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7/24/2019 Clinical and Radiographic Outcomes From Repeat Whole-Brain Radiation Therapy for Brain Metastases in the Age

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Clinical and Radiographic Outcomes From RepeatWhole-Brain Radiation Therapy for Brain Metastases

in the Age of Stereotactic RadiosurgerySusan Guo, MD,* Ehsan H. Balagamwala, MD,* Chandana Reddy, MS,* Paul Elson, ScD,w

John H. Suh, MD,*zand Samuel T. Chao, MD*z

Objectives: Repeating whole-brain radiation therapy (WBRT) inpatients with progressive/recurrent brain metastases is controversial.We retrospectively reviewed our experience of repeat WBRT in an erawhere stereotactic radiosurgery was also available.

Methods: In our IRB-approved database, 49 patients received repeatWBRT from 1996 to 2011. Median initial dose of WBRT was 30 Gy in10 fractions (range, 27 to 37.5 Gy); median reirradiation dose was

20 Gy in 10 fractions (range, 14 to 30 Gy). Median Karnofsky per-formance status (KPS) at reirradiation was 70 (range, 40 to 90).Median number of discrete lesions at reirradiation was 6 (range, 1 to30). Median interval between initial diagnosis of brain metastases andrelapse requiring repeat WBRT was 11.5 months (range, 1.5 to49.2mo). Overall survival and relapse-free survival were summarizedusing the Kaplan-Meier method. The log-rank test was used to com-

pare outcomes between groups.

Results: Ninety percent of patients completed repeat WBRT. Mediansurvival after repeat WBRT was 3 months (95% CI, 1.9-4.0). Thirteen

patients had improved neurological symptoms (27%), 12 were sta-ble (24%), and 14 had worsening symptoms (29%). On radiographicfollow-up of 22 patients, 10 (46%) were improved, 4 (18%) werestable, and 8 (36%) progressed. Improved neurological symptoms afterrepeat WBRT and higher KPS at first follow-up were associated withimproved survival (P = 0.05 and 0.02).

Conclusions: Repeat WBRT was well tolerated. Modest survival timesare seen. Prognostic factors for survival include improved neurologicalsymptoms 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 notappropriate stereotactic radiosurgery candidates.

Key Words: brain metastases, reirradiation, whole-brain radiation

therapy, retreatment, salvage treatment

(Am J Clin Oncol2014;00:000000)

Brain metastases are diagnosed in 20% to 40% of cancerpatients, with rising incidence due to improving detectionand treatment of systemic malignancy.13 Historically, brain

metastases portended a rapidly fatal course in cancer patients.As systemic treatments have advanced, there have been reportsof long-term survivors with brain metastases. One series of

1300 patients showed that 2.5% of patients survivedZ5 years,and 15 of these 32 patients had recurrence of local or distant

brain disease.4

Randomized data have shown that the combination ofsurgery and whole-brain radiation therapy (WBRT) improvesoutcomes over either modality alone.5,6 Stereotactic radio-surgery (SRS) is being used more frequently due to reports of

potentially improved local control when combined with

WBRT and potentially decreased neurocognitive toxicitiescompared with WBRT.79

The treatment paradigm is unclear for patients who haverelapsed brain metastases after prior WBRT. Options includesurgery, SRS, repeat WBRT, or palliative care. SRS is fre-quently used for salvage therapy; however, whether patientswith high volume of brain metastases and poor performancestatus 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 singleinstitutional experience of repeat whole-brain irradiation in anera where SRS was also available for treatment of brainmetastases.

MATERIALS AND METHODSUsing our IRB-approved database of brain metastasespatients, we identified 49 consecutive patients who receivedrepeat WBRT for progressive or recurrent brain metastasesfrom 1996 to 2011 at our main campus and satellite facilities.Only patients who underwent 2 courses of radiation with tra-ditional WBRT fields were included; patients who underwentreirradiation with limited fields not encompassing the whole

brain were excluded from our analysis. We also excludedpatients who received prior WBRT at other institutions.WBRT was performed using opposed laterals on a linearaccelerator with 6 MV photons. Clinical information wasextracted from the paper and electronic medical records in thisretrospective review. The date of death was obtained from themedical record; when this was not available, the date of deathwas obtained from the Social Security Death Index.

