Skip to main content
Download PDF

The indication of palliative whole-brain radiotherapy for patients with brain metastases: a simple prognostic scoring system in the era of stereotactic radiosurgery

BMC Cancer volume 24, Article number: 940 (2024) Cite this article

Abstract

Background

Stereotactic irradiation has become the mainstay treatment for brain metastases (BM), and whole-brain radiotherapy (WBRT) is often used for symptom palliation. However, the survival time of patients with BM undergoing palliative WBRT (pWBRT) is limited, making it difficult to select patients who should receive treatment.

Methods

We collected patient data from 2016 to 2022 at the Shizuoka Cancer Center and retrospectively analyzed the factors related to survival time. Overall survival (OS) was defined as the survival time after WBRT.

Results

A total of 301 patients (median age, 66 years) who underwent pWBRT were included. The primary cancers were lung, breast, gastrointestinal tract, and other cancers in 203 (67%), 38 (13%), 33 (11%), and 27 (9%) patients, respectively. Median OS of all patients was 4.1 months. In the multivariate analysis, male sex (hazard ratio [HR]:1.4), Karnofsky Performance Status (KPS) ≤ 60 (HR:1.7), presence of extracranial metastasis (ECM) (HR:1.6), neutrophil-lymphocyte ratio (NLR) ≥ 5 (HR:1.6), and lactate dehydrogenase (LDH) ≥ upper limit of normal (ULN) (HR:1.3) were significantly associated with shorter OS (all P < 0.05). To predict the OS, we created a prognostic scoring system (PSS). We gave one point to each independent prognostic factor. Median OS for patients with scores of 0–2, 3, and 4–5 were 9.0, 3.5 and 1.7 months, respectively (P < 0.001).

Conclusions

Male sex, KPS ≤ 60, presence of ECM, NLR ≥ 5, and LDH ≥ ULN were poor prognostic factors for patients with BM undergoing pWBRT. By PSS combining these factors, it may be possible to select patients who should undergo pWBRT.

Peer Review reports

Introduction

Brain metastases (BM) are the most common intracranial tumors, affecting up to 40% of all cancer patients [1]. Radiotherapy for BM has significantly changed in recent years. Stereotactic radiotherapy (STI) has become the standard treatment for patients with BM [2, 3]. In addition, the effects of targeted therapy [4] and immune checkpoint inhibitors [5] on BM have been shown. As a result, whole-brain radiotherapy (WBRT) is often used as a palliative treatment for patients with BM who are not candidates for systemic therapy, tumor resection or STI [6]. It has been reported in the QUARTZ trial that palliative WBRT (pWBRT) did not provide a clear benefit for patients with BM that have poor survival outcomes [7]. However, patients who survived longer than six months after WBRT showed significant improvements in physical and emotional functioning [8]. Therefore, patients with reasonable life expectancies should not be excluded from pWBRT, and the selection of patients for pWBRT is significant.

Several studies have attempted to identify the prognostic factors and predict the life expectancy of patients with BM. The recursive partitioning assessment (RPA) [9] and graded prognostic assessment (GPA) scores [10] are well known, which are based on clinical characteristics such as the patient age, Karnofsky Performance Status (KPS), status of extracranial disease, and number of BM. However, it is difficult to predict the patient prognosis based on clinical factors alone [11]. Blood tests can provide an objective measure of the current status of patients, which has recently been shown to correlate with outcomes in several cancers. For example, the neutrophil-lymphocyte ratio (NLR), which reflects systemic inflammation, is a predictor of overall survival (OS) after craniotomy [12] or STI [13] for BM, and lactate dehydrogenase (LDH), which may reflect high tumor load, is also a predictor of OS in patients with BM [14]. To predict the life expectancy of patients with BM, it may be helpful to combine the clinical characteristics and laboratory parameters of patients.

Herein, we collected patient data from 2016, when STI began to be used at our institute, to 2022, and retrospectively analyzed factors related to survival time after pWBRT. This study aimed to create a prognostic scoring system (PSS) for patients with BM treated with pWBRT.

Method

Patient population

All analyses were approved by the Institutional Review Board of Shizuoka Cancer Center (J2023-174-2023-1-3) and was conducted in accordance with the principles of the Declaration of Helsinki.

