Ebs melanoma

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Ebs melanoma

  1. 1. Evidence-Based SurgeryRole of Gamma Knife Surgery in Metastatic Melanoma of the Brain Sanmugarajah Paramasvaran 9th February 2012 1
  2. 2. 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 2
  3. 3. Clinical Questions:• Melanoma is a radioresistant tumour Does addition of GKS to WBRT prolong survival in metastatic melanoma of the brain? 3
  4. 4. Search strategy• P = Patients with metastatic melanoma of the brain• I = Gamma Knife Surgery and WBRT• C = WBRT• O = survival benefitSearch Keywords (exp MESH )“ Melanoma” “Brain Metas*” “Gamma Knife” “Radiotherapy” 4
  5. 5. Search Results • 71 total • 5 relevant 5
  6. 6. 2 relevant papers 6
  7. 7. Nil relevant 7
  8. 8. Selection Criteria• Cerebral melanoma metastasis• GKS + WBRT• Retrospective/prospective studies• Last 20 yrs• English Language 8
  9. 9. Levels of Evidence (NHMRC)Class l – nilClass ll – nilClass lll – nilClass lV- 7 9
  10. 10. The articles1. Outcome predictors of Gamma Knife Surgery for Melanoma Brain Metastases Donald N. Liew, M.D.et al, J Neurosurg 114:769–779, 20112. 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, 20083. 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 10
  11. 11. 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: 307–3135 Stereotactic radiosurgery for cerebral metastatic melanoma Salvador Somaza et al, J Neurosurg 79:661-666, 19936 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, 20027. 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 11
  12. 12. Summary of findingsYear /Center No Type of Methods Results/Conclusion study1993, 23 Retrosp All pts WBRT + Median survival 9 months forPittsburgh, GKS pts with single mets and 7US months for multiple mets 18/19 died due to systemic disease2002,Los 122 Retrosp 39 had WBRT + > Median survivalAngeles GKS GKS : 7.5 months GKS + WBRT : 5 months >Predictors of survival Tumor volume< 3 cm3 Absent systemic disease KPS > 80 Supratentorial location 12
  13. 13. Year /Center No Type Of Methods Result Study2005,Ohio, 26 Retrosp 14 pts had Median survival 6US WBRT + GKS, months 5 had GKS Prognostic factors : KPS>90,Female,Suprat entorial mets, absent neurology WBRT, chemo/immunotherapy, age , no of mets : not significant 13
  14. 14. Prognostic Factor Median survivalKPS >90 8 monthsKPS< 90 5 monthsSupratentorial mets 8 monthsInfratentorial mets 3 monthsTumour Volume < 1cm3 20 monthsTumour volume > 1 cm3 5 monthsNil neurology 11 monthsNeurology present 4 months 14
  15. 15. Year /Center No Type of Methods Results/Conclusion study2008, 76 Retrosp Melanoma(50),RC Median survival with GKSNew York C(23),sarcomas(3) – 5.1 months WBRT – 37 pts No realtionship with WBRT Prognostic : Single mets and and KPS score2011, 333 Retrosp WBRT + SRS(87) Median SurvivalPittsburgh ective Surgery + SRS WBRT + GKS : 4.5 m (19) SRS : 6.4 m Surgery + WBRT + SRS (31) Poor Prognostic factors  > 4 mets  KPPS < 90  no immunotherapy 15
  16. 16. Year /Center No Type of Methods Results/Conclusion study2011 77 Retrosp 16 had WBRT Median survival ; 7Bente monthsSandvei Selection:Skeie et al 1) < 4 mets 2) <3.5 cm With WBRTNorway 3) No mass No additional survival effect time 4) KPS > 70 Incidence of new brain mets not deceresed 16
  17. 17. • 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 17
  18. 18. 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 18
  19. 19. Thank You 19

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