ORIGINAL ARTICLE

Clinical and Radiographic Outcomes From Repeat

Whole-Brain Radiation Therapy for Brain Metastases
in the Age of Stereotactic Radiosurgery
Susan Guo, MD,* Ehsan H. Balagamwala, MD,* Chandana Reddy, MS,* Paul Elson, ScD,w
John H. Suh, MD,*z and Samuel T. Chao, MD*z

Objectives: Repeating whole-brain radiation therapy (WBRT) in

patients with progressive/recurrent brain metastases is controversial.
We retrospectively reviewed our experience of repeat WBRT in an era
where stereotactic radiosurgery was also available.
Methods: In our IRB-approved database, 49 patients received repeat
WBRT from 1996 to 2011. Median initial dose of WBRT was 30 Gy in
10 fractions (range, 27 to 37.5 Gy); median reirradiation dose was
20 Gy in 10 fractions (range, 14 to 30 Gy). Median Karnofsky performance status (KPS) at reirradiation was 70 (range, 40 to 90).
Median number of discrete lesions at reirradiation was 6 (range, 1 to
30). Median interval between initial diagnosis of brain metastases and
relapse requiring repeat WBRT was 11.5 months (range, 1.5 to
49.2 mo). Overall survival and relapse-free survival were summarized
using the Kaplan-Meier method. The log-rank test was used to compare outcomes between groups.
Results: Ninety percent of patients completed repeat WBRT. Median
survival after repeat WBRT was 3 months (95% CI, 1.9-4.0). Thirteen
patients had improved neurological symptoms (27%), 12 were stable (24%), and 14 had worsening symptoms (29%). On radiographic
follow-up of 22 patients, 10 (46%) were improved, 4 (18%) were
stable, and 8 (36%) progressed. Improved neurological symptoms after
repeat WBRT and higher KPS at first follow-up were associated with
improved survival (P = 0.05 and 0.02).
Conclusions: Repeat WBRT was well tolerated. Modest survival times
are seen. Prognostic factors for survival include improved neurological
symptoms after repeat WBRT and higher KPS at first follow-up.
Repeat WBRT may be useful to improve neurological symptoms in
patients with limited treatment options, especially those who are not
appropriate stereotactic radiosurgery candidates.
Key Words: brain metastases, reirradiation, whole-brain radiation
therapy, retreatment, salvage treatment

(Am J Clin Oncol 2014;00:000000)

rain metastases are diagnosed in 20% to 40% of cancer

patients, with rising incidence due to improving detection
and treatment of systemic malignancy.13 Historically, brain
metastases portended a rapidly fatal course in cancer patients.
As systemic treatments have advanced, there have been reports
of long-term survivors with brain metastases. One series of
From the Departments of *Radiation Oncology; wQuantitative Health
Sciences, Cleveland Clinic; and zRose Ella Burkhardt Brain Tumor and
Neuro-Oncology Center, Cleveland, OH.
The authors declare no conflicts of interest.
Reprints: Samuel T. Chao, MD, Department of Radiation Oncology,
Cleveland Clinic, 9500 Euclid Ave, Desk T28, Cleveland, OH 44195.
E-mail: chaos@ccf.org.
Copyright r 2014 by Lippincott Williams & Wilkins
ISSN: 0277-3732/14/000-000
DOI: 10.1097/COC.0000000000000051

American Journal of Clinical Oncology

1300 patients showed that 2.5% of patients survived Z5 years,

and 15 of these 32 patients had recurrence of local or distant
brain disease.4
Randomized data have shown that the combination of
surgery and whole-brain radiation therapy (WBRT) improves
outcomes over either modality alone.5,6 Stereotactic radiosurgery (SRS) is being used more frequently due to reports of
potentially improved local control when combined with
WBRT and potentially decreased neurocognitive toxicities
compared with WBRT.79
The treatment paradigm is unclear for patients who have
relapsed brain metastases after prior WBRT. Options include
surgery, SRS, repeat WBRT, or palliative care. SRS is frequently used for salvage therapy; however, whether patients
with high volume of brain metastases and poor performance
status truly benefit from SRS has not been well documented.
Repeat WBRT is not frequently used due to concerns of
potential toxicities.9 We retrospectively reviewed our single
institutional experience of repeat whole-brain irradiation in an
era where SRS was also available for treatment of brain
metastases.

