title: Is upfront stereotactic radiosurgery a rational treatment option for very elderly patients with brain metastases? A retrospective analysis of 106 consecutive patients age 80 years and older.
abstract: Advanced age has been shown to be a factor predicting poor survival in patients with brain metastases (BM). There have been only a few studies focusing on stereotactic radiosurgery (SRS) for elderly BM patients. The present study aimed to investigate the efficacy and limitations of SRS for very elderly BM patients.
  
  
  
  This was a retrospective observational study analyzing 106 consecutive patients (69 males/37 females) age 80 years and older who received upfront Gamma Knife SRS for BM between January 2009 and October 2015. The median age was 84 years, and the median Karnofsky performance status (KPS) was 70. Fifty-two patients had a solitary BM, and others multiple BM. The median cumulative tumor volume was 3.9 mL and the median dose prescribed was 20 Gy. Overall survival (OS), neurological death rates and distant and local intracranial tumor control rates were analyzed.
  
  
  
  No patients were lost to follow-up. Six-month and 12-month OS rates were 54% and 32%, respectively. The median OS time was 7.1 months. Competing risks analysis showed that 6-month and 12-month neurological death rates were 8% and 11%, respectively. In total, 245 / 311 tumors (79%) in 82 patients (77%) with sufficient radiological follow-up data were evaluated. Six-month and 12-month distant BM recurrence rates (per patient) after SRS were 17% and 25%, respectively. Six-month and 12-month rates of local tumor control (per lesion) were 94% and 89%, respectively. Repeat SRS, salvage WBRT and surgical resection were subsequently required in 25, 4 and 1 patient, respectively. Proportional hazard regression analysis showed that KPS ≥ 70 (HR: 0.444, P < .001), controlled primary disease/no extracranial metastases (HR: 0.361, P < .001) and female sex (HR: 0.569, P = 0.028) were independent factors predicting better OS. Similarly, tumor volume (>2 mL) was the only factor predicting a higher rate of local control failure (HR: 12.8, P = 0.003).
  
  
  
  The present study suggested an upfront SRS strategy to offer a feasible and effective treatment option for very elderly patients with limited BM. In the majority of patients, neurological death could be delayed or even prevented.
authors.affiliation: Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, 2-5-1, Honjo, Matsumoto-city, Nagano-prefecture, 390-0814, Japan. yomoshoji@gmail.com.|Saitama Gamma Knife Center, San-ai Hospital, Saitama-city, Saitama-prefecture, Japan. yomoshoji@gmail.com.
authors.forename: Shoji
authors.initials: S
authors.lastname: Yomo
authors.affiliation: Saitama Gamma Knife Center, San-ai Hospital, Saitama-city, Saitama-prefecture, Japan.
authors.forename: Motohiro
authors.initials: M
authors.lastname: Hayashi
mesh_terms: D000369:Aged, 80 and over; D001932:Brain Neoplasms / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D016371:Cranial Irradiation; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D009367:Neoplasm Staging; D011379:Prognosis; D011446:Prospective Studies; D016634:Radiosurgery; D012189:Retrospective Studies; D016879:Salvage Therapy; D015996:Survival Rate
keywords: Brain metastases; Elderly patients; Gamma knife; Stereotactic radiosurgery