Pre-operative Stereotactic Radiosurgery Followed by Resection for Patients With Brain Metastases

Study Overview
=================
Brief Summary
-----------------
This is a prospective, single arm, phase II trial to determine the local control at 6 months utilizing pre-operative stereotactic radiosurgery followed by surgery within 1 - 4 days in subjects with a diagnosis of 1-4 brain metastases and with an indication for surgical resection of at least one brain metastasis at the discretion of a neurosurgeon.

Detailed Description
-----------------
Primary Objective To evaluate 6 month in-brain local control utilizing pre-operative stereotactic radiosurgery followed by surgical resection for brain metastases. Secondary Objectives Overall survival Distant in-brain progression Rate of leptomeningeal spread Rate of radiation necrosis

Official Title
-----------------
A Phase II Study Analyzing Pre-operative Stereotactic Radiosurgery Followed by Resection for Patients With 1 - 4 Brain Metastases

Conditions
-----------------
Brain Metastases

Intervention / Treatment
-----------------
* Procedure: Radiosurgery


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria Radiographically confirmed solid tumor brain metastases Criteria for surgical resection of at least one metastasis per neurosurgeon discretion A diagnostic MRI Brain or CT Head demonstrating the presence of 1-4 solid tumor brain metastases and lesion to be resected no more than 5 cm in any direction, performed within 30 days prior to stereotactic radiosurgery. If multiple lesions are present, then the total brain metastases volume can be no more than 30 cm3 excluding the lesion to be resected. For known primary included in brainmetgpa.com, an estimated median survival no less than 6 months per brainmetgpa.com For unknown primary or known primary not included within brainmetgpa.com, an estimated median survival no less than 6 months per PI discretion Note: If patient's estimated median survival is calculated using a histology that is different than the histology demonstrated in final pathology, the patient may remain eligible for all study endpoints per PI discretion Surgical candidate per neurosurgeon discretion Surgical resection able to be performed within 1 - 4 days after radiosurgery Stereotactic radiosurgery candidate per radiation oncologist ≥ 18 years old at the time of informed consent Ability to provide written informed consent and HIPAA authorization. This will be assessed by the consenting physician using general questions to determine the patient's ability to understand the medical problem, proposed treatment, alternatives to proposed treatment, and understand the consequences of the medical choices. Platelet count > 100 k/cumm, Hgb > 7.5 gm/dL, INR < 1.3, ANC > 1.5 k/cumm Patients currently on cytotoxic chemotherapy or immunotherapy are eligible, not including anti-VEGF therapy If a patient who meets all stated eligibility criteria is enrolled on study and then discovered to be ineligible, the tissue obtained will still be deemed eligible to remain in study for evaluation. Exclusion Criteria Patients who received anti-VEGF therapy within 6 weeks prior to enrollment, as there is increased risk of fatal brain hemorrhage with surgical resection Major medical illnesses or psychiatric impairments, which in the investigator's opinion will prevent administration or completion of the protocol therapy and/or interfere with follow-up Patients with more than 4 brain metastases on MRI Brain or CT Head Lesion to be resected is more than 5 cm Total volume of metastatic disease more than 30 cm3 excluding lesion to be resected Patients with leptomeningeal metastases documented by MRI or CSF evaluation Previous whole brain radiation therapy Previous radiation therapy to lesion to be resected Planned adjuvant focal therapy including additional radiation therapy to the brain Not a surgical candidate per neurosurgeon's discretion Not a radiosurgical candidate per radiation oncologist's discretion Surgery unable to be performed between 1 - 4 days after radiosurgery Women who are pregnant or nursing are not eligible as treatment involves unforeseeable risks to the fetus or child

Ages Eligible for Study
-----------------
Minimum Age: 18 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

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


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Arm 1<br>This is a single arm study so this arm will include all eligible subjects. All subjects will have radiosurgery 1-4 days prior to surgical resection. | Procedure: Radiosurgery<br>* Stereotactic radiosurgery will be delivered on all patients utilizing gamma knife or linear accelerator based techniques as per RTOG-9005 dosing criteria (Section 11 Table 1) based on tumor diameter with the exception that the largest lesion diameter to be treated with 15 Gy will be 5 cm. All apparent, previously untreated brain metastases will be treated with radiosurgery at this time. Radiosurgery will be performed 1-4 days prior to surgical resection. Vital signs and MRI Brain planning scan will be performed on the day of radiosurgery prior to the procedure.<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of local control of any new, recurrent, or progressing tumors within the planning target volume | Measured by post-treatment MRI | 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of overall survival | Time from start of treatment to death of any cause | 6 months, 1 year, and 2 years | 
| Rate of in-brain progression free survival | Time from start of treatment to any in-brain | 6 months, 1 year, and 2 years | 
| Proportion of patients with distant in-brain failure (any new parenchymal lesion outside of the planning target volume) | Measured by post-treatment MRI | 2 years | 
| Proportion of patients with radiation necrosis (radiographic or biopsy-positive diagnosis of radiation necrosis) | Measured by post-treatment MRI | 2 years | 
| Proportion of patients with leptomeningeal spread (radiographic or CSF diagnosis of leptomeningeal disease) | Measured by post-treatment MRI | 2 years |