We retrospectively studied 580 consecutive patients who underwent WBRT at the Shizuoka Cancer Center between June 2016, which was when STI began to be used for BM with more than four lesions, and December 2022. All patients were diagnosed with BM using magnetic resonance imaging or computed tomography scan. We excluded patients with primary brain tumor, hematological malignancy, pediatric patients under the age of 15 years, post-resection BM, prophylactic irradiation for SCLC, and meningeal metastasis.

The clinical data of patients included date of birth, sex, height, body weight, past medical history, KPS, first date of WBRT, date of death or last visit, primary site of the lesion, number of BM, presence of extracranial metastasis (ECM), and regular use of oral steroids for > 4 weeks. Blood tests were performed 1 month before WBRT without intravenous steroid injection. Neutrophil, lymphocyte, serum albumin levels, LDH, and hemoglobin (Hb) were recorded. Because NLR ≥ 5 [12], serum albumin < lower limit of normal (LLN), Hb < LLN, and LDH > upper limit of normal (ULN) [14] have been reported to be prognostic factors for patients with BM, we defined these values as the respective thresholds.

Treatment

The cancer board of our institution approved WBRT for patients with the following characteristics: (1) patients unsuitable for resection and STI, and (2) a life expectancy of ≥ 3 months based on the evaluation of the medical oncologists. The prescribed dose was calculated at the isocenter of the radiation field. The WBRT treatment plan included a total dose of 30 Gy in 10 fractions for 261 patients (87%), 30 Gy in 12 fractions for 16 patients (5%), 37.5 Gy in 15 fractions for 13 patients (4%), and others for 11 patients (4%).

Statistical analysis

The OS was calculated from the first date of WBRT to the date of death due to any cause or the last visit to our hospital. Prognostic factors were analyzed using the log-rank test and Bonferroni correction for the univariate analysis and Cox regression analysis for the multivariate analysis. Statistical significance was set at P < 0.05. Statistical analysis was performed using the EZR statistical software (version 1.63) [15].

Results

Patient characteristics

A flowchart of the patient selection process is shown in Fig. 1. A total of 580 patients who underwent WBRT were analyzed, and 279 patients were excluded for the following reasons: primary brain tumor, 27; meningeal metastasis, 21; prophylactic WBRT for SCLC, 105; hematological malignancy, 21; post-resection of BM, 63; pediatric patient, 20; and unavailable blood data, 22. Finally, 301 patients who underwent pWBRT were included in this study. Two hundred seventy patients (90%) had died,14 patients were alive, and 17 patients were lost to follow-up. The Patient characteristics are shown in Table 1. The median follow-up duration was 3.9 months (interquartile range, 1.6–9.9), and the median age at the first day of WBRT was 66 years (range, 22–87). The patients with age ≥ 60 years, of male sex, a KPS ≥ 70, and with an ECM were 211 (70%), 171 (57%), 155 (51%), and 245 (81%), respectively. The primary cancers were lung, breast, gastrointestinal, gynecological, and other cancers in 203 (67%), 38 (13%), 33 (11%), 8 (3%), and 19 (6%) patients, respectively. The median NLR and serum albumin level, LDH and Hb before WBRT were 3.6 (range, 0.26–49) and 3.8 (range, 1.9–5.2), 235 (range, 122–4665) and 12.2 (range, 4.0-17.5) respectively.

Fig. 1
figure 1

The patient selection flowchart. BM, brain metastases; SCLC, small cell lung cancer; WBRT, whole-brain radiotherapy

