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Kowalchuk RO, Kim H, Harmsen WS, Jeans EB, Morris LK, Mullikin TC, Miller RC, Wong WW, Vargas CE, Trifiletti DM, Phillips RM, Choo CR, Davis BJ, Beriwal S, Tendulkar RD, Stish BJ, Breen WG, Waddle MR. Cost effectiveness of treatment strategies for high risk prostate cancer. Cancer 2022; 128:3815-3823. [PMID: 36070558 DOI: 10.1002/cncr.34450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/27/2022] [Accepted: 07/01/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Patients with high-risk prostate cancer (HRPC) have multiple accepted treatment options. Because there is no overall survival benefit of one option over another, appropriate treatment must consider patient life expectancy, quality of life, and cost. METHODS The authors compared quality-adjusted life years (QALYs) and cost effectiveness among treatment options for HRPC using a Markov model with three treatment arms: (1) external-beam radiotherapy (EBRT) delivered with 20 fractions, (2) EBRT with 23 fractions followed by low-dose-rate (LDR) brachytherapy boost, or (3) radical prostatectomy alone. An exploratory analysis considered a simultaneous integrated boost according to the FLAME trial (ClinicalTrials.gov identifier NCT01168479). RESULTS Treatment strategies were compared using the incremental cost-effectiveness ratio (ICER). EBRT with LDR brachytherapy boost was a cost-effective strategy (ICER, $20,929 per QALY gained). These results were most sensitive to variations in the biochemical failure rate. However, the results still demonstrated cost effectiveness for the brachytherapy boost paradigm, regardless of any tested parameter ranges. Probabilistic sensitivity analysis demonstrated that EBRT with LDR brachytherapy was favored in 52% of 100,000 Monte Carlo iterations. In an exploratory analysis, EBRT with a simultaneous integrated boost was also a cost-effective strategy, resulting in an ICER of $62,607 per QALY gained; however, it was not cost effective compared with EBRT plus LDR brachytherapy boost. CONCLUSIONS EBRT with LDR brachytherapy boost may be a cost-effective treatment strategy compared with EBRT alone and radical prostatectomy for HRPC, demonstrating high-value care. The current analysis suggests that a reduction in biochemical failure alone can result in cost-effective care, despite no change in overall survival.
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Affiliation(s)
- Roman O Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Hayeon Kim
- Department of Radiation Oncology, Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Elizabeth B Jeans
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lindsay K Morris
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Trey C Mullikin
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert C Miller
- Mayo Clinic, Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Daniel M Trifiletti
- Mayo Clinic, Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Ryan M Phillips
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - C R Choo
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian J Davis
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sushil Beriwal
- Allegheny Health Networks, Pittsburgh, Pennsylvania, USA.,Medical Affairs, Varian Medical Systems, Pittsburgh, Pennsylvania, USA
| | - Rahul D Tendulkar
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bradley J Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - William G Breen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark R Waddle
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
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Matsui JK, Perlow HK, Raj RK, Nalin AP, Lehrer EJ, Kotecha R, Trifiletti DM, McClelland S, Kendra K, Williams N, Owen DH, Presley CJ, Thomas EM, Beyer SJ, Blakaj DM, Ahluwalia MS, Raval RR, Palmer JD. Treatment of Brain Metastases: The Synergy of Radiotherapy and Immune Checkpoint Inhibitors. Biomedicines 2022; 10:2211. [PMID: 36140312 PMCID: PMC9496359 DOI: 10.3390/biomedicines10092211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/31/2022] [Accepted: 09/02/2022] [Indexed: 11/27/2022] Open
Abstract
Brain metastases are a devastating sequela of common primary cancers (e.g., lung, breast, and skin) and have limited effective therapeutic options. Previously, systemic chemotherapy failed to demonstrate significant benefit in patients with brain metastases, but in recent decades, targeted therapies and more recently immune checkpoint inhibitors (ICIs) have yielded promising results in preclinical and clinical studies. Furthermore, there is significant interest in harnessing the immunomodulatory effects of radiotherapy (RT) to synergize with ICIs. Herein, we discuss studies evaluating the impact of RT dose and fractionation on the immune response, early studies supporting the synergistic interaction between RT and ICIs, and ongoing clinical trials assessing the benefit of combination therapy in patients with brain metastases.
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Affiliation(s)
| | - Haley K. Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Rohit K. Raj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Ansel P. Nalin
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | | | - Shearwood McClelland
- Departments of Radiation Oncology and Neurological Surgery, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Kari Kendra
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Nicole Williams
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Dwight H. Owen
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Carolyn J. Presley
- Division of Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Evan M. Thomas
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Sasha J. Beyer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Dukagjin M. Blakaj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Manmeet S. Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA
| | - Raju R. Raval
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Joshua D. Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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53
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Upadhyay R, Yadav D, Venkatesulu BP, Singh R, Baliga S, Raval RR, Lazow MA, Salloum R, Fouladi M, Mardis ER, Zaorsky NG, Trifiletti DM, Paulino AC, Palmer JD. Risk of secondary malignant neoplasms in children following proton therapy vs. photon therapy for primary CNS tumors: A systematic review and meta-analysis. Front Oncol 2022; 12:893855. [PMID: 36033525 PMCID: PMC9413159 DOI: 10.3389/fonc.2022.893855] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 07/21/2022] [Indexed: 11/20/2022] Open
Abstract
Background Central nervous system tumors are now the most common primary neoplasms seen in children, and radiation therapy is a key component in management. Secondary malignant neoplasms (SMNs) are rare, but dreaded complications. Proton beam therapy (PBT) can potentially minimize the risk of SMNs compared to conventional photon radiation therapy (RT), and multiple recent studies with mature data have reported the risk of SMNs after PBT. We performed this systematic review and meta-analysis to characterize and compare the incidence of SMNs after proton and photon-based radiation for pediatric CNS tumors. Methods A systematic search of literature on electronic (PubMed, Cochrane Central, and Embase) databases was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method. We included studies reporting the incidence and nature of SMNs in pediatric patients with primary CNS tumors. The crude incidence of SMNs and all secondary neoplasms were separately extracted, and the random-effects model was used for pooled analysis and subgroup comparison was performed between studies using photons vs. protons. Results Twenty-four studies were included for analysis. A total of 418 SMNs were seen in 38,163 patients. The most common SMN were gliomas (40.6%) followed by meningiomas (38.7%), sarcomas (4.8%), and thyroid cancers (4.2%). The median follow-up was 8.8 years [3.3–23.2].The median latency to SMN for photons and protons were 11.9 years [5-23] and 5.9 years [5-6.7], respectively. The pooled incidence of SMNs was 1.8% (95% CI: 1.1%–2.6%, I2 = 94%) with photons and 1.5% (95% CI: 0%–4.5%, I2 = 81%) with protons. The pooled incidence of all SNs was not different [photons: 3.6% (95% CI: 2.5%–4.8%, I2 = 96%) vs. protons: 1.5% (95% CI: 0–4.5%, I2 = 80%); p = 0.21]. Conclusion We observed similar rates of SMN with PBT at 1.5% compared to 1.8% with photon-based RT for pediatric CNS tumors. We observed a shorter latency to SMN with PBT compared to RT. With increasing use of pencil beam scanning PBT and VMAT, further studies are warranted to evaluate the risk of secondary cancers in patients treated with these newer modalities.