We defined clinical response as follows: completeresponse refers to disappearance of neurological symptoms,

partial response refers to alleviation of neurological symptoms,stable refers to no change in neurological symptoms, pro-gressive disease refers to worsening of neurological symptoms,and asymptomatic refers to lack of neurological symptoms atthe beginning and end of treatment. Clinical and radiographicevaluation did not account for differences in steroid use anddosing. Patients were categorized as improved (complete or

partial response), stable, or progressive after repeat WBRT.Radiographic response was defined as follows: completeresponse refers to disappearance of radiographic brain

From the Departments of *Radiation Oncology; wQuantitative HealthSciences, Cleveland Clinic; andzRose 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: [email protected].

Copyright r 2014 by Lippincott Williams & WilkinsISSN: 0277-3732/14/000-000DOI: 10.1097/COC.0000000000000051

ORIGINAL ARTICLE

American Journal of Clinical Oncology Volume 00, Number 00, 2014 www.amjclinicaloncology.com | 1



metastases, partial response refers to decreased size or numberof brain metastases, stable refers to no change in number orsize of brain metastases, progressive disease refers to increasein number of metastases. Patients were categorized asimproved (complete or partial response), stable, or progressiveafter repeat WBRT. Relapse-free survival and overall survival

were defined from the start date of the second course of reir-radiation to the date of documented CNS progression anddeath, respectively. These outcomes were summarized usingthe Kaplan-Meier method. The log-rank test was used tocompare overall survival between patient groups.

RESULTS

Patient, tumor, and treatment characteristics at initialpresentation are listed in Table 1. The median age at initialpresentation of brain metastasis was 55 (range, 29 to 77). Nonsmall 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 atinitial diagnosis. At initial diagnosis of brain metastasis, 3

patients in this cohort had leptomeningeal disease (LMD), 40patients (82%) had extracranial disease, and 24 patients (49%)had controlled primary disease. The median initial dose ofWBRT was 30 Gy in 10 fractions (fx) (range, 20 to 37.5 Gy).At diagnosis, 51% of patients had Karnofsky performancestatus (KPS) of 90 to 100 and 82% were Radiation TherapyOncology Group recursive partitioning analysis Class II.

The median interval between the initial diagnosis of brainmetastases and relapse requiring repeat WBRT was 11.5months (range, 1.5 to 49.2 mo). Relapse was detected by MRIin 86% of patients and CT in 14% of patients.

Patient, tumor, and treatment characteristics at relapse arelisted in Table 2. The median age at repeat WBRT was 56(range, 30 to 78) and median KPS was 70 (range, 40 to 90).

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 >10lesions. One patient had a single parenchymal lesion at time ofrepeat WBRT. The patient also had concomitant LMD.Including this patient, a total of 3 patients (13%) had LMD inthe brain and/or spine at the time of repeat WBRT. Forty-six

patients (94%) had extracranial disease at the time of reirra-diation. Thirty-seven patients (76%) had controlled primarydisease at the time of reirradiation.

Ninety percent of patients completed the intended courseof reirradiation. Median survival after repeat WBRT was 3.0months (95% CI, 1.9-4.0) (Fig. 1). Twelve percent of patientswere alive beyond 6 months. The median time to relapse was1.7 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 ofradiation necrosis was seen. Documentation of steroid doseswas incomplete due to the lack of detailed medication reportsat the end of life. Additional treatments from brain metastaseswere characterized as follows. Before initial WBRT, 7 patients

TABLE 1. Patient, Tumor, and Treatment Characteristics for 49Repeat WBRT Patients at Initial Presentation

n (%)

