Skip to content

Advertisement

Radiation Oncology

What do you think about BMC? Take part in

Open Access

Stereotactic radiosurgery alone for small cell lung cancer: a neurocognitivebenefit?

  • Eric Ojerholm1Email author,
  • Michelle Alonso-Basanta1 and
  • Charles B Simone II1
Radiation Oncology20149:218

https://doi.org/10.1186/1748-717X-9-218

Received: 29 August 2014

Accepted: 14 September 2014

Published: 30 September 2014

Abstract

Yomo and Hayashi reported results of stereotactic radiosurgery alone for brainmetastases from small cell lung cancer. This strategy aims to avoid theneurocognitive effects of whole-brain radiation therapy. However, radiosurgeryalone increases the risk of distant intracranial relapse, which canindependently worsen cognition. This concern is heightened in histologies likesmall cell with high predilection for intracranial spread. The majority of studypatients developed new brain disease, suggesting radiosurgery alone may not bean optimal strategy for preserving neurocognitive function in this population.We suggest whole-brain radiation therapy should remain the standard of care forsmall cell lung cancer.

Keywords

Small cell lung cancerStereotactic radiosurgeryWhole-brain radiation therapyNeurocognitiveProphylactic cranial irradiation

Correspondence/Findings

Letter to the Editor:

Yomo and Hayashi recently reported in Radiation Oncology their experiencewith upfront stereotactic radiosurgery (SRS) for brain metastases from small celllung cancer (SCLC) [1]. The authors should be commended for this novel investigation. We agreethat SRS might play a role in SCLC, particularly for treating a limited number ofbrain metastases after prior prophylactic cranial irradiation or prior whole-brainradiation therapy (WBRT). However, we echo the authors’ call for caution inadopting SRS alone as the initial approach for intracranial disease.

The strategy of upfront SRS is gaining increasing prominence [2], spurred by the excellent local control achieved with radiosurgery and byconcerns about the side effects of WBRT. These concerns are bolstered by studiesshowing declines in neurocognition and quality of life in patients receiving WBRT [35]. On the other hand, increased intracranial tumor burden often drivescognitive dysfunction [6, 7], and a recognized downside of SRS alone is high rates of distant brainrelapse. This concern is heightened in SCLC, a biologically aggressive tumor whichdisseminates to the central nervous system in approximately two-thirds of patientsduring the course of their disease [8]. Yomo and Hayashi report that 20 of 41 patients (49%) developed new brainmetastases after initial SRS, and because follow-up imaging was available in only 34cases, this rate could be interpreted as 20 of 34 (59%). The overall outcomes fromthis study suggest that radiosurgery may be a reasonable modality in well-selectedpatients with SCLC. However, it is also possible that in populations with high ratesof intracranial relapse, an SRS approach might actually hinder – rather thanhelp – cognitive function.

Which is more important for preserving neurocognition: limiting the volume ofirradiated brain or maximizing intracranial tumor control? The answer is uncertain,and ongoing studies aim to resolve this question (e.g. NAGKC 12–01 testingWBRT versus SRS alone for five or more brain metastases and NCCTG N107C testing WBRTversus SRS following surgical resection of a brain metastasis). Should these trialsfavor SRS, we anticipate increased enthusiasm for radiosurgery in all tumorhistologies – including SCLC – and Yomo and Hayashi’s study willbe an important initial report in this population. In the meantime, however, wesuggest that WBRT remain the standard of care for patients with brain metastasesfrom SCLC.

Author information

MAB is Chief of the Central Nervous System Service and CBS 2nd is Chief of theThoracic Service in the Department of Radiation Oncology.

Abbreviations

SRS: 

Stereotactic radiosurgery

SCLC: 

Small-cell lung cancer

WBRT: 

Whole-brainradiation therapy.