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Affiliation(s)
- Rituraj Upadhyay
- Department of Radiation Oncology, The James Comprehensive Cancer Center, Ohio State University, Columbus, OH, United States
| | - Divya Yadav
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | | | - Raj Singh
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, United States
| | - Sujith Baliga
- Department of Radiation Oncology, The James Comprehensive Cancer Center, Ohio State University, Columbus, OH, United States
| | - Raju R. Raval
- Department of Radiation Oncology, The James Comprehensive Cancer Center, Ohio State University, Columbus, OH, United States
| | - Margot A. Lazow
- Department of Radiation Oncology, The James Comprehensive Cancer Center, Ohio State University, Columbus, OH, United States
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH, United States
| | - Ralph Salloum
- Department of Radiation Oncology, The James Comprehensive Cancer Center, Ohio State University, Columbus, OH, United States
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH, United States
| | - Maryam Fouladi
- Department of Radiation Oncology, The James Comprehensive Cancer Center, Ohio State University, Columbus, OH, United States
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH, United States
| | - Elaine R. Mardis
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH, United States
| | - Nicholas G. Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve School of Medicine, Cleveland, OH, United States
| | | | - Arnold C. Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Joshua D. Palmer
- Department of Radiation Oncology, The James Comprehensive Cancer Center, Ohio State University, Columbus, OH, United States
- *Correspondence: Joshua D. Palmer,
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Moassefi M, Faghani S, Conte GM, Kowalchuk RO, Vahdati S, Crompton DJ, Perez-Vega C, Cabreja RAD, Vora SA, Quiñones-Hinojosa A, Parney IF, Trifiletti DM, Erickson BJ. A deep learning model for discriminating true progression from pseudoprogression in glioblastoma patients. J Neurooncol 2022; 159:447-455. [DOI: 10.1007/s11060-022-04080-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/25/2022] [Indexed: 12/30/2022]
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55
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Lehrer EJ, Jones BM, Dickstein DR, Green S, Germano IM, Palmer JD, Laack N, Brown PD, Gondi V, Wefel JS, Sheehan JP, Trifiletti DM. The Cognitive Effects of Radiotherapy for Brain Metastases. Front Oncol 2022; 12:893264. [PMID: 35847842 PMCID: PMC9279690 DOI: 10.3389/fonc.2022.893264] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/27/2022] [Indexed: 12/24/2022] Open
Abstract
Brain metastases are the most common intracranial neoplasm and are seen in upwards of 10-30% of patients with cancer. For decades, whole brain radiation therapy (WBRT) was the mainstay of treatment in these patients. While WBRT is associated with excellent rates of intracranial tumor control, studies have demonstrated a lack of survival benefit, and WBRT is associated with higher rates of cognitive deterioration and detrimental effects on quality of life. In recent years, strategies to mitigate this risk, such as the incorporation of memantine and hippocampal avoidance have been employed with improved results. Furthermore, stereotactic radiosurgery (SRS) has emerged as an appealing treatment option over the last decade in the management of brain metastases and is associated with superior cognitive preservation and quality of life when compared to WBRT. This review article evaluates the pathogenesis and impact of cranial irradiation on cognition in patients with brain metastases, as well as current and future risk mitigation techniques.
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Affiliation(s)
- Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Brianna M. Jones
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Daniel R. Dickstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Sheryl Green
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Isabelle M. Germano
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Joshua D. Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Nadia Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Paul D. Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center Warrenville and Proton Center, Warrenville, IL, United States
| | - Jeffrey S. Wefel
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, United States
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | - Daniel M. Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
- *Correspondence: Daniel M. Trifiletti,
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56
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Seneviratne D, Advani P, Trifiletti DM, Chumsri S, Beltran CJ, Bush AF, Vallow LA. Exploring the Biological and Physical Basis of Boron Neutron Capture Therapy (BNCT) as a Promising Treatment Frontier in Breast Cancer. Cancers (Basel) 2022; 14:cancers14123009. [PMID: 35740674 PMCID: PMC9221373 DOI: 10.3390/cancers14123009] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/30/2022] [Accepted: 06/07/2022] [Indexed: 12/04/2022] Open
Abstract
Simple Summary BNCT is a biologically targeted, densely ionizing form of radiation therapy that allows for increased tumor cell kill, while reducing toxicity to surrounding normal tissues. Although BNCT has been investigated in the treatment of head and neck cancers and recurrent brain tumors, its applicability to breast cancer has not been previoulsy investigated. In this review we discuss the physical and biological properties of various boronated compounds, and advantages and challenges associated with the potential use of BNCT in the treatment of breast cancer. Abstract BNCT is a high LET radiation therapy modality that allows for biologically targeted radiation delivery to tumors while reducing normal tissue impacts. Although the clinical use of BNCT has largely been limited to phase I/II trials and has primarily focused on difficult-to-treat malignancies such as recurrent head and neck cancer and recurrent gliomas, recently there has been a renewed interest in expanding the use of BNCT to other disease sites, including breast cancer. Given its high LET characteristics, its biologically targeted and tumor specific nature, as well as its potential for use in complex treatment settings including reirradiation and widespread metastatic disease, BNCT offers several unique advantages over traditional external beam radiation therapy. The two main boron compounds investigated to date in BNCT clinical trials are BSH and BPA. Of these, BPA in particular shows promise in breast cancer given that is taken up by the LAT-1 amino acid transporter that is highly overexpressed in breast cancer cells. As the efficacy of BNCT is directly dependent on the extent of boron accumulation in tumors, extensive preclinical efforts to develop novel boron delivery agents have been undertaken in recent years. Preclinical studies have shown promise in antibody linked boron compounds targeting ER/HER2 receptors, boron encapsulating liposomes, and nanoparticle-based boron delivery systems. This review aims to summarize the physical and biological basis of BNCT, the preclinical and limited clinical data available to date, and discuss its potential to be utilized for the successful treatment of various breast cancer disease states.
