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tumors, infusions of recombinant human tumor necrosis low glucose levels, and high protein levels. [44-46]
factor induced selective permeabilization of the blood-brain
barrier to imaging tracers at sites of brain metastases. This RPA divides patients into three categories based on KPS,
method enabled the detection of smaller tumors that had age, and primary tumor control, with patients in group
been invisible using standard imaging techniques. Notably, I having a better prognosis than patients in group III.
[40]
this strategy even increased the delivery of radiolabeled The GPA evaluates the prognosis of patients with brain
trastuzumab to these metastatic lesions, demonstrating metastases based on the primary tumor diagnosis.
[39]
[42]
the translational potential of similar approaches for Histology carries prognostic significance, along with other
theranostics. subcategories (e.g. age and extracranial disease in lung
cancer patients, or number of metastases in melanoma
THE ESTIMATION OF PROGNOSIS patients). Tumor subtype based on HER2/ER/PR status
IS IMPORTANT FOR CLINICAL
MANAGEMENT and age is prognostic for breast cancer and is expanded
upon with a specific breast-GPA, currently in use in
[43]
[47]
The most widely established risk stratification scores are clinical trials. Other prognostic scores were defined
the Recursive Portioning Analysis (RPA), the Graded and are summarized in Table 1. In large retrospective
Prognostic Assessment (GPA), and Diagnosis Specific studies of melanoma patients with brain metastases, poor
Graded Prognostic Assessment (DS-GPA) [Table 1]. [40-43] prognostic factors associated with worse survival were:
Definitely, the presence of neoplastic meningitis in patients > 3 parenchymal lesions, leptomeningeal disease, brain
with solid tumors indicates a poor prognosis. Negative lesions developing concurrently with extracranial disease
prognostic factors associated with leptomeningeal tumor or while on systemic therapy for extracranial disease, poor
cell dissemination are low Karnofsky performance status performance status (KPS < 70%), elevated pretreatment
(KPS), increased age, uncontrolled intracranial pressure, LDH levels, and RPA class III. [48,49]

Table 1: Prognostic scores
Recursive partioning analysis
Class I II III
Age < 65 All patients not in Class I or class III KPS < 70%
KPS > 70%
Stable primary tumor
No extracranial metastases
Basic score for brain metastases
Score 0 1
KPS 50-70% 80-100%
Control of primary tumor No Yes
Extracranial metastases Yes No
Score index for radiosurgery
Score 0 1 2
Age (years) > 60 51-59 < 50
KPS < 50% 60-70% 80-100%
Systemic disease Progressive Stable Complete response or no
evidence for disease
Number of lesions > 3 2 1
Volume of largest target lesion > 13 mL 5-13 mL < 5 mL
Graded prognostic assessment
Score 0 0.5 1.0
Age > 60 50-59 < 50
KPS < 70% 70-80% 90-100%
CNS metastases (no.) > 3 2-3 1
Extracranial metastases Present - None
Diagnosis-specific graded prognostic assessment
i) NSCLC/SCLC
Score 0 0.5 1.0
Age > 60 50-60 < 50
KPS < 70% 70-80% 90-100%
Extracranial metastases Present - Absent
CNS metastases (no.) > 3 2-3 1
ii) Melanoma/RCC
Score 0 1 2
KPS < 70% 70-80% 90-100%
CNS metastases (no.) > 3 2-3 1
iii) Breast/GI cancer
Score 0 1 2 3 4
KPS < 70% 70% 80% 90% 100%
CNS: central nervous system; KPS: karnofsky performance status; NSCLC: non small-cell lung cancer

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Journal of Cancer Metastasis and Treatment ¦ Volume 2 ¦ May 20, 2016 ¦