Primary siteNSCLC 19 (39)SCLC 12 (24)Breast 9 (18)Melanoma 3 (6)Other 6 (12)

KPS at diagnosisr70 6 (12)80 18 (37)90-100 25 (51)

RPA class at diagnosisI 7 (14)II 40 (82)

III 2 (4)Dose/fractionation of initial WBRT

20 Gy/5 fx 1 (2)30 Gy/10 fx 38 (78)37.5 Gy/15 fx 10 (20)

Symptom response to initial WBRTAsymptomatic 19 (39)Complete or partial response 4 (8)Stable or progression 26 (53)

fx indicates fractions; NSCLC, nonsmall cell lung cancer; RPA, recursivepartitioning analysis; SCLC, small cell lung cancer; WBRT, whole-brain radi-ation therapy.

TABLE 2. Patient, Tumor, and Treatment Characteristics for 49Repeat WBRT Patients at Relapse Requiring Repeat WBRT

n (%)

KPS at relapser70 29 (59)

80 15 (31)90-100 5 (10)

Extracranial disease at relapseNo 3 (6)Yes 46 (94)

Dose/fractionation of repeat WBRT20 Gy/10 fx 28 (57)20 Gy/5 fx 16 (33)Other* 5 (10)

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

18Gy in 10 fx (1 patient), 22.5Gy in 9 fx (1 patient), and 30 Gy in 12 fx (2patients).

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

FIGURE 1. Overall survival after repeat whole-brain radiationtherapy (WBRT).

Guo et al American Journal of Clinical Oncology Volume 00, Number 00, 2014

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underwent surgical resection of brain metastases. In addition, 6patients underwent a course of SRS, and 1 patient underwent 2courses. After initial WBRT, 1 patient underwent surgicalresection. 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 ofneurological 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 radiographicfollow-up available (Table 3). Of those with follow-up imag-ing, 10 patients (46%) exhibited radiographic improvement, 4

patients (18%) were stable, and 8 patients (36%) exhibitedradiographic progression. At first follow-up after repeatWBRT, improvement of neurological symptoms and higherKPS were associated with improved survival (P = 0.05 and0.02, respectively) (Figs. 3, 4). Patients who demonstratedeither partial or complete improvement in neurological statushad a median survival of 5.4 months, compared with 3.0months in those who demonstrated stable or progressive neu-rological status. The median survivals of patients with KPSZ70, 40 to 60 and < 40 were 5.2, 3.3, 0.8 months, respectively.

A total of 6 patients (13%) had LMD. Three patients hadLMD at the time of initial WBRT and 3 patients had LMD atthe time of repeat WBRT. The median overall survival for

patients without LMD was 3.1 months compared with 1.5months for those patients who had LMD. Of the patients who

presented with LMD at diagnosis of brain metastasis, 1 had

LMD localized to the ventricular system; however, LMDsubsequently progressed after initial WBRT requiring repeatWBRT. The second patient presented with altered mentalstatus and LMD was found localized to the cerebral con-vexities and subsequently underwent initial WBRT. The third

patient had diffuse LMD in the brain and spine at diagnosisrequiring craniospinal irradiation. Of the patients that pre-sented with LMD after initial WBRT but before repeat WBRT,1 patient had diffuse LMD in the brain and spine and under-went craniospinal irradiation, another patient had LMD local-ized to the posterior fossa and underwent only repeat WBRT,and the third patient presented with imbalance and headacheswith workup revealing LMD localized to the brain andunderwent only repeat WBRT.

After repeat WBRT, 1 patient underwent SRS. On follow-up MRI 6 weeks after completing reirradiation, she was found tohave resolution of treated lesions but developed a new rightinsular lesion on MRI. She was subsequently treated with SRS 2weeks later. Two weeks after SRS, she was restaged and found tohave progressed at the primary site, had a decline in performancestatus, and was referred for palliative care. The date of last fol-low-up was 14 weeks after completing repeat WBRT.