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Affiliation(s)
- Danushka Seneviratne
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, FL 32224, USA; (D.S.); (D.M.T.); (C.J.B.); (A.F.B.); (L.A.V.)
| | - Pooja Advani
- Department of Hematology Oncology, Mayo Clinic Florida, Jacksonville, FL 32224, USA;
- Correspondence:
| | - Daniel M. Trifiletti
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, FL 32224, USA; (D.S.); (D.M.T.); (C.J.B.); (A.F.B.); (L.A.V.)
| | - Saranya Chumsri
- Department of Hematology Oncology, Mayo Clinic Florida, Jacksonville, FL 32224, USA;
| | - Chris J. Beltran
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, FL 32224, USA; (D.S.); (D.M.T.); (C.J.B.); (A.F.B.); (L.A.V.)
| | - Aaron F. Bush
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, FL 32224, USA; (D.S.); (D.M.T.); (C.J.B.); (A.F.B.); (L.A.V.)
| | - Laura A. Vallow
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, FL 32224, USA; (D.S.); (D.M.T.); (C.J.B.); (A.F.B.); (L.A.V.)
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Ruiz-Garcia H, Trifiletti DM, Mohammed N, Hung YC, Xu Z, Chytka T, Liscak R, Tripathi M, Arsanious D, Cifarelli CP, Caceres MP, Mathieu D, Speckter H, Mehta GU, Lekovic GP, Sheehan JP. Skull Base Meningiomas in Patients with Neurofibromatosis Type 2: An International Multicenter Study Evaluating Stereotactic Radiosurgery. Skull Base Surg 2022; 83:e173-e180. [PMID: 35832959 DOI: 10.1055/s-0041-1722937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/06/2020] [Indexed: 10/22/2022]
Abstract
Objective Meningiomas are the second most common tumors in neurofibromatosis type 2 (NF-2). Microsurgery is challenging in NF-2 patients presenting with skull base meningiomas due to the intrinsic risks and need for multiple interventions over time. We analyzed treatment outcomes and complications after primary Gamma Knife radiosurgery (GKRS) to delineate its role in the management of these tumors. Methods An international multicenter retrospective study approved by the International Radiosurgery Research Foundation was performed. NF-2 patients with at least one growing and/or symptomatic skull base meningioma and 6-month follow-up after primary GKRS were included. Clinical and radiosurgical parameters were recorded for analysis. Results In total, 22 NF-2 patients with 54 skull base meningiomas receiving GKRS as primary treatment met inclusion criteria. Median age at GKRS was 38 years (10-79 years). Most lesions were located in the posterior fossa (55.6%). Actuarial progression free survival (PFS) rates were 98.1% at 2 years and 90.0% at 5 and 10 years. The median follow-up time after initial GKRS was 5.0 years (0.6-25.5 years). Tumor volume at GKRS was a predictor of tumor control. Lesions >5.5 cc presented higher chances to progress after radiosurgery ( p = 0.043). Three patients (13.64%) developed adverse radiation effects. No malignant transformation or death due to meningioma or radiosurgery was reported. Conclusions GKRS is effective and safe in the management of skull base meningiomas in NF-2 patients. Tumor volume deserve greater relevance during clinical decision-making regarding the most appropriate time to treat. GKRS offers a minimally invasive approach of particular interest in this specific group of patients.
