1 Evidence-Based Surgery Role of Gamma Knife Surgery in Metastatic Melanoma of the Brain Sanmugarajah Paramasvaran 9 th February 2012
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Evidence-Based Surgery
Role of Gamma Knife Surgery in Metastatic Melanoma of the Brain
Sanmugarajah Paramasvaran
9th February 2012
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Clinical Case• 83 year old man
• Previous history of melanoma and prostatic cancer
• Intermittent confusion , gait disturbance and urinary incontinence
• MRI : 6 supratentorial mets
• Craniotomy and excision of largest/symptomatic mets
• HPE : metastatic melanoma
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Clinical Questions:
• Melanoma is a radioresistant tumour
Does addition of GKS to WBRT prolong survival in metastatic melanoma of the brain?
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Search strategy
• P = Patients with metastatic melanoma of the brain
• I = Gamma Knife Surgery and WBRT
• C = WBRT
• O = survival benefit
Search Keywords (exp MESH )
“ Melanoma” “Brain Metas*” “Gamma Knife” “Radiotherapy”
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Search Results
• 71 total
• 5 relevant
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2 relevant papers
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Nil relevant
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Selection Criteria
• Cerebral melanoma metastasis• GKS + WBRT• Retrospective/prospective studies• Last 20 yrs• English Language
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Levels of Evidence (NHMRC)
Class l – nil
Class ll – nil
Class lll – nil
Class lV- 7
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The articles
1. Outcome predictors of Gamma Knife Surgery for Melanoma Brain Metastases
Donald N. Liew, M.D.et al, J Neurosurg 114:769–779, 2011
2. Gamma Knife surgery in the management of radioresistant brain metastases in high-risk patients with melanoma, renal cell carcinoma, and sarcoma
John W. Powell et al, J Neurosurg (Suppl) 109:000–000, 2008
3. Gamma Knife Surgery in Brain Melanomas: Absence of Extracranial Metastases and Tumour Volume Strongest Indicators of Prolonged Survival
Bente Sandvei Skeie, WORLD NEUROSURGERY 75 [5/6]: 684-691, MAY/JUNE 2011
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4. Gamma Knife radiosurgery for intracranial metastatic melanoma: an analysis of survival and prognostic factors
Mehmet Koc et al; Journal of Neuro-Oncology (2005) 71: 307–313
5 Stereotactic radiosurgery for cerebral metastatic melanoma
Salvador Somaza et al, J Neurosurg 79:661-666, 1993
6 Metastatic Melanoma To The Brain: Prognostic Factors After Gamma Knife Surgery
Cheng Yu Ph.D. et al, Int. J. Radiation Oncology Biol. Phys., Vol. 52, No. 5, pp. 1277–1287, 2002
7. Cerebral Metastases from Malignant Melanoma: Current Treatment Strategies, Advances in Novel Therapeutics and Future Directions
Timothy L. Siu and Suyun Huang , Cancers 2010, 2, 364-375
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Summary of findingsYear /Center No Type of
studyMethods Results/Conclusion
1993, Pittsburgh,US
23 Retrosp All pts WBRT + GKS
Median survival 9 months for pts with single mets and 7 months for multiple mets18/19 died due to systemic disease
2002,Los Angeles
122 Retrosp 39 had WBRT + GKS
> Median survival GKS : 7.5 monthsGKS + WBRT : 5 months>Predictors of survivalTumor volume< 3 cm3
Absent systemic diseaseKPS > 80Supratentorial location
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Year /Center No Type Of Study
Methods Result
2005,Ohio,US
26 Retrosp 14 pts had WBRT + GKS, 5 had GKS
Median survival 6 monthsPrognostic factors : KPS>90,Female,Supratentorial mets, absent neurology
WBRT, chemo/immunotherapy,age , no of mets : not significant
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Prognostic Factor Median survival
KPS >90 8 months
KPS< 90 5 months
Supratentorial mets 8 months
Infratentorial mets 3 months
Tumour Volume < 1cm3 20 months
Tumour volume > 1 cm3 5 months
Nil neurology 11 months
Neurology present 4 months
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Year /Center No Type of study
Methods Results/Conclusion
2008,New York
76 Retrosp Melanoma(50),RCC(23),sarcomas(3)
WBRT – 37 pts
Median survival with GKS – 5.1 months
No realtionship with WBRT
Prognostic : Single mets and and KPS score
2011,Pittsburgh
333 Retrospective
WBRT + SRS(87)Surgery + SRS (19)
Surgery + WBRT + SRS (31)
Median SurvivalWBRT + GKS : 4.5 mSRS : 6.4 m
Poor Prognostic factors > 4 mets KPPS < 90 no immunotherapy
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Year /Center No Type of study
Methods Results/Conclusion
2011Bente Sandvei Skeie et al
Norway
77 Retrosp 16 had WBRT
Selection:1) < 4 mets2) <3.5 cm3) No mass
effect4) KPS > 70
Median survival ; 7 months
With WBRTNo additional survival time
Incidence of new brain mets not deceresed
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• GKS compares well with surgery
• WBRT had been routinely given
• Melanoma is under represented
• Randomized control study shows neurocognitive decline with WBRT*
• SRS only for resection bed
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Summary
• No evidence that WBRT + GKS improves survival
• GKS alone would be sufficient
• Selection Criteria :
1) KPS Score
2) Size < 3cm
3) No of mets < 4
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Thank You