CHAPTER 20 Outcomes of Patients with Brain Metastases from Melanoma and Renal Cell Carcinoma after Primary Stereotactic Radiosurgery Randy L. Jensen, M.D., Ph.D., Annabelle F. Shrieve, M.A., Wolfram Samlowski, M.D., and Dennis C. Shrieve, M.D., Ph.D. P atients with melanoma or renal cell carcinoma (RCC) frequently have brain metastases. 3,9,15,38,46,47 These pa- tients have traditionally been treated with surgery, palliative whole-brain radiation (WBRT), or both. Surgery, even today, is generally reserved for assessable, symptomatic lesions in patients with a good Karnofsky Performance Score. Recur- sive partition analysis (RPA), which classifies patients on a scale of I to III based on Karnofsky Performance Score, age, and tumor control, has been used to identify patients that are expected to have the greatest clinical benefit from WBRT. 10,15,40 Although WBRT is the most widely used treatment for these patients, there is a general sense among those treating these patients that melanoma and RCC are considered radioresistant. 6,8,14,18,25,26 Stereotactic radiosurgery (SRS) performed using either linear accelerator- or gamma knife-based systems can achieve higher radiation doses within the tumor volume and theoretically can increase responses in these radiore- sistant tumors. Numerous reports have shown effective local control and prolonged patient survival after SRS for these lesions. 1,6,8,16,18,30,33,35,43 Early control of brain metastases is important in these patients, because many of them also have extracranial metastases. We hypothesized that early diagnosis and aggressive treatment of brain metastases with SRS in these patients could spare many patients WBRT. In addition, it seemed likely that this would permit early systemic ther- apy. The ultimate goal was to achieve improvement in sur- vival rates. We report our experience with using SRS as a primary treatment modality in patients with RCC and mela- noma brain metastasis. CLINICAL MATERIALS AND METHODS Data Collection After obtaining approval from the Institutional Review Board, we prospectively (from January 2006) collected pa- tient clinical data on patients undergoing SRS procedures at the Huntsman Cancer Institute at the University of Utah. We also retrospectively reviewed patients treated before January 2006. All patients included in this analysis had a minimum potential follow-up of 1 year after treatment with SRS. The following clinical information was obtained: age and sex; RPA class; date of primary diagnosis (if known); date of radiographic diagnosis of brain metastases and number of brain metastases; date of SRS, surgery, or WBRT; number of SRS treatments; radiation dose administered by SRS; and apparent cause of death (systemic, neurologic, or both). Follow-up imaging studies, when available, were used to assess tumor response. The Internet-based Social Security Death Index (http//ssdi.genealogy.rootsweb.com) was used to obtain survival data when it was not available from our records. Presumed cause of death (when no autopsy data were available) was determined according to imaging information and clinical notes at last follow-up visit. Clinical Management Strategy All patients with Stage IIIb or IV melanoma (based on 2001 American Joint Committee on Cancer recommenda- tions 4 ) are screened with magnetic resonance (MR) imaging or contrast-enhanced computed tomography scan of the brain at the time of initial evaluation at the Huntsman Cancer Institute. Patients with RCC were screened with brain MR imaging at the time of any neurological symptoms. Follow-up brain imaging was performed annually for 2 years or earlier if symptoms warranted. Patients were treated aggressively when brain metastases were discovered. SRS was used as the primary treatment modality if there were five or less brain metastases. WBRT was usually used if more than five brain metastases were detected, with stereotactic boost to larger lesions. Patients were closely monitored with brain imaging studies (generally gadolinium-enhanced MR imaging) at least every 2 months, and salvage treatment (including SRS boost to one or more growing lesions or WBRT, if not previously used, to five or more new lesions) was used if there was evidence of radiographic disease progression. Palliative sur- Copyright © 2008 by The Congress of Neurological Surgeons 0148-703/08/5501-0150 Clinical Neurosurgery • Volume 55, 2008 150