J Korean Neurosurg Soc.  2018 Sep;61(5):592-599. 10.3340/jkns.2017.0303.005.

Gamma Knife Radiosurgery for Metastatic Brain Tumors with Exophytic Hemorrhage

• Park ES
• Lee EJ
• Yun JH
• Cho YH
• Kim JH
• Kwon DH

• KMID: 2420067
• DOI: http://doi.org/10.3340/jkns.2017.0303.005

Abstract

OBJECTIVE
Metastatic brain tumors (MBTs) often present with intracerebral hemorrhage. Although Gamma Knife surgery (GKS) is a valid treatment option for hemorrhagic MBTs, its efficacy is unclear. To achieve oncologic control and reduce radiation toxicity, we used a radiosurgical targeting technique that confines the tumor core within the hematoma when performing GKS in patients with such tumors. We reviewed our experience in this endeavor, focusing on local tumor control and treatment-associated morbidities.
METHODS
From 2007 to 2014, 13 patients with hemorrhagic MBTs were treated via GKS using our targeting technique. The median marginal dose prescribed was 23 Gy (range, 20-25). GKS was performed approximately 2 weeks after tumor bleeding to allow the patient's condition to stabilize.
RESULTS
The primary sites of the MBTs included the liver (n=7), lung (n=2), kidney (n=1), and stomach (n=1); in two cases, the primary tumor was a melanoma. The mean tumor volume was 4.00 cm³ (range, 0.74-11.0). The mean overall survival duration after GKS was 12.5 months (range, 3-29), and three patients are still alive at the time of the review. The local tumor control rate was 92% (tumor disappearance 23%, tumor regression 46%, and stable disease 23%). There was one (8%) instance of local recurrence, which occurred 11 months after GKS in the solid portion of the tumor. No GKS-related complications were observed.
CONCLUSION
Our experience shows that GKS performed in conjunction with our targeting technique safely and effectively treats hemorrhagic MBTs. The success of this technique may reflect the presence of scattered metastatic tumor cells in the hematoma that do not proliferate owing to the inadequate microenvironment of the hematoma. We suggest that GKS can be a useful treatment option for patients with hemorrhagic MBTs that are not amenable to surgery.

Keyword

Neurosurgical procedures; Cerebral hemorrhage; Neoplasm metastases; Radiosurgery

MeSH Terms

Brain Neoplasms*
Brain*
Cerebral Hemorrhage
Hematoma
Hemorrhage*
Humans
Kidney
Liver
Lung
Melanoma
Neoplasm Metastasis
Neurosurgical Procedures
Radiosurgery*
Recurrence
Stomach
Tumor Burden

Figure

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  Fig. 1. Radiosurgical targeting technique for metastatic brain tumor with hemorrhage. T1-weighted (A), gd-enhanced T1-weighted (b), and T2-weighted (c) magnetic resonance images (MRi) obtained before gamma knife surgery (gkS). d : gd-enhanced T1-weighted images demonstrating dose planning.

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  Fig. 2. The measuring method using the gammaPlan treatment planning system for tumor and hematoma volumes.

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  Fig. 3. kaplan-Meier curves showing patient’s overall survival and imaging-verified progression free survival. The median overall survival time after gkS was 12.5 months at the time of evaluation. The actuarial survival rates were 69.2% and 46.1% at 6 and 12 months after gkS, respectively. imaging-verified progression free survival rates were 46.1% and 30.7% at 6 and 12 months after gkS, respectively. gkS : gamma knife surgery.

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  Fig. 4. A 40-year-old man with hepatocellular carcinoma presented with visual disturbance and headache. brain computed tomography (cT) and magnetic resonance imaging revealed metastatic brain tumor with hemorrhage. gkS was performed with 25 gy at the 50% isodose line. At the time of treatment, the hematoma and tumor volume measured 22.17 cm3 and 2.50 cm3 , respectively. The serial images document success in the local tumor control. cT (A), flAiR (b), and gd-enhanced T1-weighted (c) images obtained before gkS. gd-enhanced T1-weighted images demonstrating dose planning (d-f). T2-weighted (g), flAiR (h), and gdenhanced T1-weighted (i) images obtained 2 months after gkS. T2-weighted (j), flAiR (k), and gd-enhanced T1-weighted (l) images obtained 15 months after gkS. gkS : gamma knife surgery, flAiR : fluid attenuated inversion recovery.

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  Fig. 5. A 63-year-old man with small-cell lung carcinoma presented with headache with dizziness. brain MRi showed metastatic brain tumor with hemorrhage. gkS was performed with 25 gy at the 50% isodose line. At the time of treatment, the hematoma and tumor volume measured 12.15 cm3 and 7.10 cm3, respectively. The serial images document success in the local tumor control until 9 months of follow-up. however, the recurred tumor was detected in previously treated area of the solid tumor portion on the follow-up MRi at 11 month follow-up. -weighted axial (A), gd-enhanced T1-weighted axial (b), and coronal (c) images obtained before gkS. gd-enhanced T1-weighted and T2-weighted images demonstrating dose planning (d-f). g-i : T1-weighted axial (A), gd-enhanced T1-weighted axial (b), and coronal (c) images obtained 3 months after gkS. j-l : T1-weighted axial (A), gd-enhanced T1-weighted axial (b), and coronal (c) images obtained 9 months after gkS. M-O : T1-weighted axial (A), gd-enhanced T1-weighted axial (b), and coronal (c) images obtained 11 months after gkS. MRi : magnetic resonance imaging, gkS : gamma knife surgery.

Reference

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