This randomized phase III trial compares memantine hydrochloride and whole-brain
radiotherapy with or without hippocampal avoidance in reducing neurocognitive decline in
patients with cancer that has spread to the brain. Whole brain radiotherapy (WBRT) is the
most common treatment for brain metastasis. Unfortunately, the majority of patients with
brain metastases experience cognitive deterioration after WBRT. Memantine hydrochloride may
enhance cognitive function by binding to and inhibiting channels of receptors located in the
central nervous system. Radiation therapy uses high energy x-rays to kill tumor cells and
shrink tumors. Using radiation techniques, such as intensity modulated radiotherapy to avoid
the hippocampal region during WBRT, may reduce the radiation dose to the hippocampus and
help limit the radiation-induced cognitive decline. It is not yet known whether giving
memantine hydrochloride and WBRT with or without hippocampal avoidance works better in
reducing neurocognitive decline in patients with brain metastases.
Inclusion Criteria:
- PRIOR TO STEP 1 REGISTRATION:
- Brain metastases outside a 5-mm margin around either hippocampus must be visible on
contrast-enhanced magnetic resonance imaging (MRI) performed =< 21 days prior to Step
1 registration; an allowed exception, regarding ability to image brain metastases,
would be that patients who had undergone radiosurgery or surgical resection and are
planning adjuvant WBRT do not have to have visible disease but do need a pre-surgery
MRI or computed tomography (CT) scan demonstrating brain metastases; however, the
brain metastases could not have been within 5 mm of either hippocampus
- Patients must have a gadolinium contrast-enhanced three-dimensional spoiled gradient
(SPGR), magnetization-prepared rapid gradient echo (MP-RAGE), or turbo field echo
(TFE) axial MRI scan with standard axial and coronal gadolinium contrast-enhanced
T1-weighted sequence and axial T2/FLAIR sequence acquisitions; to yield acceptable
image quality, the gadolinium contrast-enhanced three-dimensional SPGR, MP-RAGE, or
TFE axial MRI scan should use the smallest possible axial slice thickness not
exceeding 1. 5 mm; the associated coronal and sagittal contrast-enhanced T1 sequences
can be up to 2. 5 mm in slice thickness; this MRI must be obtained =< 21 days prior to
step 1 registration; the vendor specific MRI protocols are available for download
from the Alzheimer's Disease Neuroimaging Initiative (ADNI)
- Patients must provide study-specific informed consent prior to registration
- PRIOR TO STEP 2 REGISTRATION:
- The following baseline neurocognitive assessments must be completed prior to Step 2
registration: HVLT-R, TMT, and COWA; the neurocognitive assessment will be uploaded
into the NRG RAVE System for evaluation by Dr. Wefel; once the upload is complete, a
notification will be sent to proceed to Step 2; NOTE: completed baseline
neurocognitive assessments can be uploaded at the time of Step 1 registration
- Pathologically (histologically or cytologically) proven diagnosis of solid tumor
malignancy within 5 years prior to Step 2 registration; if the original histologic
proof of malignancy is greater than 5 years, then pathological (i. e., more recent)
confirmation is required (e. g., from a systemic metastasis or brain metastasis)
- History and physical examination within 28 days prior to Step 2 registration
- Karnofsky Performance Status of >= 70 within 28 days prior to Step 2 registration
- Serum creatinine =< 3 mg/dL (265 μmol/L) and creatinine clearance >= 30 ml/min
- Blood urea nitrogen (BUN) within institutional upper limit of normal (e. g. < 20
mg/dL)
- Total bilirubin =< 2. 5 mg/dL (43 μmol/L)
- Patients may have had prior therapy for brain metastasis, including radiosurgery and
surgical resection; patients must have completed prior therapy by at least 14 days
prior to Step 2 for surgical resection and 7 days for radiosurgery
- Negative serum pregnancy test (in women of childbearing potential) =< 14 days prior
to Step 2; women of childbearing potential and men who are sexually active must
practice adequate contraception while on study
- Patients who are primary English or French speakers are eligible
Exclusion Criteria:
- Prior external beam radiation therapy to the brain or whole brain radiation therapy
- Planned cytotoxic chemotherapy during the WBRT only; patients may have had prior
chemotherapy
- Radiographic evidence of hydrocephalus or other architectural distortion of the
ventricular system, including placement of external ventricular drain or
ventriculoperitoneal shunt
- Severe, active co-morbidity defined as follows:
- Unstable angina and/or congestive heart failure requiring hospitalization within
the last 6 months
- Transmural myocardial infarction within the last 6 months
- Acute bacterial or fungal infection requiring intravenous antibiotics at the
time of registration
- Chronic obstructive pulmonary disease exacerbation or other acute respiratory
illness precluding study therapy at the time of registration
- Severe hepatic disease defined as a diagnosis of Child-Pugh class B or C hepatic
disease
- Renal tubular acidosis or metabolic acidosis
- Human immunodeficiency virus (HIV) positive with cluster of differentiation
(CD)4 count < 200 cells/microliter; note that patients who are HIV positive are
eligible, provided they are under treatment with highly active antiretroviral
therapy (HAART) and have a CD4 count >= 200 cells/microliter within 30 days
prior to registration; note also that HIV testing is not required for
eligibility for this protocol
- Pregnant or lactating women, or women of childbearing potential and men who are
sexually active and not willing/able to use medically acceptable forms of
contraception
- Prior allergic reaction to memantine
- Current alcohol or drug abuse (may exacerbate lethargy/dizziness with memantine)
- Intractable seizures while on adequate anticonvulsant therapy—more than 1 seizure per
month for the past 2 months
- Patients with definitive leptomeningeal metastases
- Patients with brain metastases from primary germ cell tumors, small cell carcinoma,
unknown primary, or lymphoma
- Contraindication to MR imaging such as implanted metal devices or foreign bodies
- Contraindication to gadolinium contrast administration during MR imaging, such as
allergy or insufficient renal function
- Current use of (other N-methyl D-aspartate [NMDA] antagonists) amantadine, ketamine,
or dextromethorphan
