A Prospective Phase III Trial to Compare Stereotactic Radiosurgery Versus Whole Brain Radiation Therapy

Study Groups:

If you are found to be eligible to take part in this study, you will be randomly assigned (as
in the flip of a coin) to 1 of 2 study groups. You will have an equal chance of being
assigned to either group:

- If you are in Group 1, you will receive whole brain radiation treatment.

- If you are in Group 2, you will receive stereotactic radiosurgery.

Study Procedures:

If you are in Group 1, you will receive whole brain radiation treatment each day,
Monday-Friday starting on Day 1. If you are an inpatient, you may receive radiation treatment
on weekends as well. You will continue to receive radiation treatment up to Day 14.

If you are in Group 2, you will receive stereotactic radiosurgery on Day 1. As part of the
stereotactic radiosurgery procedure, you will receive a very accurate kind of MRI scan on the
morning of the procedure. If this MRI scan identifies more tumors, you may still continue to
participate in the study with up to 20 tumors. If there are more than 20 tumors found on the
treatment planning MRI scan on the day of the SRS treatment, then you are not eligible to
participate in the study. In this case, your study doctor will discuss with you other
treatment options off of the study, which may include stereotactic radiosurgery and/or whole
brain radiation therapy.

No matter which group you are in, you will sign a separate consent form for whole brain
radiation or stereotactic radiosurgery that will explain the procedures and risks in detail.

Study Visits:

At 1, 4, 6, 9, and 12 months (+/- 14 days) after your assigned treatment, you will return to
the clinic:

- You will have a physical exam, including measurement of your vital signs.

- You will be asked about any drugs you may be taking.

- You will have an MRI scan to check the status of the disease.

- You will complete the 7 cognitive function tests.

- You will complete 3 questionnaires that ask about your quality of life and any symptoms
you may be having.

Length of Study Participation:

Your active participation on the study will be over when you have completed the follow-up
visits.

Follow-Up Visits:

If the study doctor thinks it is needed, you will return to the clinic for follow-up visits.
The following tests and procedures will be performed:

- You will have a physical exam, including measurement of your vital signs.

- You will be asked about any drugs you may be taking.

- You will have an MRI to check the status of the disease.

Inclusion Criteria:

1. All patients must have histological proof of malignant cancer, which is metastatic.
Histological proof may be obtained from the primary tumor or another metastatic site.
However, cytology alone is not an acceptable method of diagnosis.

2. All patients must have greater than 3 but less than or equal to 15 metastatic lesions
seen on a contrast enhancing MRI scan obtained not less than one month prior to study
enrollment. Patients who are found to have up to 20 metastatic lesions at the time of
treatment planning (on volumetric MRI once the head frame is in place) may still
participate in the trial.

3. All patients must be >/= 18 years of age.

4. All patients must sign informed consent verifying that they are aware of the
investigational nature of this study in keeping with the rules and policies of M.D.
Anderson Cancer Center. The only acceptable consent form is the one attached at the
end of this protocol, and it must have been approved and amended by the M.D. Anderson
IRB.

5. All patients must be eligible to have all lesions treated with SRS (i.e. maximum
diameter of largest lesion < 3.5cm) as determined by the radiation oncologist .

6. All patients must have adequate liver, renal, and hematologic function as defined by
Aspartate Amino Transferase (AST)/Alanine Amino Transferase (ALT)/Alkaline Phosphatase
< 2.5 times normal, calculated creatinine clearance > 30ml/min, and platelet count >
50,000.

7. All patients should have normal coagulation, with international normalized ratio (INR)
< 1.3 and able to withhold anti-coagulation medications a minimum of 24 hours prior to
radiosurgery (or until INR normalizes), on the day of treatment and 24 hours after
radiosurgery has concluded. Those patients getting WBRT may continue these
medications.

8. Patients can be undergoing concurrent systemic therapy, such as temozolomide, at the
discretion of their treating oncologist.

Exclusion Criteria:

1. Patients are excluded from this trial if they have melanoma, small cell carcinoma,
lymphoma/leukemia, or germ cell histology (note, melanoma patients will be eligible
for the sister trial to this trial which will be open simultaneously).

2. Patients will be excluded if they have had prior surgical resection of metastatic
cancer from the brain.

3. Patients will be excluded if there is radiographic or CSF cytological evidence of
leptomeningeal disease.

4. Patients will be excluded if they have had prior Whole Brain Radiotherapy (WBRT) or
prophylactic cranial irradiation (PCI). Prior SRS or Gamma Knife radiosurgery to 1-3
metastases with minimum of (6) weeks to the most recent scan are allowed on protocol.

5. Female patients of childbearing age will be excluded if they are pregnant as assessed
by serum b-HCG or urine pregnancy test. A serum b-HCG test or urine pregnancy test
will be performed no greater than 14 days prior to study registration.

6. Patients will be excluded if they are unable to obtain an MRI scan.

7. Patients will be excluded if they have < 4 lesions, or > 15 lesions at enrollment or >
20 lesions at the time of treatment (note: patients who qualify for enrollment based
on having 4-15 lesions, but who are discovered to have up to 20 lesions on the
volumetric MRI used for treatment planning will be allowed to continue on study).