MATERIALS AND METHODS

Using our IRB-approved database of brain metastases
patients, we identified 49 consecutive patients who received
repeat WBRT for progressive or recurrent brain metastases
from 1996 to 2011 at our main campus and satellite facilities.
Only patients who underwent 2 courses of radiation with traditional WBRT fields were included; patients who underwent
reirradiation with limited fields not encompassing the whole
brain were excluded from our analysis. We also excluded
patients who received prior WBRT at other institutions.
WBRT was performed using opposed laterals on a linear
accelerator with 6 MV photons. Clinical information was
extracted from the paper and electronic medical records in this
retrospective review. The date of death was obtained from the
medical record; when this was not available, the date of death
was obtained from the Social Security Death Index.
We defined clinical response as follows: complete
response refers to disappearance of neurological symptoms,
partial response refers to alleviation of neurological symptoms,
stable refers to no change in neurological symptoms, progressive disease refers to worsening of neurological symptoms,
and asymptomatic refers to lack of neurological symptoms at
the beginning and end of treatment. Clinical and radiographic
evaluation did not account for differences in steroid use and
dosing. Patients were categorized as improved (complete or
partial response), stable, or progressive after repeat WBRT.
Radiographic response was defined as follows: complete
response refers to disappearance of radiographic brain

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American Journal of Clinical Oncology

Guo et al

metastases, partial response refers to decreased size or number

of brain metastases, stable refers to no change in number or
size of brain metastases, progressive disease refers to increase
in number of metastases. Patients were categorized as
improved (complete or partial response), stable, or progressive
after repeat WBRT. Relapse-free survival and overall survival
were defined from the start date of the second course of reirradiation to the date of documented CNS progression and
death, respectively. These outcomes were summarized using
the Kaplan-Meier method. The log-rank test was used to
compare overall survival between patient groups.

RESULTS
Patient, tumor, and treatment characteristics at initial
presentation are listed in Table 1. The median age at initial
presentation of brain metastasis was 55 (range, 29 to 77). Non
small cell lung cancer (39%), small cell lung cancer (24%),
and breast cancer (18%) were the most common primary sites.
The median number of lesions treated at initial WBRT was 4
(range, 1 to 21). Thirteen patients (27%) had 1 brain lesion at
initial diagnosis. At initial diagnosis of brain metastasis, 3
patients in this cohort had leptomeningeal disease (LMD), 40
patients (82%) had extracranial disease, and 24 patients (49%)
had controlled primary disease. The median initial dose of
WBRT was 30 Gy in 10 fractions (fx) (range, 20 to 37.5 Gy).
At diagnosis, 51% of patients had Karnofsky performance
status (KPS) of 90 to 100 and 82% were Radiation Therapy
Oncology Group recursive partitioning analysis Class II.
The median interval between the initial diagnosis of brain
metastases and relapse requiring repeat WBRT was 11.5
months (range, 1.5 to 49.2 mo). Relapse was detected by MRI
in 86% of patients and CT in 14% of patients.
Patient, tumor, and treatment characteristics at relapse are
listed in Table 2. The median age at repeat WBRT was 56
(range, 30 to 78) and median KPS was 70 (range, 40 to 90).
TABLE 1. Patient, Tumor, and Treatment Characteristics for 49
Repeat WBRT Patients at Initial Presentation

n (%)
Primary site
NSCLC
SCLC
Breast
Melanoma
Other
KPS at diagnosis
r70
80
90-100
RPA class at diagnosis
I
II
III
Dose/fractionation of initial WBRT
20 Gy/5 fx
30 Gy/10 fx
37.5 Gy/15 fx
Symptom response to initial WBRT
Asymptomatic
Complete or partial response
Stable or progression

19
12
9
3
6

(39)
(24)
(18)
(6)
(12)

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TABLE 2. Patient, Tumor, and Treatment Characteristics for 49

Repeat WBRT Patients at Relapse Requiring Repeat WBRT

n (%)
KPS at relapse
r70
80
90-100
Extracranial disease at relapse
No
Yes
Dose/fractionation of repeat WBRT
20 Gy/10 fx
20 Gy/5 fx
Other*

29 (59)
15 (31)
5 (10)
3 (6)
46 (94)
28 (57)
16 (33)
5 (10)

*Other fractionation schemes delivered included 14 Gy in 5 fx (1 patient),

18 Gy in 10 fx (1 patient), 22.5 Gy in 9 fx (1 patient), and 30 Gy in 12 fx (2
patients).
fx indicates fractions; WBRT, whole-brain radiation therapy.

