1. Evidence-Based Surgery
Role of Gamma Knife Surgery in Metastatic
Melanoma of the Brain
Sanmugarajah Paramasvaran
9th February 2012
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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
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3. 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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4. 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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5. Search Results
• 71 total
• 5 relevant
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6. 2 relevant papers
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7. Nil relevant
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8. Selection Criteria
• Cerebral melanoma metastasis
• GKS + WBRT
• Retrospective/prospective studies
• Last 20 yrs
• English Language
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9. Levels of Evidence (NHMRC)
Class l – nil
Class ll – nil
Class lll – nil
Class lV- 7
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10. 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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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: 307–313
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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12. Summary of findings
Year /Center No Type of Methods Results/Conclusion
study
1993, 23 Retrosp All pts WBRT + Median survival 9 months for
Pittsburgh, GKS pts with single mets and 7
US months for multiple mets
18/19 died due to systemic
disease
2002,Los 122 Retrosp 39 had WBRT + > Median survival
Angeles GKS GKS : 7.5 months
GKS + WBRT : 5 months
>Predictors of survival
Tumor volume< 3 cm3
Absent systemic disease
KPS > 80
Supratentorial location
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13. Year /Center No Type Of Methods Result
Study
2005,Ohio, 26 Retrosp 14 pts had Median survival 6
US 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
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14. 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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15. Year /Center No Type of Methods Results/Conclusion
study
2008, 76 Retrosp Melanoma(50),RC Median survival with GKS
New York C(23),sarcomas(3) – 5.1 months
WBRT – 37 pts No realtionship with
WBRT
Prognostic : Single mets
and and KPS score
2011, 333 Retrosp WBRT + SRS(87) Median Survival
Pittsburgh 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
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16. Year /Center No Type of Methods Results/Conclusion
study
2011 77 Retrosp 16 had WBRT Median survival ; 7
Bente months
Sandvei Selection:
Skeie et al 1) < 4 mets
2) <3.5 cm With WBRT
Norway 3) No mass No additional survival
effect time
4) KPS > 70
Incidence of new
brain mets not
deceresed
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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
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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
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19. Thank You
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