Full size image
Table 1 Patient characteristics
Full size table

Univariate and multivariate analyses of the OS

Figure 2A presents the Kaplan–Meier survival curves for patients with BM treated with WBRT. The median OS for all patients was 4.1 months (95% confidence interval [CI]: 3.3–4.7 months). Table 2 shows the factors associated with the OS. In the univariate analysis, the factors associated with a shorter OS were male sex (median OS, 3.2 months; 95% CI: 2.3–4.0 months, P < 0.01), KPS ≤ 60 (median OS, 2.4 months; 95% CI: 2.0–3.1 months, P < 0.01), not lung cancer (median OS, 2.8 months; 95% CI: 2.0–3.6 months, P = 0.02), presence of ECM (median OS, 3.6 months; 95% CI: 2.9–4.3 months, P = 0.04), NLR ≥ 5 (median OS, 2.2 months; 95% CI: 1.8–2.6 months, P < 0.01), serum albumin < 3.5 (median OS, 2.1 months, 95% CI: 1.6–2.4 months, P < 0.01), LDH > ULN (median OS, 2.5 months, 95% CI: 2.1–3.1 months, P < 0.01) and Hb < LLN (median OS, 2.9 months, 95% CI: 2.4–3.7 months, P < 0.01). RPA was a significant predictor of prognosis, but GPA was not. Driver gene mutations such as EGFR/ALK/ROS1 were not significant prognostic factors in patients with non-SCLC (P = 0.56). In the multivariate analysis, the factors associated with a shorter OS were male sex (hazard ratio [HR]: 1.4, 95% CI: 1.1–1.8, P = 0.01), KPS ≤ 60 (HR: 1.7, 95% CI: 1.3–2.2, P < 0.01), presence of ECM (HR: 1.6, 95% CI: 1.1–2.2, P < 0.01), NLR ≥ 5 (HR: 1.6, 95% CI: 1.2–2.1, P < 0.01), and LDH > ULN (HR: 1.3, 95% CI: 1.0–1.7, P = 0.03). The Kaplan–Meier curves for these factors are shown in Fig. 2B and F. Since we aimed to establish a PSS that can be used regardless of primary cancer, the primary site was not included as a factor in the multivariate analysis.

Fig. 2
figure 2

Kaplan–Meier curves of the overall survival. a. All patients. b. Sex of the patients. c. Presence of extracranial metastasis. d. Karnofsky performance status ≥ 70 or ≤ 60. e. Neutrophil-lymphocyte ratio ≥ 5 or < 5. f. Lactate dehydrogenase ≥ upper limit of normal or < upper limit of normal. g. Prognostic score 0–2, 3 and 4–5

Full size image
Table 2 Univariate and multivariate analysis of the OS
Full size table

Prognostic scoring system for patients with BM treated with pWBRT

A new PSS was introduced to predict the survival of patients after pWBRT. The PSS was associated with male sex and the presence of ECM, KPS, NLR, and LDH, which were independent prognostic factors. A score of one was assigned to male sex, presence of ECM, KPS ≤ 60, NLR ≥ 5, and LDH > ULN, and a score of zero to female sex, absence of ECM, KPS ≥ 70, NLR < 5, and LDH ≤ ULN. Since the HR of each variable was almost equivalent, the weights of the assigned scores were set equally among these factors. The Kaplan–Meier survival curve showed that the median duration of OS for 129 patients with a score of 0–2, 89 patients with a score of 3 and 83 patients with a score of 4–5 were 9.0 (95% CI: 6.4–10.4), 3.5 (95% CI: 2.8–4.7) and 1.7 months (95% CI: 1.3–2.1), respectively (P < 0.001; Fig. 2G; Table 3). Lung cancer patients were almost equally included in each group.

Table 3 The details of the prognostic scoring system for patients with brain metastases treated with palliative whole brain radiotherapy
Full size table

Discussion

The purpose of WBRT has changed to palliation due to STI having an increased use for the treatment of BM. In recent years, the prognosis of patients undergoing pWBRT has been reported to be poor at 2.8–3.7 months [16, 17]. In our study, the median OS of patients receiving pWBRT was also poor (4.1 months), which is consistent with previous reports. Since the effectiveness of palliation has been confirmed in patients who survive for more than half a year after WBRT [8], patients who can survive for a long time should be selected. The Radiation Therapy Oncology Group reported the RPA [9] and GPA [10] as prognostic tools for cancer patients with BM. However, the treatment methods for BM have changed significantly since the publication of these reports. Therefore, we believe that it would be meaningful to create a prognostic tool that is limited to patients with BM who are undergoing pWBRT.

In this study, male sex, presence of ECM, KPS ≤ 60, NLR ≥ 5, and LDH > ULN were significant poor prognostic factors for patients undergoing pWBRT based on the multivariate analysis. In a retrospective analysis of 239 patients with BM who received pWBRT, male sex was reported to be a poor prognostic factor [17], similar with our results. The KPS, although no significant difference was found in the QUARTZ trial, tended to be related to patient prognosis [7]. The KPS has been reported to be an independent predictive factor in non-SCLC patients with BM who underwent pWBRT [18]. In addition, the KPS is a prognostic factor for terminally ill cancer patients [19, 20]. Regarding the NLR ≥ 5, patients with a low NLR may experience prolonged survival after WBRT for advanced non-SCLC [21]. Similarly, the NLR has been reported to be a prognostic factor after resection [12] and radiation therapy [13] in patients with BM. To the best of our knowledge, this is the first study to examine the NLR in patients with cancer who underwent pWBRT. LDH was reported to be a factor in the LabBM score, which was reported in a cohort of 1200 cancer patients with BM [14]. LDH may reflect high tumor load and inflammation. LabBM score consists of Hb, platelet count, LDH, C-reactive protein (CRP) and serum albumin. Because systemic inflammation was reported to be associated with cancer　development and progression [13], NLR, LDH, and CRP may be important factors in the cancer journey. Hence, blood tests can provide an objective measure of the current status of patients. Because CRP data was missing in 10% of patients, CRP could not be analyzed in this study. To create a PSS for patients with BM who receive pWBRT, the combination of the clinical characteristics and laboratory parameters of patients may be better.

