Radiosurgery Practice Guideline Initiative …

1 1 Radiosurgery Practice Guideline InitiativeStereotactic Radiosurgery for Patients with Metastatic Brain TumorsRadiosurgery Practice Guideline Report # 5-08 ORIGINAL Guideline : May 2008 MOST RECENT LITERATURE SEARCH: May 2008 This Practice Guideline , together with a report on Metastatic Brain Tumor Management is anoriginal Guideline approved by The International Radiosurgery Association and issued in IRSA (International Radiosurgery Association) Radiosurgery Practice Guideline Initiative aims to improve outcomes forbrain metastases Radiosurgery by assisting physicians and clinicians in applying research evidence to clinical decisions whilepromoting the responsible use of health care Guideline is copyrighted by IRSA (2008)

2 And may not be reproduced without the written permission of IRSA. IRSA reserves the right to revoke copyright authorization at any time without Guideline is not intended as a substitute for professional medical advice and does not address specific treatments orconditions for any patient. Those consulting this Guideline are to seek qualified consultation utilizing information specific totheir medical situation. Further, IRSA does not warrant any instrument or equipment nor make any representations concerningits fitness for use in any particular instance nor any other warranties WORDS brain metastases WBRT stereotactic Radiosurgery Gamma Knife linear acceleratorKEY WORDS Bragg peak proton therapy irradiationMetastatic Brain TumorsConsensus StatementObjectiveTo develop a consensus-based Radiosurgery practiceguideline for brain metastases treatment recommendationsto be used by medical and public health professionals whodiagnose and manage

3 Patients with brain metastatic working group included physicians and physicists fromthe staff of major medical centers that provide first author (AN) conducted a literature search inconjunction with the preparation of this document anddevelopment of other clinical guidelines . The literatureidentified was reviewed and opinions were sought fromexperts in the diagnosis and management of brain metastasesincluding members of the working ProcessThe initial draft of the consensus statement was a synthesisof research information obtained in the evidence gatheringprocess.

4 Members of the working group provided formalwritten comments that were incorporated into the preliminarydraft of the statement. No significant disagreements final statement incorporates extensive relevant evidenceobtained by the literature search in conjunction with the finalconsensus recommendations supported by all working CompositionThe Radiosurgery guidelines group is comprised ofneurosurgeons, neuro-oncologists, radiation and medicaloncologists and physicists. Community representatives didnot participate in the development of this of Group Members: Ajay Niranjan, , , Neurosurgeon, Chair; L.

5 Dade Lunsford, ,Neurosurgeon; Richard L. Weiner, , Neurosurgeon; GailL. Rosseau, , Neurosurgeon; Gene H. Barnett, , , Neurosurgeon; Massaki Yamamoto, ; Lawrence S. Chin, , ,Neurosurgeon; Paul J. Miller, , Radiation Oncologist;Andrew E. Sloan, , Neurosurgeon; Burton L. Speiser, , Radiation Oncologist; Sandra S. Vermeulen, ,Radiation Oncologist; Harish Thakrar, , RadiationOncologist; Frank Lieberman, , Neuro-Oncologist;David Schiff, , Neuro-Oncologist; Sammie R. Coy, , Medical Physicist; Tonya K. Ledbetter, , ,Editor; Rebecca L.

6 Emerick, , , , recommendations are made regarding targetpopulation, treatment alternatives, interventions and practicesand additional research needs. Appropriate use ofradiosurgery for patients with brain metastases Guideline is intended to provide the scientific foundationand initial framework for patients who have been diagnosedwith brain metastases. The assessment and recommendationsprovided herein represent the best professional judgment ofthe working group at this time, based on clinical researchdata and expertise currently available.

7 The conclusions andrecommendations will be regularly reassessed as newinformation becomes RadiosurgeryBrain stereotactic Radiosurgery (SRS) involves the use ofprecisely directed, closed skull, single session radiation tocreate a desired radiobiologic response within the brain targetwith acceptable minimal effects on surrounding structuresor tissues. In the case of brain metastases, highly conformal,precisely focused radiation is delivered to the metastatictumor in a single session under the direct supervision of aradiosurgery team.

8 At Centers of Excellence, theradiosurgery team includes a neurosurgeon, a radiationoncologist, a physicist and a registered of Brain MetastasesEpidemiologic FeaturesMetastatic brain tumors are the most common intracranialneoplasms in adults and are a significant cause of morbidityand mortality. They outnumber primary brain tumors by aratio of 10 Approximately million individuals werediagnosed with cancer in 2005 2006. Conservativeestimates suggest that 100,000 170,000 new cases of brainmetastases are diagnosed every year in the United States( ).

9 59,108 Between 20% and 40% of all patients withmetastatic cancer will have brain metastases at estimate of the incidence rate of metastatic brain tumorsvaries from 11 per 100, ,127 In two large populationcohorts of patients who were diagnosed with colorectal, lung,breast or kidney carcinoma or melanoma, brain metastaseswere diagnosed in of ,108 The incidencevaried by primary tumor site. The cumulative incidence wasestimated at in patients with lung carcinoma, in patients with renal carcinoma, inpatients with melanoma, in patients with breastcarcinoma, and in patients with majority of patients who develop brain metastases havea known primary cancer (metachronous presentation).

10 Noprimary systemic site of cancer is detected in 5 10% ofpatients with brain ,95 Patients with a history oflung cancer have the shortest latency period between thetime of initial diagnosis and the diagnosis of brain metastases(median, 6 9 months). For renal cell carcinoma, the intervalis approximately one year. Patients with breast, melanomaand colon cancer experience spread of their disease to thebrain at a median latency of approximately two Therate of breast cancer metastases to the brain may be higheramong patients treated with trastuzumab (Herceptin ).