The median dose used for repeat WBRT was 20 Gy in 10 fx

(range, 14 to 30 Gy).
The median number of discrete lesions at time of repeat
WBRT was 6 (range, 1 to 30); twelve patients (26%) had >10
lesions. One patient had a single parenchymal lesion at time of
repeat WBRT. The patient also had concomitant LMD.
Including this patient, a total of 3 patients (13%) had LMD in
the brain and/or spine at the time of repeat WBRT. Forty-six
patients (94%) had extracranial disease at the time of reirradiation. Thirty-seven patients (76%) had controlled primary
disease at the time of reirradiation.
Ninety percent of patients completed the intended course
of reirradiation. Median survival after repeat WBRT was 3.0
months (95% CI, 1.9-4.0) (Fig. 1). Twelve percent of patients
were alive beyond 6 months. The median time to relapse was
1.7 months (95% CI, 1.3-2.1) (Fig. 2). Acute toxicities were
not beyond those expected from WBRT and included alopecia,
skin changes, fatigue, and headaches. No definitive evidence of
radiation necrosis was seen. Documentation of steroid doses
was incomplete due to the lack of detailed medication reports
at the end of life. Additional treatments from brain metastases
were characterized as follows. Before initial WBRT, 7 patients

6 (12)
18 (37)
25 (51)
7 (14)
40 (82)
2 (4)
1 (2)
38 (78)
10 (20)
19 (39)
4 (8)
26 (53)

fx indicates fractions; NSCLC, nonsmall cell lung cancer; RPA, recursive

partitioning analysis; SCLC, small cell lung cancer; WBRT, whole-brain radiation therapy.

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FIGURE 1. Overall survival after repeat whole-brain radiation

therapy (WBRT).
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American Journal of Clinical Oncology

Volume 00, Number 00, 2014

FIGURE 2. Relapse-free survival after repeat whole-brain radiation therapy (WBRT).

underwent surgical resection of brain metastases. In addition, 6

patients underwent a course of SRS, and 1 patient underwent 2
courses. After initial WBRT, 1 patient underwent surgical
resection. In addition, 9 patients underwent a course of SRS, 5
patients underwent 2 courses, 2 patients underwent 3 courses,
and 1 patient underwent 4 courses of SRS.
After repeat WBRT, 13 patients had improvement of
neurological symptoms (27%), 12 had stable symptoms (24%),
14 had worsening symptoms (29%), and 10 were not evaluable
(20%). Twenty-seven patients (55%) did not have radiographic
follow-up available (Table 3). Of those with follow-up imaging, 10 patients (46%) exhibited radiographic improvement, 4
patients (18%) were stable, and 8 patients (36%) exhibited
radiographic progression. At first follow-up after repeat
WBRT, improvement of neurological symptoms and higher
KPS were associated with improved survival (P = 0.05 and
0.02, respectively) (Figs. 3, 4). Patients who demonstrated
either partial or complete improvement in neurological status
had a median survival of 5.4 months, compared with 3.0
months in those who demonstrated stable or progressive neurological status. The median survivals of patients with KPS
Z70, 40 to 60 and < 40 were 5.2, 3.3, 0.8 months, respectively.
A total of 6 patients (13%) had LMD. Three patients had
LMD at the time of initial WBRT and 3 patients had LMD at
the time of repeat WBRT. The median overall survival for
patients without LMD was 3.1 months compared with 1.5
months for those patients who had LMD. Of the patients who

Repeat WBRT Outcomes in the Age of SRS

FIGURE 3. Overall survival by neurological symptom response.

presented with LMD at diagnosis of brain metastasis, 1 had

LMD localized to the ventricular system; however, LMD
subsequently progressed after initial WBRT requiring repeat
WBRT. The second patient presented with altered mental
status and LMD was found localized to the cerebral convexities and subsequently underwent initial WBRT. The third
patient had diffuse LMD in the brain and spine at diagnosis
requiring craniospinal irradiation. Of the patients that presented with LMD after initial WBRT but before repeat WBRT,
1 patient had diffuse LMD in the brain and spine and underwent craniospinal irradiation, another patient had LMD localized to the posterior fossa and underwent only repeat WBRT,
and the third patient presented with imbalance and headaches
with workup revealing LMD localized to the brain and
underwent only repeat WBRT.
After repeat WBRT, 1 patient underwent SRS. On followup MRI 6 weeks after completing reirradiation, she was found to
have resolution of treated lesions but developed a new right
insular lesion on MRI. She was subsequently treated with SRS 2
weeks later. Two weeks after SRS, she was restaged and found to
have progressed at the primary site, had a decline in performance
status, and was referred for palliative care. The date of last follow-up was 14 weeks after completing repeat WBRT.