We created a PSS for patients with BM who had undergone pWBRT. This PSS consisted of male sex and the presence of ECM, KPS, NLR, and LDH, which were independent prognostic factors based on the analyses. We assigned one point to each factor and created a simple PSS. The median OS for patients with a score 0–2, those with score 3 and those with score 4–5 were 9.0, 3.5 and 1.7 months, respectively. This PSS may be useful for predicting patients who will survive for more than half a year. Based on the results of the QUARTZ trial, patients with a score of 0–2 may be recommended pWBRT and patients with a score of 4–5 may be recommended best care support. Recently, a multicenter retrospective study conducted in Spain reported a prognostic index for patients with BM treated with pWBRT [17]. The study showed seven factors that are necessary for predicting patient prognosis, such as ECOG PS ≥ 2, digestive cancer, urothelium cancer, prior WBRT, absence of systemic treatment after WBRT, history of targeted treatment prior to BM, and high CRP value. The study assigned 1–3 points to each factor and divided them into three groups: good, intermediate, and poor prognosis. Compared to their report, our study may be more easily used in clinical practice because of the simplified scoring and grouping of patients. Although we believe that chemotherapy, targeted therapy, and immune checkpoint inhibitors before and after pWBRT are important factors, we were unable to collect such data for some cases in this study.

This study had some limitations. The analyzed data were obtained from a single facility, and there was a risk of patient selection bias. Although the sample size was sufficient for the statistical analysis, the results were not validated. In the future, we need to validate this PSS in patients with BM from multiple centers. The blood test results, such as CRP levels, should have been analyzed, but were excluded from the analysis because they could not be collected from some patients.

Conclusion

Male sex, KPS ≤ 60, presence of ECM, NLR ≥ 5, and LDH > ULN were poor prognostic factors for patients with BM who underwent pWBRT. By PSS combining these factors, it may be possible to select patients who should undergo pWBRT. In the future, we need to validate this PSS in patients with BM from multiple centers.

Data availability

The datasets generated and/or analyzed in the current study are available from the corresponding author upon reasonable request.

Abbreviations

BM:

Brain metastases

CI:

Confidence interval

CRP:

C-reactive protein

ECM:

Extracranial metastasis

GPA:

Graded prognostic assessment

Hb:

Hemoglobin

HR:

Hazard ratio

KPS:

Karnofsky performance status

LDH:

Lactate dehydrogenase

LLN:

Lower limit of normal

NLR:

Neutophil-lymphocyte ratio

OS:

Overall survival

PSS:

Prognostic scoring system

pWBRT:

Palliative whole brain radiotherapy

RPA:

Recursive partitioning assessment score

SCLC:

Small cell lung cancer

STI:

Stereotactic irradiation

ULN:

Upper limit of normal

WBRT:

Whole brain radiotherapy

References

  1. Nussbaum ES, Djalilian HR, Cho KH, Hall WA. Brain metastases. Histology, multiplicity, surgery, and survival. Cancer. 1996;78(8):1781–8.

    Article  CAS  PubMed  Google Scholar 

  2. Yamamoto M, Serizawa T, Shuto T, Akabane A, Higuchi Y, Kawagishi J, Yamanaka K, Sato Y, Jokura H, Yomo S, et al. Stereotactic radiosurgery for patients with multiple brain metastases (JLGK0901): a multi-institutional prospective observational study. Lancet Oncol. 2014;15(4):387–95.

    Article  PubMed  Google Scholar 

  3. Nagai N, Koide Y, Shindo Y, Hashimoto S, Tachibana H, Kodaira T, Ishihara S, Naganawa S. Retrospective non-inferiority study of stereotactic radiosurgery for more than ten brain metastases. J Neurooncol. 2023;163(2):385–95.