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

TABLE 3. Clinical and Radiographic Response to Repeat WBRT

n (%)

Clinical symptoms response to repeat WBRTImproved 13 (27)Stable 12 (24)Progression 14 (29)

Not available 10 (20)Radiographic response to repeat WBRT

Improved 10 (20)Stable 4 (8)Progression 8 (16)

Not available 27 (55)

WBRT indicates whole-brain radiation therapy.

FIGURE 3. Overall survival by neurological symptom response.

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

American Journal of Clinical Oncology Volume 00, Number 00, 2014 Repeat WBRT Outcomes in the Age of SRS

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DISCUSSION

Eight other series have reported outcomes of repeatWBRT, spanning from 1974 to 2008.1017 These series, alongwith our results, are summarized in Table 4. We will focus on2 of the modern series that reported outcomes on repeat WBRTin an era where SRS was available.

Sadikov et al16

reported a series of 72 patients reirra-diated for brain metastases from 1997 to 2003 at PrincessMargaret Cancer Center. Most patients received an initial doseof 20 Gy in 5 fx and a range of doses for repeat WBRT. Thirty-one percent of patients experienced a partial clinical responseafter reirradiation, 27% remained stable, and 32% deteriorated.Patients with ECOG performance status 0 to 1 at time ofretreatment lived longer. The median survival after reirradia-tion was 4.1 months. In responders, the median duration ofresponse was 5.1 months. One patient was reported to havememory impairment and pituitary insufficiency after 5 monthsof progression-free survival. The authors concluded that repeatWBRT may be a useful treatment in carefully selected

patients. Of note, patients who received any SRS wereexcluded from their analysis.

Son et al17 reported a series of 17 brain metastasis patientswho underwent WBRT from 2002 to 2008 and subsequentlyreceived repeat WBRT at the Massachusetts General Hospital.The second course of WBRT was given upon radiographic dis-ease progression in 8 patients. Of 10 patients with completefollow-up data, 8 patients experienced complete or partialsymptom resolution, whereas 2 did not show clinical improve-ment. The time to radiographic progression was 5.2 months. Themedian survival after repeat WBRT was 5.2 months. Patientswith stable extracranial disease had an improved median survivalcompared with those with extracranial disease progression.Acute toxicities occurred in 71% of patients but were mild tomoderate in severity. Repeat WBRT was well tolerated. The

authors concluded that in select patients and especially thosewith stable extracranial disease, repeat WBRT may be anappropriate and effective intervention to provide symptomaticrelief and slow intracranial disease progression.

Our series, the most modern of these series, adds to thegrowing body literature that repeat WBRT is well tolerated and

effective in selected patients. Our 49 patients form this thelargest series in which SRS has also been used as a treatmentmodality in conjunction with repeat WBRT. Over 90% of

patients completed repeat WBRT. One third of our patientsexperienced improved neurological symptoms, which is con-sistent with results from the 8 other repeat WBRT series(Table 4). Our median survival of 3 months is also consistentwith reported survivals after reirradiation, which range from 2to 5 months.1017

We tested various factors for prognostic correlationincluding age, KPS, primary disease control, systemic diseasecontrol, recursive partitioning analysis, time to relapse, clinicalresponse after initial WBRT, and number of lesions. Of the

potential prognostic factors examined, only patients whoexhibited improvement of neurological symptoms after reir-radiation and those who exhibited higher KPS at first follow-up

had improved survival in our study. The magnitude of KPS atfirst follow-up correlated with overall survival. Patients withKPSZ70 had the best survival compared with patients withKPS scores of 40 to 60 and < 40. ECOG performance status

before repeat WBRT was observed to be a strong prognosticfactor for survival in the Princess Margaret series.16 Prognosticfactors identified in other series include absence of extracranialmetastases and clinical response to initial WBRT14,16,17

Patients with brain metastases encompass a very hetero-genous population. The improved response rates across themultiple series range from 27% to 80%, and our response rateof 27% is in line with the lower part of this range. The majority

