title: Gamma knife surgery for brain metastases: indications for and limitations of a local treatment protocol.
abstract: OBJECTIVE
  The purpose of this retrospective study was to evaluate results of a local treatment protocol using gamma knife surgery (GKS) for brain metastases without upfront whole brain radiation therapy (WBRT).
  
  
  METHODS
  Results for 521 consecutive patients satisfying the following 3 criteria were analysed: 1) a maximum of 3 tumours with a diameter of 25 mm or more; 2) no prior WBRT; 3) no surgically in accessible large (>30 mm) tumours. Large tumours were surgically removed and all smaller lesions were treated by GKS without up front WBRT. New lesions, detected with follow-up MRI, were appropriately treated with repeat GKS. Overall survival (OS), neurological survival (NS), qualitative survival (QS) and new lesion-free survival (NLFS) curves were calculated and the prognostic values of covariates were obtained. OS and NS were compared according to tumour number.
  
  
  RESULTS
  In total, 1023 separate sessions were required to treat 4562 lesions. The primary organs were lung in 369 patients, gastro-intestinal tract in 70, breast in 33, urinary tract in 24, and others/unknown in 25. The median OS period was 9.0 months. On multivariate analysis, the significant prognostic factors for OS were found to be extracranial disease (risk factor: active), Karnofsky performance status (KPS) score (<70) and gender (male). NS and QS at one year were 85.6% and 73.0%, respectively. The only significantly poor prognostic factor for NS was carcinomatous meningitis. NLFS at 6 months was 68.9%. For both OS and NS, the differences between a few (</=3) and many (4-10) brain lesions were not significant (OS: p=0.3128, NS: p=0.5509). Patients with numerous (>10) tumours had a significantly poorer prognosis than those with </=10.
  
  
  CONCLUSIONS
  Our protocol, aggressively applying GKS, provides excellent results in selected patients with </=10 brain lesions and no carcinomatous meningitis.
authors.affiliation: Department of Neurosurgery, Chiba Cardiovascular Center, Ichihara, Japan. QWT03231@nifty.ne.jp
authors.forename: T
authors.initials: T
authors.lastname: Serizawa
authors.forename: N
authors.initials: N
authors.lastname: Saeki
authors.forename: Y
authors.initials: Y
authors.lastname: Higuchi
authors.forename: J
authors.initials: J
authors.lastname: Ono
authors.forename: T
authors.initials: T
authors.lastname: Iuchi
authors.forename: O
authors.initials: O
authors.lastname: Nagano
authors.forename: A
authors.initials: A
authors.lastname: Yamaura
mesh_terms: D000368:Aged; D001925:Brain Damage, Chronic / Q000175:diagnosis / Q000401:mortality; D001932:Brain Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000556:secondary* / Q000601:surgery*; D001943:Breast Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000601:surgery; D002423:Cause of Death; D003952:Diagnostic Imaging; D018572:Disease-Free Survival; D005260:Female; D005770:Gastrointestinal Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000601:surgery; D006801:Humans; D017567:Karnofsky Performance Status; D008175:Lung Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000175:diagnosis / Q000401:mortality / Q000601:surgery; D009382:Neoplasms, Unknown Primary / Q000175:diagnosis / Q000401:mortality / Q000601:surgery; D009460:Neurologic Examination; D011183:Postoperative Complications / Q000175:diagnosis / Q000401:mortality; D011379:Prognosis; D016634:Radiosurgery; D012086:Reoperation; D012189:Retrospective Studies; D012737:Sex Factors; D015996:Survival Rate; D014571:Urologic Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000601:surgery