title: Surgical Resection of Brain Metastases and the Risk of Leptomeningeal Recurrence in Patients Treated With Stereotactic Radiosurgery.
abstract: OBJECTIVE
  Recent prospective data have shown that patients with solitary or oligometastatic disease to the brain may be treated with upfront stereotactic radiosurgery (SRS) with deferral of whole-brain radiation therapy (WBRT). This has been extrapolated to the treatment of patients with resected lesions. The aim of this study was to assess the risk of leptomeningeal disease (LMD) in patients treated with SRS to the postsurgical resection cavity for brain metastases compared with patients treated with SRS to intact metastases.
  
  
  METHODS
  Four hundred sixty-five patients treated with SRS without upfront WBRT at a single institution were identified; 330 of these with at least 3 months' follow-up were included in this analysis. One hundred twelve patients had undergone surgical resection of at least 1 lesion before SRS compared with 218 treated for intact metastases. Time to LMD and overall survival (OS) time were estimated from date of radiosurgery, and LMD was analyzed by the use of cumulative incidence method with death as a competing risk. Univariate and multivariate analyses were performed with competing risk regression to determine whether various clinical factors predicted for LMD.
  
  
  RESULTS
  With a median follow-up time of 9.0 months, 39 patients (12%) experienced LMD at a median of 6.0 months after SRS. At 1 year, the cumulative incidence of LMD, with death as a competing risk, was 5.2% for the patients without surgical resection versus 16.9% for those treated with surgery (Gray test, P<.01). On multivariate analysis, prior surgical resection (P<.01) and breast cancer primary (P=.03) were significant predictors of LMD development. The median OS times for patients undergoing surgery compared with SRS alone were 12.9 and 10.6 months, respectively (log-rank P=.06).
  
  
  CONCLUSIONS
  In patients undergoing SRS with deferral of upfront WBRT for intracranial metastatic disease, prior surgical resection and breast cancer primary are associated with an increased risk for the development of LMD.
authors: Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan. Electronic address: Matthewjohnson@beaumont.edu.
authors: Matthew D
authors: MD
authors: Johnson
authors: Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan.
authors: Vladimir
authors: V
authors: Avkshtol
authors: Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
authors: Andrew M
authors: AM
authors: Baschnagel
authors: Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan.
authors: Kurt
authors: K
authors: Meyer
authors: Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan.
authors: Hong
authors: H
authors: Ye
authors: Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan.
authors: Inga S
authors: IS
authors: Grills
authors: Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan.
authors: Peter Y
authors: PY
authors: Chen
authors: Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan.
authors: Ann
authors: A
authors: Maitz
authors: Department of Neurosurgery, William Beaumont Hospital, Royal Oak, Michigan.
authors: Rick E
authors: RE
authors: Olson
authors: Department of Neurosurgery, William Beaumont Hospital, Royal Oak, Michigan.
authors: Daniel R
authors: DR
authors: Pieper
authors: Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan.
authors: Daniel J
authors: DJ
authors: Krauss
mesh_terms: D000368:Aged; D000704:Analysis of Variance; D001932:Brain Neoplasms / Q000401:mortality / Q000532:radiotherapy / Q000556:secondary* / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008577:Meningeal Neoplasms / Q000209:etiology* / Q000401:mortality / Q000532:radiotherapy; D008875:Middle Aged; D016609:Neoplasms, Second Primary / Q000209:etiology* / Q000401:mortality / Q000532:radiotherapy; D016634:Radiosurgery; D012044:Regression Analysis; D012189:Retrospective Studies; D016879:Salvage Therapy / Q000379:methods