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Affiliation(s)
- Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, United States.,Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, United States.,Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Nasser Mohammed
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, United States
| | - Yi-Chieh Hung
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, United States
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, United States
| | - Tomas Chytka
- Department of Neurological Surgery, Na Homolce Hospital, Prague, Czech Republic
| | - Roman Liscak
- Department of Neurological Surgery, Na Homolce Hospital, Prague, Czech Republic
| | - Manjul Tripathi
- Department of Neurological Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - David Arsanious
- Department of Neurological Surgery, West Virginia University, Morgantown, West Virginia, United States
| | - Christopher P Cifarelli
- Department of Neurological Surgery, West Virginia University, Morgantown, West Virginia, United States
| | - Marco Perez Caceres
- Department of Neurological Surgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Canada
| | - David Mathieu
- Department of Neurological Surgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Canada
| | - Herwin Speckter
- Department of Neurological Surgery, Dominican Gamma Knife Center and CEDIMAT Hospital, Santo Domingo, Dominican Republic
| | - Gautam U Mehta
- Department of Neurological Surgery, House Ear Institute, Los Angeles, California, United States
| | - Gregory P Lekovic
- Department of Neurological Surgery, House Ear Institute, Los Angeles, California, United States
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, United States
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58
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Perez-Vega C, Ramos-Fresnedo A, Tripathi S, Domingo RA, Ravindran K, Almeida JP, Peterson J, Trifiletti DM, Chaichana KL, Quinones-Hinojosa A, Samson SL. Treatment of recurrent and persistent Cushing's disease after first transsphenoidal surgery: lessons learned from an international meta-analysis. Pituitary 2022; 25:540-549. [PMID: 35508745 DOI: 10.1007/s11102-022-01215-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Transsphenoidal surgery (TSS) is the first-line treatment for patients with Cushing's Disease (CD). Recurrence rates after a first TSS range between 3 and 22% within 3 years. Management of recurrent or persistent CD may include repeat TSS or stereotactic radiosurgery (SRS). We performed a meta-analysis to explore the overall efficacy of TSS and SRS for patients with CD after an initial surgical intervention. METHODS EMBASE, PubMed, SCOPUS, and Cochrane databases were searched from their dates-of-inception up to December 2021. Inclusion criteria were comprised of patients with an established diagnosis of CD who presented with persistent or biochemically recurrent disease after a first TSS for tumor resection and were treated with a second TSS or SRS. RESULTS Search criteria yielded 2,116 studies of which 37 articles from 15 countries were included for analysis. Mean age ranged between 29.9 and 47.9 years, and mean follow-up was 11-104 months. TSS was used in 669 (67.7%) patients, while SRS was used in 320 (32.4%) patients, and remission rates for CD were 59% (95%CI 0.49-0.68) and 74% (95%CI 0.54-0.88), respectively. There was no statistically significant difference in the remission rate between TSS and SRS (P = 0.15). The remission rate of patients with recurrent CD undergoing TSS was 53% (95%CI 0.32-0.73), and for persistent CD was 41% (95%CI 0.28-0.56) (P = 0.36). CONCLUSION Both TSS and SRS are possible approaches for the treatment of recurrent or persistent CD after a first TSS. Our data show that either TSS or SRS represent viable treatment options to achieve remission for this subset of patients.
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Affiliation(s)
- Carlos Perez-Vega
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Shashwat Tripathi
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ricardo A Domingo
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Joao P Almeida
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Jennifer Peterson
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | | | | | | | - Susan L Samson
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA.
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Department of Neurologic Surgery, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA.
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59
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Vaishnav YJ, Singh R, Didwania P, Lehrer EJ, Bakaeva T, Harris TJ, Migliori ME, Sheehan JP, Trifiletti DM. Radiotherapy and Radiosurgery in the Management of Optic Nerve Sheath Meningiomas: An International Systematic Review and Meta-Analysis of Twenty Studies. World Neurosurg 2022; 164:e929-e944. [PMID: 35609728 DOI: 10.1016/j.wneu.2022.05.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/15/2022] [Accepted: 05/16/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Optic nerve sheath meningiomas (ONMs) are often managed with radiotherapy (RT) with the goal of achieving radiographic local control (LC) and preventing deterioration of visual acuity (VA). We aimed to perform a systematic review and meta-analysis of outcomes for patients with ONM treated with RT. METHODS The PICOS/PRISMA/MOOSE selection criteria were used to identify studies. Primary outcomes were stable or improved VA and radiographic LC at last follow-up. The secondary outcomes were incidences of radiation-induced retinopathy and xerophthalmia and stable or improved visual fields (VFs). Weighted random-effects meta-analyses using the DerSimonian and Laird methods were conducted to characterize effect sizes. Mixed-effects regression models were used to examine potential correlations between gross tumor volume (GTV) and outcomes. RESULTS In total, 444 patients with ONM across 20 published studies were included. The estimated LC rate was 99.8% (95% confidence interval [CI], 98.3%-100%), and the estimated proportion of patients with stable or improved VA or VF was 89.7% (95% CI, 86.2%-92.4%) and 93.3% (95% CI, 89.5%-95.8%), respectively. Estimated incidences of radiation-induced retinopathy and xerophthalmia were 7.2% and 10.1%, respectively. GTV was significantly associated with VA (P = 0.014) with estimated VA rates of 96.4%, 91.4%, and 80.5% for GTVs of 2.0, 3.0, and 4.0 cm3, respectively. CONCLUSIONS RT was well tolerated, with excellent LC achieved. Nearly 90% of patients noted either stability or improvement in VA and VF. Larger ONMs were associated with poorer VA.
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Affiliation(s)
- Yash J Vaishnav
- Department of Ophthalmology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
| | - Raj Singh
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Prabhanjan Didwania
- Rady School of Management, University of California San Diego, San Diego, California, USA
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Tatiana Bakaeva
- Department of Ophthalmology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Timothy J Harris
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Michael E Migliori
- Department of Ophthalmology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
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Ruiz-Garcia H, Middlebrooks EH, Trifiletti DM, Chaichana KL, Quinones-Hinojosa A, Sheehan JP. The Extent of Resection in Gliomas-Evidence-Based Recommendations on Methodological Aspects of Research Design. World Neurosurg 2022; 161:382-395.e3. [PMID: 35505558 DOI: 10.1016/j.wneu.2021.08.140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 08/30/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Modern neurosurgery has established maximal safe resection as a cornerstone in the management of diffuse gliomas. Evaluation of the extent of resection (EOR), and its association with certain outcomes or interventions, heavily depends on an adequate methodology to draw strong conclusions. We aim to identify weaknesses and limitations that may threaten the internal validity and generalizability of studies involving the EOR in patients with glioma and to suggest methodological recommendations that may help mitigate these threats. METHODS A systematic search was performed by querying PubMed, Web of Science, and Scopus since inception to April 30, 2021 using PICOS/PRISMA guidelines. Articles were then screened to identify high-impact studies evaluating the EOR in patients diagnosed with diffuse gliomas in accordance with predefined criteria. We identify common weakness and limitations during the evaluation of the EOR in the selected studies and then delineate potential methodological recommendations for future endeavors dealing with the EOR. RESULTS We identified 31 high-impact studies and found several research design issues including inconsistencies regarding EOR terminology, measurement, data collection, analysis, and reporting. Although some of these issues were related to now outdated reporting standards, many were still present in recent publications and deserve attention in contemporary and future research. CONCLUSIONS There is a current need to focus more attention to the methodological aspects of glioma research. Methodological inconsistencies may introduce weaknesses into the internal validity of the studies and hamper comparative analysis of cohorts from different institutions. We hope our recommendations will eventually help develop stronger methodological designs in future research endeavors.
