Improvement in Quality of Survival Following Whole-Brain Irradiation for Brain Metastasis

The benefits of palliative therapy for patients with brain metastases have often been questioned (1–4) since these patients usually have widely disseminated disease and a limited survival. Assessment of therapeutic gain or successful palliation has proved to be the most difficult task. Prolongation of life (2, 5), or “increased survival for at least six months without further disability” (3), has been the surgical criterion for success, and amelioration of signs was reported as the criterion in the largest radiotherapeutic series (6). Yet, ultimately, it is the improvement of the functional capacity of the patient, his regained intellectual awareness and physical abilities, that determines whether a palliative result has been achieved. It is the purpose of this study to review the clinical findings, results, and implications of the treatment of brain metastases in 108 patients treated with whole-brain radiation. A patient classification based on functional status, which defines improvement and reports successful palliation in terms of quality of survival, is used to express the results. Methods One hundred eight patients were treated with whole-brain radiation for metastatic carcinoma from September 1958 to July 1966. The site of the primary tumor is shown in Table I. Metastases were predominantly of pulmonary (68 patients) and breast (15 patients) origin. Of the presenting symptoms and signs, most patients had multiple deficits. Motor loss, cranial nerve signs, and intellectual impairment predominated (Table II). A review of laboratory and x-ray studies (Table III) revealed that lumbar puncture, brain scan, and electroencephalogram were simple procedures with a high yield of positive findings. The electroencephalogram, however, was often reported as revealing nonspecific abnormalities. Thirty-five of the 108 patients did not receive treatment for their primary tumor. A little more than half of the patients, 56 out of the 108 total, were treated with super-voltage whole-brain radiation. The other 52 patients were treated with orthovoltage. The usual daily dose was 200 rads, central axis. Over 75 per cent of the patients received more than 2,500–3,000 rads (Fig.1). Twenty-four patients had received 2,500 rads or less and are described in the “Results” section. Ninety-six patients received at least three preliminary build-up doses of whole-brain radiation (50, 100, and 150 rads) before the daily dose of 200 rads was begun. Twenty-six patients had a surgical procedure prior to or concomitant with radiotherapy. Thirty-nine patients were treated with steroids during therapy. Sixteen patients were given a second course of whole-brain radiation when neurological symptoms recurred. Results The reason that 24 patients had low-dose, whole-brain irradiation (2,500 rads or less) is best described by the results of therapy. Seventeen of these patients failed to complete the proposed course of irradiation because of deterioration, and 3 failed to improve.