title: Multi-institutional Nomogram Predicting Survival Free From Salvage Whole Brain Radiation After Radiosurgery in Patients With Brain Metastases.
abstract: Optimal patient selection for stereotactic radiosurgery (SRS) as the initial treatment for brain metastases is complicated and controversial. This study aimed to develop a nomogram that predicts survival without salvage whole brain radiation therapy (WBRT) after upfront SRS.
  
  
  
  Multi-institutional data were analyzed from 895 patients with 2095 lesions treated with SRS without prior or planned WBRT. Cox proportional hazards regression model was used to identify independent pre-SRS predictors of WBRT-free survival, which were integrated to build a nomogram that was subjected to bootstrap validation.
  
  
  
  Median WBRT-free survival was 8 months (range, 0.1-139 months). Significant independent predictors for inferior WBRT-free survival were age (hazard ratio [HR] 1.1 for each 10-year increase), HER2(-) breast cancer (HR 1.6 relative to other histologic features), colorectal cancer (HR 1.4 relative to other histologic features), increasing number of brain metastases (HR 1.09, 1.32, 1.37, and 1.87 for 2, 3, 4, and 5+ lesions, respectively), presence of neurologic symptoms (HR 1.26), progressive systemic disease (HR 1.35), and increasing extracranial disease burden (HR 1.31 for oligometastatic and HR 1.56 for widespread). Additionally, HER2(+) breast cancer (HR 0.81) and melanoma (HR 1.11) trended toward significance. The independently weighted hazard ratios were used to create a nomogram to display estimated probabilities of 6-month and 12-month WBRT-free survival with a corrected Harrell's C concordance statistic of 0.62.
  
  
  
  Our nomogram can be used at initial evaluation to help select patients best suited for upfront SRS for brain metastases while reducing expense and morbidity in patients who derive minimal or no benefit.
authors.affiliation: Department of Radiation Oncology, Rhode Island Hospital, Brown University Warren Alpert Medical School, Providence, Rhode Island; Department of Radiation Oncology, Perlmutter Cancer Center, NYU School of Medicine, New York, New York.
authors.forename: Daniel
authors.initials: D
authors.lastname: Gorovets
authors.affiliation: Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Radiation Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: Diandra
authors.initials: D
authors.lastname: Ayala-Peacock
authors.affiliation: Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts.
authors.forename: David J
authors.initials: DJ
authors.lastname: Tybor
authors.affiliation: Department of Radiation Oncology, Rhode Island Hospital, Brown University Warren Alpert Medical School, Providence, Rhode Island; Department of Radiation Oncology, UMass Memorial Medical Center, University of Massachusetts School of Medicine, Worcester, Massachusetts.
authors.forename: Paul
authors.initials: P
authors.lastname: Rava
authors.affiliation: Department of Radiation Oncology, Rhode Island Hospital, Brown University Warren Alpert Medical School, Providence, Rhode Island.
authors.forename: Daniel
authors.initials: D
authors.lastname: Ebner
authors.affiliation: Department of Neurosurgery, Rhode Island Hospital, Brown University Warren Alpert Medical School, Providence, Rhode Island.
authors.forename: Deus
authors.initials: D
authors.lastname: Cielo
authors.affiliation: Department of Neurosurgery, Rhode Island Hospital, Brown University Warren Alpert Medical School, Providence, Rhode Island.
authors.forename: Georg
authors.initials: G
authors.lastname: Norén
authors.affiliation: Department of Radiation Oncology, Rhode Island Hospital, Brown University Warren Alpert Medical School, Providence, Rhode Island.
authors.forename: David E
authors.initials: DE
authors.lastname: Wazer
authors.affiliation: Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina.
authors.forename: Michael
authors.initials: M
authors.lastname: Chan
authors.affiliation: Department of Radiation Oncology, Rhode Island Hospital, Brown University Warren Alpert Medical School, Providence, Rhode Island. Electronic address: jhepel@lifespan.org.
authors.forename: Jaroslaw T
authors.initials: JT
authors.lastname: Hepel
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001932:Brain Neoplasms / Q000401:mortality / Q000532:radiotherapy* / Q000556:secondary*; D001943:Breast Neoplasms / Q000473:pathology; D015179:Colorectal Neoplasms / Q000473:pathology; D016371:Cranial Irradiation; D018450:Disease Progression; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008545:Melanoma / Q000401:mortality / Q000532:radiotherapy / Q000556:secondary; D008875:Middle Aged; D049451:Nomograms; D018579:Patient Selection; D016016:Proportional Hazards Models; D016634:Radiosurgery; D012189:Retrospective Studies; D016879:Salvage Therapy; D013997:Time Factors