    Article  PubMed  Google Scholar 

  4. Hui C, Qu V, Wang JY, von Eyben R, Chang YC, Chiang PL, Liang CH, Lu JT, Li G, Hayden-Gephart M, et al. Local control of brain metastases with osimertinib alone in patients with EGFR-mutant non-small cell lung cancer. J Neurooncol. 2022;160(1):233–40.

    Article  CAS  PubMed  Google Scholar 

  5. Wakuda K, Yabe M, Kodama H, Nishioka N, Miyawaki T, Miyawaki E, Mamesaya N, Kawamura T, Kobayashi H, Omori S, et al. Efficacy of pembrolizumab in patients with brain metastasis caused by previously untreated non-small cell lung cancer with high tumor PD-L1 expression. Lung Cancer. 2021;151:60–8.

    Article  CAS  PubMed  Google Scholar 

  6. Suh JH, Kotecha R, Chao ST, Ahluwalia MS, Sahgal A, Chang EL. Current approaches to the management of brain metastases. Nat Rev Clin Oncol. 2020;17(5):279–99.

    Article  PubMed  Google Scholar 

  7. Mulvenna P, Nankivell M, Barton R, Faivre-Finn C, Wilson P, McColl E, Moore B, Brisbane I, Ardron D, Holt T, et al. Dexamethasone and supportive care with or without whole brain radiotherapy in treating patients with non-small cell lung cancer with brain metastases unsuitable for resection or stereotactic radiotherapy (QUARTZ): results from a phase 3, non-inferiority, randomised trial. Lancet. 2016;388(10055):2004–14.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Adegboyega B, Joseph A, Alabi A, Omomila J, Ngema LM, Ainsworth V, Chin J, Evbuomwan MO, Ngwa W. Patient reported outcomes following whole brain radiotherapy in patients with brain metastases in NSIA-LUTH Cancer Center. BMC Cancer. 2023;23(1):1233.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Gaspar L, Scott C, Rotman M, Asbell S, Phillips T, Wasserman T, McKenna WG, Byhardt R. Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy Oncology Group (RTOG) brain metastases trials. Int J Radiat Oncol Biol Phys. 1997;37(4):745–51.

    Article  CAS  PubMed  Google Scholar 

  10. Sperduto PW, Berkey B, Gaspar LE, Mehta M, Curran W. A new prognostic index and comparison to three other indices for patients with brain metastases: an analysis of 1,960 patients in the RTOG database. Int J Radiat Oncol Biol Phys. 2008;70(2):510–4.

    Article  PubMed  Google Scholar 

  11. Kondziolka D, Parry PV, Lunsford LD, Kano H, Flickinger JC, Rakfal S, Arai Y, Loeffler JS, Rush S, Knisely JP, et al. The accuracy of predicting survival in individual patients with cancer. J Neurosurg. 2014;120(1):24–30.

    Article  PubMed  Google Scholar 

  12. Mitsuya K, Nakasu Y, Kurakane T, Hayashi N, Harada H, Nozaki K. Elevated preoperative neutrophil-to-lymphocyte ratio as a predictor of worse survival after resection in patients with brain metastasis. J Neurosurg. 2017;127(2):433–7.

    Article  PubMed  Google Scholar 

  13. Cho A, Untersteiner H, Fitschek F, Khalaveh F, Pruckner P, Pavo N, Rössler K, Dorfer C, Gatterbauer B, Höller C, et al. The clinical relevance of laboratory prognostic scores for patients with radiosurgically treated brain metastases of non-pulmonary primary tumor. J Neurooncol. 2021;153(3):497–505.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Berghoff AS, Wolpert F, Holland-Letz T, Koller R, Widhalm G, Gatterbauer B, Dieckmann K, Birner P, Bartsch R, Zielinski CC, et al. Combining standard clinical blood values for improving survival prediction in patients with newly diagnosed brain metastases-development and validation of the LabBM score. Neuro Oncol. 2017;19(9):1255–62.

    CAS  PubMed  PubMed Central  Google Scholar 

  15. Kanda Y. Investigation of the freely available easy-to-use software ‘EZR’ for medical statistics. Bone Marrow Transpl. 2013;48(3):452–8.

    Article  CAS  Google Scholar 

  16. Keit E, Lee SF, Woodward M, Rembielak A, Shiue K, Desideri I, Oldenburger E, Bienz M, Rades D, Theodorou M, et al. Palliative whole brain radiation therapy: an international state of practice. Ann Palliat Med. 2023;12(6):1155–64.