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Affiliation(s)
- Henry Ruiz-Garcia
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA; Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, Florida, USA
| | - Erik H Middlebrooks
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA; Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Daniel M Trifiletti
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA; Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | | | | | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA.
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Ryan C, Stoltzfus KC, Horn S, Chen H, Louie AV, Lehrer EJ, Trifiletti DM, Fox EJ, Abraham JA, Zaorsky NG. Epidemiology of bone metastases. Bone 2022; 158:115783. [PMID: 33276151 DOI: 10.1016/j.bone.2020.115783] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 11/29/2020] [Accepted: 11/29/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND This study evaluated the incidence of de novo bone metastasis across all primary cancer sites and their impact on survival by primary cancer site, age, race, and sex. QUESTIONS/PURPOSES Our objectives were (I) characterize the epidemiology of de novo bone metastasis with respect to patient demographics, (II) characterize the incidence by primary site, age, and sex (2010-2015), and (III) compare survival of de novo metastatic cancer patients with and without bone metastasis. METHODS This is a retrospective, population-based study using nationally representative data from the Surveillance, Epidemiology, and End Results program, 2010-2015. Incidence rates by year of diagnosis, annual percentage changes, Kaplan-Meier, univariate and multiple Cox regression models are included in the analysis. RESULTS Of patients with cancer in the SEER database, 5.1% were diagnosed with metastasis to bone, equaling ~18.8 per 100,000 bone metastasis diagnoses in the US per year (2010-2015). For adults >25, lung cancer is the most common primary site (2015 rate: 8.7 per 100,000) with de novo bone metastases, then prostate and breast primaries (2015 rates: 3.19 and 2.38 per 100,000, respectively). For patients <20 years old, endocrine cancers and soft tissue sarcomas are the most common primaries. Incidence is increasing for prostate (Annual Percentage Change (APC) = 4.6%, P < 0.001) and stomach (APC = 5.0%, P = 0.001) cancers. The presence of de novo bone metastasis was associated with a limited reduction in overall survival (HR = 1.02, 95%, CI = [1.01-1.03], p < 0.001) when compared to patients with other non-bone metastases. CONCLUSION The presence of bone metastasis versus metastasis to other sites has disease site-specific impact on survival. The incidence of de novo bone metastasis varies by age, sex, and primary disease site.
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Affiliation(s)
- Casey Ryan
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Kelsey C Stoltzfus
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Samantha Horn
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Hanbo Chen
- Department of Radiation Oncology, Amsterdam University Medical Centers - Location VUmc, Amsterdam, Netherlands
| | - Alexander V Louie
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Edward J Fox
- Penn State Hershey Bone and Joint Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - John A Abraham
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA; Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA. https://twitter.com/NicholasZaorsky
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Agha A, Wang X, Wang M, Lehrer EJ, Horn SR, Rosenberg JC, Trifiletti DM, Diaz R, Louie AV, Zaorsky NG. Long-Term Risk of Death From Heart Disease Among Breast Cancer Patients. Front Cardiovasc Med 2022; 9:784409. [PMID: 35498020 PMCID: PMC9043135 DOI: 10.3389/fcvm.2022.784409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 03/01/2022] [Indexed: 12/02/2022] Open
Abstract
Background Most breast cancer patients die of non-cancer causes. The risk of death from heart disease, a leading cause of death, is unknown. The aim of this study is to characterize the long-term risk of fatal heart disease in breast cancer patients. Methods This retrospective study used the Surveillance, Epidemiology, and End Results (SEER) database. Standard mortality ratios (SMR) were calculated for breast cancer patients diagnosed from 1992 to 2014. Patients were stratified by receipt of radiotherapy and/or chemotherapy, disease laterality, and diagnosis era. Hazard ratios (HRs) and odds ratios (ORs) were calculated to compare the risk of death from heart disease among other breast cancer patients. Results There were 1,059,048 patients diagnosed with breast cancer from 1992 to 2014, of which 47,872 (4.6%) died from heart disease. The SMR for death from heart disease at 10+ years for patients who received only radiotherapy was 2.92 (95% CI 2.81–3.04, p < 0.001) and in patients who received only chemotherapy was 5.05 (95% CI 4.57–5.55, p < 0.001). There was no statistically significant difference in SMR for death from heart disease for left-sided vs. right-sided disease. At 10+ years, heart disease made up 28% of deaths from non-primary cancer. HRs and ORs showed that the risk of death from heart disease was highest in patients older than 70 years of age and with longer follow-up. Conclusion The risk of fatal heart disease was highest in older breast cancer patients with longer follow-up (i.e., >5–10 years) and who received chemotherapy. These patients should be referred to cardio-oncology clinics to mitigate this risk.
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Affiliation(s)
- Aya Agha
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, United States
| | - Xi Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, United States
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, United States
| | - Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Samantha R. Horn
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, United States
| | - Jennifer C. Rosenberg
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, United States
| | | | - Roberto Diaz
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, United States
| | - Alexander V. Louie
- Department of Radiation Oncology, Odette Cancer Centre – Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Nicholas G. Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve School of Medicine, Cleveland, OH, United States
- *Correspondence: Nicholas G. Zaorsky,
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Waqar M, Trifiletti DM, McBain C, O'Connor J, Coope DJ, Akkari L, Quinones-Hinojosa A, Borst GR. Early Therapeutic Interventions for Newly Diagnosed Glioblastoma: Rationale and Review of the Literature. Curr Oncol Rep 2022; 24:311-324. [PMID: 35119629 PMCID: PMC8885508 DOI: 10.1007/s11912-021-01157-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2021] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Glioblastoma is the commonest primary brain cancer in adults whose outcomes are amongst the worst of any cancer. The current treatment pathway comprises surgery and postoperative chemoradiotherapy though unresectable diffusely infiltrative tumour cells remain untreated for several weeks post-diagnosis. Intratumoural heterogeneity combined with increased hypoxia in the postoperative tumour microenvironment potentially decreases the efficacy of adjuvant interventions and fails to prevent early postoperative regrowth, called rapid early progression (REP). In this review, we discuss the clinical implications and biological foundations of post-surgery REP. Subsequently, clinical interventions potentially targeting this phenomenon are reviewed systematically. RECENT FINDINGS Early interventions include early systemic chemotherapy, neoadjuvant immunotherapy, local therapies delivered during surgery (including Gliadel wafers, nanoparticles and stem cell therapy) and several radiotherapy techniques. We critically appraise and compare these strategies in terms of their efficacy, toxicity, challenges and potential to prolong survival. Finally, we discuss the most promising strategies that could benefit future glioblastoma patients. There is biological rationale to suggest that early interventions could improve the outcome of glioblastoma patients and they should be investigated in future trials.
