title: A nomogram for predicting distant brain failure in patients treated with gamma knife stereotactic radiosurgery without whole brain radiotherapy.
abstract: BACKGROUND
  We review our single institution experience to determine predictive factors for early and delayed distant brain failure (DBF) after radiosurgery without whole brain radiotherapy (WBRT) for brain metastases.
  
  
  METHODS
  Between January 2000 and December 2010, a total of 464 patients were treated with Gamma Knife stereotactic radiosurgery (SRS) without WBRT for primary management of newly diagnosed brain metastases. Histology, systemic disease, RPA class, and number of metastases were evaluated as possible predictors of DBF rate. DBF rates were determined by serial MRI. Kaplan-Meier method was used to estimate rate of DBF. Multivariate analysis was performed using Cox Proportional Hazard regression.
  
  
  RESULTS
  Median number of lesions treated was 1 (range 1-13). Median time to DBF was 4.9 months. Twenty-seven percent of patients ultimately required WBRT with median time to WBRT of 5.6 months. Progressive systemic disease (χ(2)= 16.748, P < .001), number of metastases at SRS (χ(2) = 27.216, P < .001), discovery of new metastases at time of SRS (χ(2) = 9.197, P < .01), and histology (χ(2) = 12.819, P < .07) were factors that predicted for earlier time to distant failure. High risk histologic subtypes (melanoma, her2 negative breast, χ(2) = 11.020, P < .001) and low risk subtypes (her2 + breast, χ(2) = 11.343, P < .001) were identified. Progressive systemic disease (χ(2) = 9.549, P < .01), number of brain metastases (χ(2) = 16.953, P < .001), minimum SRS dose (χ(2) = 21.609, P < .001), and widespread metastatic disease (χ(2) = 29.396, P < .001) were predictive of shorter time to WBRT.
  
  
  CONCLUSIONS
  Systemic disease, number of metastases, and histology are factors that predict distant failure rate after primary radiosurgical management of brain metastases.
authors.affiliation: Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina (D.N.A.-P., A.M.P., J.T.L., J.G.K., J.J.U., J.D.B., E.G.S., M.D.C.); Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.W.L., S.B.T.); Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina (S.I.); Brain Tumor Center of Excellence, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.M.P., J.D.B., A.W.L., S.B.T., E.G.S., M.D.C.).
authors.forename: Diandra N
authors.initials: DN
authors.lastname: Ayala-Peacock
authors.affiliation: Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina (D.N.A.-P., A.M.P., J.T.L., J.G.K., J.J.U., J.D.B., E.G.S., M.D.C.); Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.W.L., S.B.T.); Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina (S.I.); Brain Tumor Center of Excellence, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.M.P., J.D.B., A.W.L., S.B.T., E.G.S., M.D.C.).
authors.forename: Ann M
authors.initials: AM
authors.lastname: Peiffer
authors.affiliation: Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina (D.N.A.-P., A.M.P., J.T.L., J.G.K., J.J.U., J.D.B., E.G.S., M.D.C.); Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.W.L., S.B.T.); Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina (S.I.); Brain Tumor Center of Excellence, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.M.P., J.D.B., A.W.L., S.B.T., E.G.S., M.D.C.).
authors.forename: John T
authors.initials: JT
authors.lastname: Lucas
authors.affiliation: Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina (D.N.A.-P., A.M.P., J.T.L., J.G.K., J.J.U., J.D.B., E.G.S., M.D.C.); Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.W.L., S.B.T.); Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina (S.I.); Brain Tumor Center of Excellence, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.M.P., J.D.B., A.W.L., S.B.T., E.G.S., M.D.C.).
authors.forename: Scott
authors.initials: S
authors.lastname: Isom
authors.affiliation: Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina (D.N.A.-P., A.M.P., J.T.L., J.G.K., J.J.U., J.D.B., E.G.S., M.D.C.); Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.W.L., S.B.T.); Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina (S.I.); Brain Tumor Center of Excellence, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.M.P., J.D.B., A.W.L., S.B.T., E.G.S., M.D.C.).
authors.forename: J Griff
authors.initials: JG
authors.lastname: Kuremsky
authors.affiliation: Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina (D.N.A.-P., A.M.P., J.T.L., J.G.K., J.J.U., J.D.B., E.G.S., M.D.C.); Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.W.L., S.B.T.); Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina (S.I.); Brain Tumor Center of Excellence, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.M.P., J.D.B., A.W.L., S.B.T., E.G.S., M.D.C.).
authors.forename: James J
authors.initials: JJ
authors.lastname: Urbanic
authors.affiliation: Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina (D.N.A.-P., A.M.P., J.T.L., J.G.K., J.J.U., J.D.B., E.G.S., M.D.C.); Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.W.L., S.B.T.); Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina (S.I.); Brain Tumor Center of Excellence, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.M.P., J.D.B., A.W.L., S.B.T., E.G.S., M.D.C.).
authors.forename: J Daniel
authors.initials: JD
authors.lastname: Bourland
authors.affiliation: Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina (D.N.A.-P., A.M.P., J.T.L., J.G.K., J.J.U., J.D.B., E.G.S., M.D.C.); Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.W.L., S.B.T.); Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina (S.I.); Brain Tumor Center of Excellence, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.M.P., J.D.B., A.W.L., S.B.T., E.G.S., M.D.C.).
authors.forename: Adrian W
authors.initials: AW
authors.lastname: Laxton
authors.affiliation: Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina (D.N.A.-P., A.M.P., J.T.L., J.G.K., J.J.U., J.D.B., E.G.S., M.D.C.); Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.W.L., S.B.T.); Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina (S.I.); Brain Tumor Center of Excellence, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.M.P., J.D.B., A.W.L., S.B.T., E.G.S., M.D.C.).
authors.forename: Stephen B
authors.initials: SB
authors.lastname: Tatter
authors.affiliation: Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina (D.N.A.-P., A.M.P., J.T.L., J.G.K., J.J.U., J.D.B., E.G.S., M.D.C.); Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.W.L., S.B.T.); Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina (S.I.); Brain Tumor Center of Excellence, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.M.P., J.D.B., A.W.L., S.B.T., E.G.S., M.D.C.).
authors.forename: Edward G
authors.initials: EG
authors.lastname: Shaw
authors.affiliation: Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina (D.N.A.-P., A.M.P., J.T.L., J.G.K., J.J.U., J.D.B., E.G.S., M.D.C.); Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.W.L., S.B.T.); Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina (S.I.); Brain Tumor Center of Excellence, Wake Forest School of Medicine, Winston-Salem, North Carolina (A.M.P., J.D.B., A.W.L., S.B.T., E.G.S., M.D.C.).
authors.forename: Michael D
authors.initials: MD
authors.lastname: Chan
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001932:Brain Neoplasms / Q000175:diagnosis* / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D049451:Nomograms; D016634:Radiosurgery; D016896:Treatment Outcome
keywords: brain metastases; distant brain failure; nomogram; stereotactic radiosurgery