Selection Criteria :

1) KPS Score

2) Size < 3cm

3) No of mets < 4

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Thank You