TABLE 3. Clinical and Radiographic Response to Repeat WBRT

n (%)
Clinical symptoms response to repeat WBRT
Improved
Stable
Progression
Not available
Radiographic response to repeat WBRT
Improved
Stable
Progression
Not available

13
12
14
10

(27)
(24)
(29)
(20)

10
4
8
27

(20)
(8)
(16)
(55)

WBRT indicates whole-brain radiation therapy.

FIGURE 4. Overall survival by KPS at first follow-up.

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American Journal of Clinical Oncology

Guo et al

DISCUSSION

Volume 00, Number 00, 2014

authors concluded that in select patients and especially those

with stable extracranial disease, repeat WBRT may be an
appropriate and effective intervention to provide symptomatic
relief and slow intracranial disease progression.
Our series, the most modern of these series, adds to the
growing body literature that repeat WBRT is well tolerated and
effective in selected patients. Our 49 patients form this the
largest series in which SRS has also been used as a treatment
modality in conjunction with repeat WBRT. Over 90% of
patients completed repeat WBRT. One third of our patients
experienced improved neurological symptoms, which is consistent with results from the 8 other repeat WBRT series
(Table 4). Our median survival of 3 months is also consistent
with reported survivals after reirradiation, which range from 2
to 5 months.1017
We tested various factors for prognostic correlation
including age, KPS, primary disease control, systemic disease
control, recursive partitioning analysis, time to relapse, clinical
response after initial WBRT, and number of lesions. Of the
potential prognostic factors examined, only patients who
exhibited improvement of neurological symptoms after reirradiation and those who exhibited higher KPS at first follow-up
had improved survival in our study. The magnitude of KPS at
first follow-up correlated with overall survival. Patients with
KPSZ70 had the best survival compared with patients with
KPS scores of 40 to 60 and < 40. ECOG performance status
before repeat WBRT was observed to be a strong prognostic
factor for survival in the Princess Margaret series.16 Prognostic
factors identified in other series include absence of extracranial
metastases and clinical response to initial WBRT14,16,17
Patients with brain metastases encompass a very heterogenous population. The improved response rates across the
multiple series range from 27% to 80%, and our response rate
of 27% is in line with the lower part of this range. The majority

Eight other series have reported outcomes of repeat

WBRT, spanning from 1974 to 2008.1017 These series, along
with our results, are summarized in Table 4. We will focus on
2 of the modern series that reported outcomes on repeat WBRT
in an era where SRS was available.
Sadikov et al16 reported a series of 72 patients reirradiated for brain metastases from 1997 to 2003 at Princess
Margaret Cancer Center. Most patients received an initial dose
of 20 Gy in 5 fx and a range of doses for repeat WBRT. Thirtyone percent of patients experienced a partial clinical response
after reirradiation, 27% remained stable, and 32% deteriorated.
Patients with ECOG performance status 0 to 1 at time of
retreatment lived longer. The median survival after reirradiation was 4.1 months. In responders, the median duration of
response was 5.1 months. One patient was reported to have
memory impairment and pituitary insufficiency after 5 months
of progression-free survival. The authors concluded that repeat
WBRT may be a useful treatment in carefully selected
patients. Of note, patients who received any SRS were
excluded from their analysis.
Son et al17 reported a series of 17 brain metastasis patients
who underwent WBRT from 2002 to 2008 and subsequently
received repeat WBRT at the Massachusetts General Hospital.
The second course of WBRT was given upon radiographic disease progression in 8 patients. Of 10 patients with complete
follow-up data, 8 patients experienced complete or partial
symptom resolution, whereas 2 did not show clinical improvement. The time to radiographic progression was 5.2 months. The
median survival after repeat WBRT was 5.2 months. Patients
with stable extracranial disease had an improved median survival
compared with those with extracranial disease progression.
Acute toxicities occurred in 71% of patients but were mild to
moderate in severity. Repeat WBRT was well tolerated. The