TABLE 4. Comparison With Major Series of Repeat WBRT

This

Study

Shehata

et al10Kurup

et al11

Hazuka

and

Kinzie12Cooper

et al13Wong

et al14

Abdel-

Wahab

et al15Sadikov

et al16 Son et al17

n 49 35 56 44 52 86 15 72 17Initial RT 30 Gy/

10 fx10 Gy/1 fx

30 Gy/10 fx18Gy/3 fx 30Gy/10

fx30 Gy/10

fx30Gy/10 fx 30Gy/15

fx20 G y/5 fx 35 G y/14 fx

Repeat WBRT 20 G y/10 fx

10Gy/1 fx 20Gy/10fx

25Gy/8 fx 25Gy/10fx

20Gy/10 fx 30Gy/20fx (twice

daily)

25Gy/10 fx 21. 6Gy/12 fx

Interval (mo) 11.5(median)

6.3 (mean) 7.8(median)

> 4 7.6 (median) 10(median)

9.6 (median) 15 (median)

Response (%)Improved 27 68 75 27 42 70 60 40 80Stable 24 25 12.5 41 52 29 27 33 20

None 29 12.5 14 6 33 Stable or noresponse

Toxicity Nopatients

w/RN

83% noacute side

effects

17.8%acute, 1

patient RN

8autopsies,

3 RN

5 patients w/radiographicabnormality

1 patient memoryloss, pituitaryinsufficiency

71% at least1 acute side

effectSurvival after

repeat WBRT(mo)

3(median)

3.5(median)

2(median)

4(median)

4 (median) 3.2(median)

4.1 (median) 5.2 (median)

Time to progressionafter repeatWBRT (mo)

1.7(median)

2.5 2.75 4.1 (median) 2.6 (median)

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.





of patients in our cohort (94%) had extracranial disease atrelapse. We also included patients with LMD. Furthermore,59% of our cohort had KPSr70 at the time or reirradiation. Itis likely that the patients in our cohort had a higher burden ofdisease and worse performance status than the patients in otherseries, and therefore did not respond as well to repeat WBRT.

Twenty percent of our patients showed objectiveimprovement on radiographic follow-up. However, follow-upimaging is not routinely assessed in patients with brain meta-stases and was not available in 55% of the patients in ourreview, which may introduce selection bias in that patients withrepeat imaging were ones who were well enough to tolerate it.In light of this limitation, our series remains one of the twoseries that reports radiographic outcomes in these patients. Sonet al17 reported a mean time to radiographic progression of 5.2months in 10 of 17 patients with radiographic follow-up in theirseries.

Of the 8 major series reporting outcomes on repeat WBRT,only 2 of them took place in the SRS era.16,17 The series bySadikov and colleagues excluded patients treated with SRS forrecurrence. Therefore, we draw many comparisons with ourseries to the Massachusetts General series because theirs is the

only other report of repeat WBRT when SRS was availableas salvage therapy. However, one key difference is that theMassachusetts General series included patients who received

prophylactic cranial irradiation for small cell lung cancer as thefirst course of WBRT. Five of 17 patients received their firstcourse of WBRT prophylactically. These patients exhibitedlower overall survival than the rest of their cohort, which mayreflect a different natural history than patients with other pri-mary tumors. We excluded prophylactic cranial irradiation

patients from our analysis but did include patients with smallcell lung cancer who received WBRT for existing brain meta-stases. The Massachusetts General series also identified that

patients with stable extracranial disease had a significantlyimproved 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 thatour patient population may have a higher burden of disease. Thismay explain why median survival (3.0mo) in our series isshorter than their reported median survival of 5.2 months.

Although the median survival in our series after reirra-diation was modest, these patients represent a subset of

patients who are not able to undergo more focal treatment fortheir brain metastases either due to declining performancestatus or high volume of disease. Chao et al4 reported a mediansurvival of 9.9 months after SRS in patients who underwent

prior WBRT. Their series of 111 patients was the largest seriesreporting outcomes of salvage SRS after prior WBRT.Emerging evidence suggests that volume of brain metastases isan accurate predictor of survival.1820 Because patients whoundergo repeat WBRT are likely not candidates for SRS due tovolume of disease, the median survival for these patients ismuch lower than those reported for patients treated with SRSfor recurrence of brain metastases.