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Affiliation(s)
- Mueez Waqar
- Department of Academic Neurological Surgery, Geoffrey Jefferson Brain Research Centre, Salford Royal Foundation Trust, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health and Manchester Cancer Research Centre, University of Manchester, Manchester, UK
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Florida, 4500 San Pablo Road S, Mayo 1N, Jacksonville, FL, 32224, USA
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Catherine McBain
- Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Dept 58, Floor 2a, Room 21-2-13, Wilmslow Road, Manchester, M20 4BX, UK
| | - James O'Connor
- Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Dept 58, Floor 2a, Room 21-2-13, Wilmslow Road, Manchester, M20 4BX, UK
| | - David J Coope
- Department of Academic Neurological Surgery, Geoffrey Jefferson Brain Research Centre, Salford Royal Foundation Trust, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health and Manchester Cancer Research Centre, University of Manchester, Manchester, UK
| | - Leila Akkari
- Division of Tumour Biology and Immunology, The Netherlands Cancer Institute, Oncode Institute, Amsterdam, The Netherlands
| | - Alfredo Quinones-Hinojosa
- Department of Radiation Oncology, Mayo Clinic Florida, 4500 San Pablo Road S, Mayo 1N, Jacksonville, FL, 32224, USA
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Gerben R Borst
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health and Manchester Cancer Research Centre, University of Manchester, Manchester, UK.
- Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Dept 58, Floor 2a, Room 21-2-13, Wilmslow Road, Manchester, M20 4BX, UK.
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Chen CJ, Ding D, Lee CC, Kearns K, Pomeraniec IJ, Ironside N, Kondziolka DS, Trifiletti DM, Liscak R, Cockroft KM, Lee JYK, Sheehan JP. 300 Stereotactic Radiosurgery With Versus Without Embolization for Brain Arteriovenous Malformations. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Hatten SJ, Lehrer EJ, Liao J, Sha CM, Trifiletti DM, Siva S, McBride SM, Palma D, Holder SL, Zaorsky NG. A patient-level data meta-analysis of the abscopal effect. Adv Radiat Oncol 2022; 7:100909. [PMID: 35372719 PMCID: PMC8971834 DOI: 10.1016/j.adro.2022.100909] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 01/12/2022] [Indexed: 11/03/2022] Open
Abstract
Purpose Methods and Materials Results Conclusions
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Nourzadeh H, Hui C, Ahmad M, Sadeghzadehyazdi N, Watkins WT, Dutta SW, Alonso CE, Trifiletti DM, Siebers JV. Knowledge-based quality control of organ delineations in radiation therapy. Med Phys 2022; 49:1368-1381. [PMID: 35028948 DOI: 10.1002/mp.15458] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 10/17/2021] [Accepted: 12/17/2021] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To reduce the likelihood of errors in organ delineations used for radiotherapy treatment planning, a knowledge-based quality control (KBQC) system, which discriminates between valid and anomalous delineations is developed. METHOD AND MATERIALS The KBQC is comprised of a group-wise inference system and anomaly detection modules trained using historical priors from 296 locally advanced lung and prostate cancer patient computational tomographies (CTs). The inference system discriminates different organs based on shape, relational, and intensity features. For a given delineated image set, the inference system solves a combinatorial optimization problem that results in an organ group whose relational features follow those of the training set considering the posterior probabilities obtained from support vector machine (SVM), discriminant subspace ensemble (DSE), and artificial neural network (ANN) classifiers. These classifiers are trained on nonrelational features with a 10-fold cross-validation scheme. The anomaly detection module is a bank of ANN autoencoders, each corresponding with an organ, trained on nonrelational features. A heuristic rule detects anomalous organs that exceed predefined organ-specific tolerances for the feature reconstruction error and the classifier's posterior probabilities. Independent data sets with anomalous delineations were used to test the overall performance of the KBQC system. The anomalous delineations were manually manipulated, computer-generated, or propagated based on a transformation obtained by imperfect registrations. Both peer-review-based scoring system and shape similarity coefficient (DSC) were used to label regions of interest (ROIs) as normal or anomalous in two independent test cohorts. RESULTS The accuracy of the classifiers was ≥ $\ge$ 99.8%, and the minimum per-class F1-scores were 0.99, 0.99, and 0.98 for SVM, DSE, and ANN, respectively. The group-wise inference system reduced the miss-classification likelihood for the test data set with anomalous delineations compared to each individual classifier and a fused classifier that used the average posterior probability of all classifiers. For 15 independent locally advanced lung patients, the system detected > $>$ 79% of the anomalous ROIs. For 1320 auto-segmented abdominopelvic organs, the anomaly detection system identified anomalous delineations, which also had low Dice similarity coefficient values with respect to manually delineated organs in the training data set. CONCLUSION The KBQC system detected anomalous delineations with superior accuracy compared to classification methods that judge only based on posterior probabilities.