TABLE 4. Comparison With Major Series of Repeat WBRT

This
Study
n
Initial RT
Repeat WBRT
Interval (mo)
Response (%)
Improved
Stable
None
Toxicity

Shehata
et al10

Kurup
et al11

Hazuka
and
Kinzie12

Cooper
et al13

49
35
56
44
52
30 Gy/ 10 Gy/1 fx 18 Gy/3 fx 30 Gy/10 30 Gy/10
10 fx 30 Gy/10 fx
fx
fx
20 Gy/ 10 Gy/1 fx 20 Gy/10 25 Gy/8 fx 25 Gy/10
10 fx
fx
fx

Wong
et al14
86
30 Gy/10 fx
20 Gy/10 fx

AbdelWahab
et al15
15
30 Gy/15
fx
30 Gy/20
fx (twice
daily)
10
(median)

Sadikov
et al16

Son et al17

72
20 Gy/5 fx

17
35 Gy/14 fx

25 Gy/10 fx

21.6 Gy/12 fx

9.6 (median)

15 (median)

11.5
(median)

6.3 (mean)

7.8
(median)

>4

7.6 (median)

27
24
29

68
25

75
12.5
12.5

27
41
14

42
52
6

70
29

60
27

40
33
33

5 patients w/
radiographic
abnormality
4 (median)

1 patient memory
loss, pituitary
insufficiency
4.1 (median)

80
20
Stable or no
response
71% at least
1 acute side
effect
5.2 (median)

4.1 (median)

2.6 (median)

No
83% no
17.8%
8

patients acute side

acute, 1
autopsies,
w/RN
effects
patient RN
3 RN
3

3.5
2
4
(median)
(median) (median) (median)

Survival after
repeat WBRT
(mo)
Time to progression
1.7
after repeat
(median)
WBRT (mo)

2.5

3.2
(median)

2.75

fx indicates fractions; RN, radiation necrosis; WBRT, whole-brain radiation therapy.

Adapted from Son et al.17 Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from
the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.

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American Journal of Clinical Oncology

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of patients in our cohort (94%) had extracranial disease at

relapse. We also included patients with LMD. Furthermore,
59% of our cohort had KPSr70 at the time or reirradiation. It
is likely that the patients in our cohort had a higher burden of
disease and worse performance status than the patients in other
series, and therefore did not respond as well to repeat WBRT.
Twenty percent of our patients showed objective
improvement on radiographic follow-up. However, follow-up
imaging is not routinely assessed in patients with brain metastases and was not available in 55% of the patients in our
review, which may introduce selection bias in that patients with
repeat imaging were ones who were well enough to tolerate it.
In light of this limitation, our series remains one of the two
series that reports radiographic outcomes in these patients. Son
et al17 reported a mean time to radiographic progression of 5.2
months in 10 of 17 patients with radiographic follow-up in their
series.
Of the 8 major series reporting outcomes on repeat WBRT,
only 2 of them took place in the SRS era.16,17 The series by
Sadikov and colleagues excluded patients treated with SRS for
recurrence. Therefore, we draw many comparisons with our
series to the Massachusetts General series because theirs is the
only other report of repeat WBRT when SRS was available
as salvage therapy. However, one key difference is that the
Massachusetts General series included patients who received
prophylactic cranial irradiation for small cell lung cancer as the
first course of WBRT. Five of 17 patients received their first
course of WBRT prophylactically. These patients exhibited
lower overall survival than the rest of their cohort, which may
reflect a different natural history than patients with other primary tumors. We excluded prophylactic cranial irradiation
patients from our analysis but did include patients with small
cell lung cancer who received WBRT for existing brain metastases. The Massachusetts General series also identified that
patients with stable extracranial disease had a significantly
improved median survival time after reirradiation compared with
patients who had progressive extracranial disease. In our series,
94% of patients had extracranial disease at relapse, reflecting that
our patient population may have a higher burden of disease. This
may explain why median survival (3.0 mo) in our series is
shorter than their reported median survival of 5.2 months.
Although the median survival in our series after reirradiation was modest, these patients represent a subset of
patients who are not able to undergo more focal treatment for
their brain metastases either due to declining performance
status or high volume of disease. Chao et al4 reported a median
survival of 9.9 months after SRS in patients who underwent
prior WBRT. Their series of 111 patients was the largest series
reporting outcomes of salvage SRS after prior WBRT.
Emerging evidence suggests that volume of brain metastases is
an accurate predictor of survival.1820 Because patients who
undergo repeat WBRT are likely not candidates for SRS due to
volume of disease, the median survival for these patients is
much lower than those reported for patients treated with SRS
for recurrence of brain metastases.
Hunter et al21 reported on their outcomes in treating 64
patients with Z5 intracranial lesions in a single SRS session.
The median overall survival was 7.5 months and median KPS
was 80 (range, 60 to 100). The authors found that the number
of treated lesions or the primary histology did not have a
significant impact on survival. However, a KPSZ80 significantly impacted overall survival (median overall survival,
4.8 mo for KPSr70 vs. 8.8 mo for KPSZ80, P = 0.0097). The
authors also report that prior WBRT (defined as WBRT >1 mo
before SRS) had a positive impact on overall survival. SRS
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Repeat WBRT Outcomes in the Age of SRS