    Article  PubMed  Google Scholar 

  17. Flores-Paco P, Vargas-Aliaga A, Guevara MG, Lopera I, Ruiz LR, López-Herrero M, Camús JA, López-González J, Inga-Saavedra E, Montero M et al. A new updated prognostic index for patients with brain metastases (BMs) treated with palliative whole brain radiotherapy (WBRT) in the era of precision oncology. METASNCore project. J Neurooncol 2024.

  18. Harada H, Asakura H, Ogawa H, Mori K, Takahashi T, Nakasu Y, Nishimura T. Prognostic factors in patients with brain metastasis from non-small cell lung cancer treated with whole-brain radiotherapy. J Cancer Res Ther. 2016;12(1):267–70.

    Article  CAS  PubMed  Google Scholar 

  19. Morita T, Tsunoda J, Inoue S, Chihara S. The Palliative Prognostic Index: a scoring system for survival prediction of terminally ill cancer patients. Support Care Cancer. 1999;7(3):128–33.

    Article  CAS  PubMed  Google Scholar 

  20. Pirovano M, Maltoni M, Nanni O, Marinari M, Indelli M, Zaninetta G, Petrella V, Barni S, Zecca E, Scarpi E, et al. A new palliative prognostic score: a first step for the staging of terminally ill cancer patients. Italian Multicenter and Study Group on Palliative Care. J Pain Symptom Manage. 1999;17(4):231–9.

    Article  CAS  PubMed  Google Scholar 

  21. Doi H, Nakamatsu K, Anami S, Fukuda K, Inada M, Tatebe H, Ishikawa K, Kanamori S, Monzen H, Nishimura Y. Neutrophil-to-lymphocyte ratio predicts Survival after whole-brain Radiotherapy in Non-small Cell Lung Cancer. Vivo. 2019;33(1):195–201.

    Article  CAS  Google Scholar 

Download references

Acknowledgements

We would like to thank Editage (www.editage.com) for the English language editing.

Funding

The authors declare that no funds, grants, or other support was received during the preparation of this manuscript.

Author information

Authors and Affiliations

  1. Division of Neurosurgery, Shizuoka Cancer Center, Nagaizumi, Japan

    Toshiaki Hirose, Shoichi Deguchi, Koichi Mitsuya & Nakamasa Hayashi

  2. Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8560, Aichi, Japan

    Toshiaki Hirose, Shoichi Deguchi & Ryuta Saito

  3. Radiation and Proton Therapy Center, Shizuoka Cancer Center, Nagaizumi, Japan

    Kazuaki Yasui, Minoru Inoue, Tsuyoshi Onoe, Hirofumi Ogawa, Hirofumi Asakura, Hideyuki Harada, Shigeyuki Murayama & Tetsuo Nishimura

Authors
  1. Toshiaki Hirose
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Shoichi Deguchi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kazuaki Yasui
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Minoru Inoue
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Tsuyoshi Onoe
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Hirofumi Ogawa
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Hirofumi Asakura
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Koichi Mitsuya
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Hideyuki Harada
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Shigeyuki Murayama
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Nakamasa Hayashi
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Tetsuo Nishimura
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Ryuta Saito
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All the authors contributed to the design and conception of this study. TH and SD conducted the data collection and analysis, and prepared the first draft of the manuscript. All authors commented on and critically revised previous drafts of the manuscript, and approved of the final manuscript.

Corresponding author

Correspondence to Shoichi Deguchi.

Ethics declarations

Ethics approval and consent to participate

The study was conducted in accordance with the principles of the Declaration of Helsinki. This study was approved by the Institutional Review Board of Shizuoka Cancer Center (J2023-174-2023-1-3) This study collected data from hospital medical records from the period of June 2016 and December 2022. The need for written informed consent was waived by the Shizuoka Cancer Center ethics committee due to the retrospective nature of the study. This study neither contains personal information nor involves commercial interests.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it.The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hirose, T., Deguchi, S., Yasui, K. et al. The indication of palliative whole-brain radiotherapy for patients with brain metastases: a simple prognostic scoring system in the era of stereotactic radiosurgery. BMC Cancer 24, 940 (2024). https://doi.org/10.1186/s12885-024-12729-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12885-024-12729-1

Keywords

BMC Cancer

ISSN: 1471-2407

Contact us