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Affiliation(s)
- Hamidreza Nourzadeh
- Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Radiation Oncology Department, University of Virginia, Charlottesville, Virginia, USA
| | | | - Mahmoud Ahmad
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Sunil W Dutta
- Radiation Oncology Department, Emory University, Georgia, USA
| | | | | | - Jeffrey V Siebers
- Radiation Oncology Department, University of Virginia, Charlottesville, Virginia, USA
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Kowalchuk RO, Johnson-Tesch BA, Marion JT, Mullikin TC, Harmsen WS, Rose PS, Siontis BL, Kim DK, Costello BA, Morris JM, Gao RW, Shiraishi S, Lucido JJ, Sio TT, Trifiletti DM, Olivier KR, Owen D, Stish BJ, Waddle MR, Laack NN, Park SS, Brown PD, Merrell KW. Development and Assessment of a Predictive Score for Vertebral Compression Fracture After Stereotactic Body Radiation Therapy for Spinal Metastases. JAMA Oncol 2022; 8:412-419. [PMID: 35084429 PMCID: PMC8796057 DOI: 10.1001/jamaoncol.2021.7008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
IMPORTANCE Vertebral compression fracture (VCF) is a potential adverse effect following treatment with stereotactic body radiation therapy (SBRT) for spinal metastases. OBJECTIVE To develop and assess a risk stratification model for VCF after SBRT. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study conducted at a high-volume referral center included 331 patients who had undergone 464 spine SBRT treatments from December 2007 through October 2019. Data analysis was conducted from November 1, 2020, to August 17, 2021. Exclusions included proton therapy, prior surgical intervention, vertebroplasty, or missing data. EXPOSURES One and 3 fraction spine SBRT treatments were most commonly delivered. Single-fraction treatments generally involved prescribed doses of 16 to 24 Gy (median, 20 Gy; range, 16-30 Gy) to gross disease compared with multifraction treatment that delivered a median of 30 Gy (range, 21-50 Gy). MAIN OUTCOMES AND MEASURES The VCF and radiography components of the spinal instability neoplastic score were determined by a radiologist. Recursive partitioning analysis was conducted using separate training (70%), internal validation (15%), and test (15%) sets. The log-rank test was the criterion for node splitting. RESULTS Of the 331 participants, 88 were women (27%), and the mean (IQR) age was 63 (59-72) years. With a median follow-up of 21 months (IQR, 11-39 months), we identified 84 VCFs (18%), including 65 (77%) de novo and 19 (23%) progressive fractures. There was a median of 9 months (IQR, 3-21 months) to developing a VCF. From 15 candidate variables, 6 were identified using the backward selection method, feature importance testing, and a correlation heatmap. Four were selected via recursive partitioning analysis: epidural tumor extension, lumbar location, gross tumor volume of more than 10 cc, and a spinal instability neoplastic score of more than 6. One point was assigned to each variable, and the resulting multivariable Cox model had a concordance of 0.760. The hazard ratio per 1-point increase for VCF was 1.93 (95% CI, 1.62-2.30; P < .001). The cumulative incidence of VCF at 2 years (with death as a competing risk) was 6.7% (95% CI, 4.2%-10.7%) for low-risk (score, 0-1; 273 [58.3%]), 17.0% (95% CI, 10.8%-26.7%) for intermediate-risk (score, 2; 99 [21.3%]), and 35.4% (95% CI, 26.7%-46.9%) for high-risk cases (score, 3-4; 92 [19.8%]) (P < .001). Similar results were observed for freedom from VCF using stratification. CONCLUSIONS AND RELEVANCE The results of this cohort study identify a subgroup of patients with high risk for VCF following treatment with SBRT who may potentially benefit from undergoing prophylactic spinal stabilization or vertebroplasty.
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Affiliation(s)
| | | | | | - Trey C. Mullikin
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - William S. Harmsen
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Peter S. Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Dong Kun Kim
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Robert W. Gao
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Satomi Shiraishi
- Division of Medical Physics, Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - John J. Lucido
- Division of Medical Physics, Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Terence T. Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | | | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Bradley J. Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Mark R. Waddle
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Nadia N. Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sean S. Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Paul D. Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Ramos-Fresnedo A, Pullen MW, Perez-Vega C, Domingo RA, Akinduro OO, Almeida JP, Suarez-Meade P, Marenco-Hillembrand L, Jentoft ME, Bendok BR, Trifiletti DM, Chaichana KL, Porter AB, Quiñones-Hinojosa A, Burns TC, Kizilbash SH, Middlebrooks EH, Sherman WJ. The survival outcomes of molecular glioblastoma IDH-wildtype: a multicenter study. J Neurooncol 2022; 157:177-185. [PMID: 35175545 DOI: 10.1007/s11060-022-03960-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 02/01/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Histological diagnosis of glioblastoma (GBM) was determined by the presence of necrosis or microvascular proliferation (histGBM). The 2021 WHO classification now considers IDH-wildtype diffuse astrocytic tumors without the histological features of glioblastoma (that would have otherwise been classified as grade 2 or 3) as molecular GBM (molGBM, WHO grade 4) if they harbor any of the following molecular abnormalities: TERT promoter mutation, EGFR amplification, or chromosomal + 7/- 10 copy changes. The objective of this study was to explore and compare the survival outcomes between histGBM and molGBM. METHODS Medical records for patients diagnosed with GBM at the three tertiary care academic centers of our institution from November 2017 to October 2021. Only patients who underwent adjuvant chemoradiation were included. Patients without molecular feature testing or with an IDH mutation were excluded. Univariable and multivariable analyses were performed to evaluate progression-free (PFS) and overall- survival (OS). RESULTS 708 consecutive patients were included; 643 with histGBM and 65 with molGBM. Median PFS was 8 months (histGBM) and 13 months (molGBM) (p = 0.0237) and median OS was 21 months (histGBM) versus 26 months (molGBM) (p = 0.435). Multivariable analysis on the molGBM sub-group showed a worse PFS if there was contrast enhancement on MRI (HR 6.224 [CI 95% 2.187-17.714], p < 0.001) and a superior PFS on patients with MGMT methylation (HR 0.026 [CI 95% 0.065-0.655], p = 0.007). CONCLUSIONS molGBM has a similar OS but significantly longer PFS when compared to histGBM. The presence of contrast enhancement and MGMT methylation seem to affect the clinical behavior of this subset of tumors.