offers several advantages compared with WBRT: SRS can be

performed in one session, whereas WBRT requires multiple
sessions which can be a significant burden on patients with
limited life expectancy; WBRT is limited to 1 or at most 2
courses, whereas SRS can be repeated multiple times; and SRS
has not been shown to have significant effects on memory and
cognition. On the basis of this series, the series from Hunter
et al, and other studies,2123 salvage SRS for multiple metastases is more appropriate for those patients with higher performance scores and WBRT more appropriate for those with
lower performance scores.
Steroid use was difficult to assess given the limited
documentation at the end of life. Several patients were able to
decrease their steroid dose after repeat WBRT but were also
given additional steroids close to their date of death. Thus,
steroid usage was highly dependent on the time of assessment.
We were not able to draw any meaningful conclusions from
the limited information in the medical record. Similarly, steroid use was not well documented in other series of repeat
WBRT patients. The authors of the Massachusetts General
series had equal difficulty characterizing the role of reirradiation on steroid usage given small sample size, differences in
reasoning for steroid initiation, and variations in dose
throughout a patients treatment course.17
Multiple retrospective reviews have reported that repeat
WBRT is safe.1417 Including our series, outcomes have now
been reported on 426 patients who underwent reirradiation.
Four patients have been noted to have radiation necrosis when
the aforementioned series are combined.11,12 No reports of
radiation necrosis are described in the more modern series of
repeat WBRT. As SRS is being used more frequently for
salvage of brain metastases and patients are receiving more
cumulative doses of radiation to the brain, more attention must
be paid to document toxicities. We have not seen increased
acute or late effects in patients who underwent SRS in addition
to repeat WBRT, nor was this observed in the Massachusetts
General series.15 The short median survival in patients who
undergo repeat WBRT likely contributes to these very low
rates of radiation necrosis or other late toxicities.
Our data are limited by its retrospective nature. This
population of patients is challenging to study because they are
at the end of life. Because many patients are on hospice and die
at home, there are limited data in the medical record about
their neurological status after treatment. This may result in
underreporting of treatment toxicity and steroid usage. However, as others have pointed out, concerns about unreported
late effects should be balanced by the more likely occurrence
of neurological deterioration if brain metastases remain
untreated.16 An additional limitation was the lack of quantification of the volume of disease on the MRI at time of WBRT.
Studies have shown that volume and not number of metastases
has been prognostic for response.24 We did not have access to
radiographic images for all patients, only the radiology report,
and therefore were not able to calculate volume of disease
accurately.

CONCLUSIONS
Repeat WBRT was tolerable and safe in the vast majority
of our patients and those reported in the literature. Modest
survival times are seen after reirradiation. Potential prognostic
factors for survival in our series include improvement of
neurological symptoms after reirradiation and higher KPS at
first follow-up. Although SRS is increasingly used for salvage
treatment of brain metastases after prior WBRT, repeat WBRT
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is a viable option for palliating some patients with limited

performance status and high-volume brain disease. The high
treatment completion rate, sizeable clinical response rate, and
limited toxicities suggest that repeat WBRT is worthwhile in
selected patients with limited treatment options for recurrent
brain metastases.
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