Hunter et al21 reported on their outcomes in treating 64patients with Z5 intracranial lesions in a single SRS session.The median overall survival was 7.5 months and median KPSwas 80 (range, 60 to 100). The authors found that the numberof treated lesions or the primary histology did not have asignificant impact on survival. However, a KPSZ80 sig-nificantly impacted overall survival (median overall survival,4.8 mo for KPSr70 vs. 8.8 mo for KPSZ80,P = 0.0097). Theauthors also report that prior WBRT (defined as WBRT >1 mo

before SRS) had a positive impact on overall survival. SRS

offers several advantages compared with WBRT: SRS can beperformed in one session, whereas WBRT requires multiplesessions which can be a significant burden on patients withlimited life expectancy; WBRT is limited to 1 or at most 2courses, whereas SRS can be repeated multiple times; and SRShas not been shown to have significant effects on memory and

cognition. On the basis of this series, the series from Hunteret al, and other studies,2123 salvage SRS for multiple meta-stases is more appropriate for those patients with higher per-formance scores and WBRT more appropriate for those withlower performance scores.

Steroid use was difficult to assess given the limiteddocumentation at the end of life. Several patients were able todecrease their steroid dose after repeat WBRT but were alsogiven 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 fromthe limited information in the medical record. Similarly, ste-roid use was not well documented in other series of repeatWBRT patients. The authors of the Massachusetts Generalseries had equal difficulty characterizing the role of reirradia-tion on steroid usage given small sample size, differences in

reasoning for steroid initiation, and variations in dosethroughout a patients treatment course.17

Multiple retrospective reviews have reported that repeatWBRT 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 whenthe aforementioned series are combined.11,12 No reports ofradiation necrosis are described in the more modern series ofrepeat WBRT. As SRS is being used more frequently forsalvage of brain metastases and patients are receiving morecumulative doses of radiation to the brain, more attention must

be paid to document toxicities. We have not seen increasedacute or late effects in patients who underwent SRS in additionto repeat WBRT, nor was this observed in the MassachusettsGeneral series.15 The short median survival in patients who

undergo repeat WBRT likely contributes to these very lowrates of radiation necrosis or other late toxicities.

Our data are limited by its retrospective nature. Thispopulation of patients is challenging to study because they areat the end of life. Because many patients are on hospice and dieat home, there are limited data in the medical record abouttheir neurological status after treatment. This may result inunderreporting of treatment toxicity and steroid usage. How-ever, as others have pointed out, concerns about unreportedlate effects should be balanced by the more likely occurrenceof neurological deterioration if brain metastases remainuntreated.16 An additional limitation was the lack of quantifi-cation of the volume of disease on the MRI at time of WBRT.Studies have shown that volume and not number of metastaseshas been prognostic for response.24 We did not have access toradiographic images for all patients, only the radiology report,and therefore were not able to calculate volume of diseaseaccurately.

CONCLUSIONS

Repeat WBRT was tolerable and safe in the vast majorityof our patients and those reported in the literature. Modestsurvival times are seen after reirradiation. Potential prognosticfactors for survival in our series include improvement ofneurological symptoms after reirradiation and higher KPS atfirst follow-up. Although SRS is increasingly used for salvagetreatment of brain metastases after prior WBRT, repeat WBRT

American Journal of Clinical Oncology Volume 00, Number 00, 2014 Repeat WBRT Outcomes in the Age of SRS

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is a viable option for palliating some patients with limitedperformance status and high-volume brain disease. The hightreatment completion rate, sizeable clinical response rate, andlimited toxicities suggest that repeat WBRT is worthwhile inselected patients with limited treatment options for recurrent

brain metastases.

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