title: A multi-institutional review of radiosurgery alone vs. radiosurgery with whole brain radiotherapy as the initial management of brain metastases.
abstract: OBJECTIVE
  Data collected from 10 institutions were reviewed to compare survival probabilities of patients with newly diagnosed brain metastases managed initially with radiosurgery (RS) alone vs. RS + whole brain radiotherapy (WBRT).
  
  
  METHODS
  A database was created from raw data submitted from 10 institutions on patients treated with RS for brain metastases. The major exclusion criteria were resection of a brain metastasis and interval from the end of WBRT until RS >1 month (to try to ensure that the up-front intent was to combine RS + WBRT and that RS was not given for recurrent brain metastases). Survival was estimated using the Kaplan-Meier method from the date of first treatment for brain metastases until death or last follow-up. Survival times were compared for patients managed initially with RS alone vs. RS + WBRT using the Cox proportional hazards model to adjust for known prognostic factors or Radiation Therapy Oncology Group recursive partitioning analysis (RPA) class.
  
  
  RESULTS
  Out of 983 patients, 31 were excluded because treatment began after 6/1/98; 159 were excluded because brain metastases were resected; 179 were excluded because there was an interval >1 month from WBRT until RS; and 45 were excluded for other reasons. Of the 569 evaluable patients, 268 had RS alone initially (24% of whom ultimately had salvage WBRT), and 301 had RS + up-front WBRT. The median survival times for patients treated with RS alone initially vs. RS + WBRT were 14.0 vs. 15.2 months for RPA Class 1 patients, 8.2 vs. 7.0 months for Class 2, and 5.3 vs. 5.5 months for Class 3, respectively. With adjustment by RPA class, there was no survival difference comparing RS alone initially to RS + up-front WBRT (p = 0.33, hazard ratio = 1.09).
  
  
  CONCLUSIONS
  Omission of up-front WBRT does not seem to compromise length of survival in patients treated with RS for newly diagnosed brain metastases.
authors.affiliation: Department of Radiation Oncology, University of California-San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0226, USA. sneed@radonc17.ucsf.edu
authors.forename: Penny K
authors.initials: PK
authors.lastname: Sneed
authors.forename: John H
authors.initials: JH
authors.lastname: Suh
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Goetsch
authors.forename: Seema N
authors.initials: SN
authors.lastname: Sanghavi
authors.forename: Richard
authors.initials: R
authors.lastname: Chappell
authors.forename: John M
authors.initials: JM
authors.lastname: Buatti
authors.forename: William F
authors.initials: WF
authors.lastname: Regine
authors.forename: Eduardo
authors.initials: E
authors.lastname: Weltman
authors.forename: Vernon J
authors.initials: VJ
authors.lastname: King
authors.forename: John C
authors.initials: JC
authors.lastname: Breneman
authors.forename: Paul W
authors.initials: PW
authors.lastname: Sperduto
authors.forename: Minesh P
authors.initials: MP
authors.lastname: Mehta
mesh_terms: D000368:Aged; D000704:Analysis of Variance; D001932:Brain Neoplasms / Q000401:mortality / Q000532:radiotherapy / Q000556:secondary / Q000601:surgery*; D003131:Combined Modality Therapy; D016371:Cranial Irradiation / Q000401:mortality; D016208:Databases, Factual; D006801:Humans; D008875:Middle Aged; D018579:Patient Selection; D016634:Radiosurgery / Q000401:mortality; D011879:Radiotherapy Dosage; D016879:Salvage Therapy; D013997:Time Factors