Declarations

Authors’ Affiliations

(1)
Department of Radiation Oncology, University of Pennsylvania

References

  1. Yomo S, Hayashi M: Upfront stereotactic radiosurgery in patients with brain metastases fromsmall cell lung cancer. Radiat Oncol 2014, 9: 152. 10.1186/1748-717X-9-152PubMed CentralView ArticlePubMedGoogle Scholar
  2. Yamamoto M, Serizawa T, Shuto T, Akabane A, Higuchi Y, Kawagishi J, Yamanaka K, Sato Y, Jokura H, Yomo S, Nagano O, Kenai H, Moriki A, Suzuki S, Kida Y, Iwai Y, Hayashi M, Onishi H, Gondo M, Sato M, Akimitsu T, Kubo K, Kikuchi Y, Shibasaki T, Goto T, Takanashi M, Mori Y, Takakura K, Saeki N, Kunieda E, et al.: Stereotactic radiosurgery for patients with multiple brain metastases(JLGK0901): a multi-institutional prospective observational study. Lancet Oncol 2014,15(4):387-395. 10.1016/S1470-2045(14)70061-0View ArticlePubMedGoogle Scholar
  3. Gondi V, Paulus R, Bruner DW, Meyers CA, Gore EM, Wolfson A, Werner-Wasik M, Sun AY, Choy H, Movsas B: Decline in tested and self-reported cognitive functioning after prophylacticcranial irradiation for lung cancer: pooled secondary analysis of RadiationTherapy Oncology Group randomized trials 0212 and 0214. Int J Radiat Oncol Biol Phys 2013,86(4):656-664. 10.1016/j.ijrobp.2013.02.033PubMed CentralView ArticlePubMedGoogle Scholar
  4. Chang EL, Wefel JS, Hess KR, Allen PK, Lang FF, Kornguth DG, Arbuckle RB, Swint JM, Shiu AS, Maor MH, Meyers CA: Neurocognition in patients with brain metastases treated with radiosurgery orradiosurgery plus whole-brain irradiation: a randomised controlled trial. Lancet Oncol 2009,10(11):1037-1044. 10.1016/S1470-2045(09)70263-3View ArticlePubMedGoogle Scholar
  5. Soffietti R, Kocher M, Abacioglu UM, Villa S, Fauchon F, Baumert BG, Fariselli L, Tzuk-Shina T, Kortmann RD, Carrie C, Ben Hassel M, Kouri M, Valeinis E, van den Berge D, Mueller RP, Tridello G, Collette L, Bottomley A: A European Organisation for Research and Treatment of Cancer phase III trialof adjuvant whole-brain radiotherapy versus observation in patients with oneto three brain metastases from solid tumors after surgical resection orradiosurgery: quality-of-life results. J Clin Oncol 2013,31(1):65-72. 10.1200/JCO.2011.41.0639View ArticlePubMedGoogle Scholar
  6. Li J, Bentzen SM, Renschler M, Mehta MP: Regression after whole-brain radiation therapy for brain metastasescorrelates with survival and improved neurocognitive function. J Clin Oncol 2007,25(10):1260-1266. 10.1200/JCO.2006.09.2536View ArticlePubMedGoogle Scholar
  7. Regine WF, Scott C, Murray K, Curran W: Neurocognitive outcome in brain metastases patients treated withaccelerated-fractionation vs. accelerated-hyperfractionated radiotherapy: ananalysis from Radiation Therapy Oncology Group Study 91–04. Int J Radiat Oncol Biol Phys 2001,51(3):711-717. 10.1016/S0360-3016(01)01676-5View ArticlePubMedGoogle Scholar
  8. Seute T, Leffers P, Ten Velde GP, Twijnstra A: Neurologic disorders in 432 consecutive patients with small cell lungcarcinoma. Cancer 2004,100(4):801-806. 10.1002/cncr.20043View ArticlePubMedGoogle Scholar

Copyright

© Ojerholm et al.; licensee BioMed Central Ltd. 2014

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/4.0), whichpermits unrestricted use, distribution, and reproduction in any medium, provided theoriginal work is properly credited. The Creative Commons Public Domain Dedicationwaiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to thedata made available in this article, unless otherwise stated.

Advertisement