Stereotactic Radiosurgery in Treating Patients With Brain Metastases

Study Overview
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Brief Summary
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RATIONALE: Stereotactic radiosurgery may be able to send x-rays directly to the tumor and cause less damage to normal tissue. Giving stereotactic radiosurgery before surgery may make the tumor smaller and reduce the amount of normal tissue that needs to be removed. PURPOSE: This phase II trial is studying how well stereotactic radiosurgery works in treating patients with brain metastases.

Detailed Description
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OBJECTIVES: Primary To estimate the rate of recurrence at the surgical site in patients with brain metastases treated with neoadjuvant stereotactic radiosurgery (SRS) compared with historical data documenting recurrence at the surgical site after surgical resection and whole-brain radiotherapy (WBRT). Secondary To estimate the rate of salvage WBRT, SRS, or surgery in patients treated with neoadjuvant SRS alone. To determine the volume of adjacent normal brain parenchyma irradiated in these patients. To estimate the rate of new brain metastases outside of the neoadjuvant SRS site in these patients. To estimate the quality of life of these patients after neoadjuvant SRS alone. To assess the effect of SRS and surgical intervention on the preservation of neurocognitive functioning in these patients. To determine the clinical significance (mass effect, cognitive functioning, and other symptoms) of locally recurrent brain metastases at the time of their occurrence in these patients. To estimate the rate of death due to neurologic causes, defined as death attributable to the progression of neurological disease, in these patients. To estimate the overall survival of these patients. OUTLINE: Patients undergo stereotactic radiosurgery over 30 to 90 minutes. Approximately 2-4 weeks later, patients undergo surgical resection of brain metastasis. Quality of life and neurocognitive function are assessed periodically using the FACT-Br subscales and Mini-Mental State Exam. After completion of study treatment, patients are followed every 3 months for 1 year and then every 6 months for 1 year.

Official Title
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Phase II Single-arm Study of Pre-operative Stereotactic Radiosurgery for Brain Metastases.

Conditions
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Metastatic Cancer, Unspecified Adult Solid Tumor, Protocol Specific

Intervention / Treatment
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* Procedure: therapeutic conventional surgery
* Radiation: stereotactic radiosurgery


Participation Criteria
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Eligibility Criteria
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DISEASE CHARACTERISTICS: Diagnosis of brain metastases from an extracranial primary site Tumor ≤ 4 cm in maximal extent in any plane on contrast MRI Scheduled to undergo gross total resection of a single brain metastasis confirmed by histology Up to 4 metastases allowed provided the largest mass is amenable to surgical resection and all non-resected masses are amenable to stereotactic radiosurgery (SRS) RTOG Recursive Partitioning Analysis (RPA) class 1 or 2, as defined by the following: RPA class 1: Karnofsky performance status (KPS) 70-100%; age < 65 years; controlled primary disease; and no extracranial metastatic disease RPA class 2: KPS 70-100%; uncontrolled primary disease; and/or extracranial metastatic disease No lesion located in anatomic regions that are not amenable to SRS, including the brain stem, optic apparatus, or eloquent cortex No primary lesion with radiosensitive histology (e.g., small cell carcinoma, germ cell tumors, lymphoma, leukemia, or multiple myeloma) No radiographic or cytologic evidence of leptomeningeal disease PATIENT CHARACTERISTICS: See Disease Characteristics Not pregnant or nursing Negative pregnancy test No concurrent uncontrolled illness including, but not limited to, any of the following: Symptomatic congestive heart failure Unstable angina pectoris Psychiatric illness No contraindication to SRS, whole-brain radiotherapy, or MRI PRIOR CONCURRENT THERAPY: See Disease Characteristics No prior brain surgery other than resection of metastasis No prior brain radiotherapy

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Pre-Operative SRS<br>SRS pre-operatively with the planned target volume defined as the tumor plus a 3-mm margin. | Procedure: therapeutic conventional surgery<br>* Surgery of a single brain metastasis.<br>Radiation: stereotactic radiosurgery<br>* Pre-operative single fraction SRS<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Patients With Local Recurrence at the Surgical Site Within 12 Months After Stereotactic Radiosurgery (SRS) | Number of patients with local recurrence at the surgical site within 12 months after stereotactic radiosurgery (SRS) as measured by magnetic resonance imaging (MRI). To determine local recurrence, we evaluated follow-up MRI's for reappearance of a lesion in exactly the same site in the brain as the first lesion(s). | Within 12 months after SRS | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Patients Receiving Salvage Whole-brain Radiotherapy, Stereotactic Radiosurgery (SRS), or Surgery | Number of patients receiving salvage whole-brain radiotherapy, stereotactic radiosurgery (SRS), or surgery | Within 24 months post-SRS | 
| Volume of Adjacent Normal Brain Parenchyma Irradiated | Volume of adjacent normal brain parenchyma irradiated during stereotactic radiosurgery (SRS). | At time of SRS | 
| Number of Patients With New Brain Metastases Outside of the Pre-operative Stereotactic Radiosurgery (SRS) Site | Number of patients with new brain metastases outside of the pre-operative stereotactic radiosurgery (SRS) site. | Within 24 months post-SRS | 
| Quality of Life After Stereotactic Radiosurgery (SRS) as Measured by the Functional Assessment of Cancer Therapy-Brain (FACT-Br) | Quality of life as measured by the change in FACT-Br scores from baseline. The FACT-Br (version 4) is comprised of the Functional Assessment of Cancer Therapy-General (FACT-G), a 27-item core questionnaire evaluating the domains of physical, family/social, emotional and functional well-being, with the addition of 23 brain cancer specific questions. The FACT-G total score is the sum of the four FACT-G domain scores. The Brain Cancer Subscale (BrCS) is the sum of 19 brain cancer specific questions. The FACT-Br Trial Outcome Index (TOI) is the sum of the BrCS score and the physical and family/social domain scores. The FACT-Br total score is the sum of the FACT-G total score and the BrCS score. Change score = score post-SRS minus the score at baseline. Positive change scores indicate improved quality of life. | Administered at baseline and every 3 months post-SRS | 
| Preservation of Neurocognitive Functioning as Measure by the Mini-Mental State Exam (MMSE) | Cognition as measured by the change in the Mini-Mental State Exam (MMSE) scores from baseline. The MMSE is an 11-item measure that tests five areas of cognitive function: orientation, registration, attention and calculation, recall and language. The maximum score is 30. Change score = score post-SRS minus the score at baseline. Positive change scores indicate improved cognition. | Administered at baseline and every 3 months post-SRS | 
| Clinical Significance of Locally Recurrent Brain Metastases | Number of patients with clinical significance (mass effect, cognitive functioning, and other symptoms) of locally recurrent brain metastases at the time of their occurrence. | 24 months post-SRS | 
| Number of Patients Who Died Due to Neurological Causes | Number of patients who died due to neurological causes defined as death attributable to the progression of neurological disease. | Within 24 months post-SRS | 
| Overall Survival (OS) | Time in months from the date of stereotactic radiosurgery (SRS) to the date of death due to any cause. Patients alive as of the last follow-up had OS censored at the last follow-up date. Median OS was estimated using a Kaplan-Meier curve. | 24 months after SRS | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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tumors metastatic to brain, unspecified adult solid tumor, protocol specific