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Affiliation(s)
| | | | | | | | | | - Joao P Almeida
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - Mark E Jentoft
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, USA
| | | | | | | | - Alyx B Porter
- Department of Neurology, Mayo Clinic, Phoenix, AZ, USA
| | | | | | | | | | - Wendy J Sherman
- Division Chair, Neuro-Oncology, Department of Neurology, Mayo Clinic, 4500 San Pablo Rd. S, Jacksonville, FL, 32224, USA.
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Lehrer EJ, Ruiz-Garcia H, Nehlsen AD, Sindhu KK, Estrada RS, Borst GR, Sheehan JP, Quinones-Hinojosa A, Trifiletti DM. Preoperative Stereotactic Radiosurgery for Glioblastoma. Biology (Basel) 2022; 11:194. [PMID: 35205059 PMCID: PMC8869151 DOI: 10.3390/biology11020194] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 11/16/2022]
Abstract
Glioblastoma is a devastating primary brain tumor with a median overall survival of approximately 15 months despite the use of optimal modern therapy. While GBM has been studied for decades, modern therapies have allowed for a reduction in treatment-related toxicities, while the prognosis has largely been unchanged. Adjuvant stereotactic radiosurgery (SRS) was previously studied in GBM; however, the results were disappointing. SRS is a highly conformal radiation technique that permits the delivery of high doses of ionizing radiation in 1-5 sessions while largely sparing surrounding healthy tissues. Furthermore, studies have shown that the delivery of ablative doses of ionizing radiation within the central nervous system is associated with enhanced anti-tumor immunity. While SRS is commonly used in the definitive and adjuvant settings for other CNS malignancies, its role in the preoperative setting has become a topic of great interest due to the potential for reduced treatment volumes due to the treatment of an intact tumor, and a lower risk of nodular leptomeningeal disease and radiation necrosis. While early reports of SRS in the adjuvant setting for glioblastoma were disappointing, its role in the preoperative setting and its impact on the anti-tumor adaptive immune response is largely unknown. In this review, we provide an overview of GBM, discuss the potential role of preoperative SRS, and discuss the possible immunogenic effects of this therapy.
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Affiliation(s)
- Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.J.L.); (A.D.N.); (K.K.S.)
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (R.S.E.)
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - Anthony D. Nehlsen
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.J.L.); (A.D.N.); (K.K.S.)
| | - Kunal K. Sindhu
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.J.L.); (A.D.N.); (K.K.S.)
| | - Rachel Sarabia Estrada
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (R.S.E.)
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - Gerben R. Borst
- The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK;
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine & Health, The University of Manchester, 555 Wilmslow Road, Manchester M20 4GJ, UK
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA 22908, USA;
| | | | - Daniel M. Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (R.S.E.)
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL 32224, USA;
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Lehrer EJ, Gurewitz J, Bernstein K, Patel D, Kondziolka D, Niranjan A, Wei Z, Lunsford LD, Malouff TD, Ruiz‐Garcia H, Patel S, Bonney PA, Hwang L, Yu C, Zada G, Mathieu D, Trudel C, Prasad RN, Palmer JD, Jones BM, Sharma S, Fakhoury KR, Rusthoven CG, Deibert CP, Picozzi P, Franzini A, Attuati L, Lee C, Yang H, Ahluwalia MS, Sheehan JP, Trifiletti DM. Radiation necrosis in renal cell carcinoma brain metastases treated with checkpoint inhibitors and radiosurgery: An international multicenter study. Cancer 2022; 128:1429-1438. [DOI: 10.1002/cncr.34087] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/08/2021] [Accepted: 11/22/2021] [Indexed: 12/18/2022]
Affiliation(s)
- Eric J. Lehrer
- Department of Radiation Oncology Icahn School of Medicine at Mount Sinai New York New York
| | - Jason Gurewitz
- Department of Radiation Oncology NYU Langone Medical Center New York New York
| | - Kenneth Bernstein
- Department of Radiation Oncology NYU Langone Medical Center New York New York
| | - Dev Patel
- Department of Neurosurgery NYU Langone Medical Center New York New York
| | | | - Ajay Niranjan
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Zhishuo Wei
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - L. Dade Lunsford
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | | | | | - Samir Patel
- Division of Radiation Oncology Department of Oncology University of Alberta Edmonton Alberta Canada
| | - Phillip A. Bonney
- Department of Neurosurgery University of Southern California Los Angeles California
| | - Lindsay Hwang
- Department of Radiation Oncology University of Southern California Los Angeles California
| | - Cheng Yu
- Department of Neurosurgery University of Southern California Los Angeles California
| | - Gabriel Zada
- Department of Neurosurgery University of Southern California Los Angeles California
| | - David Mathieu
- Department of Neurosurgery Université de Sherbrooke, Centre de Recherche du CHUS Quebec Quebec Canada
| | - Claire Trudel
- Department of Medicine Université de Sherbrooke, Centre de Recherche du CHUS Quebec Quebec Canada
| | - Rahul N. Prasad
- Department of Radiation Oncology Ohio State University Wexner Medical Center Columbus Ohio
| | - Joshua D. Palmer
- Department of Radiation Oncology Ohio State University Wexner Medical Center Columbus Ohio
| | - Brianna M. Jones
- Department of Radiation Oncology Icahn School of Medicine at Mount Sinai New York New York
| | - Sonam Sharma
- Department of Radiation Oncology Icahn School of Medicine at Mount Sinai New York New York
| | | | - Chad G. Rusthoven
- Department of Radiation Oncology University of Colorado Denver Colorado
| | | | - Piero Picozzi
- Department of Neurosurgery Humanitas Research Hospital–IRCCS Rozzano Italy
| | - Andrea Franzini
- Department of Neurosurgery Humanitas Research Hospital–IRCCS Rozzano Italy
| | - Luca Attuati
- Department of Neurosurgery Humanitas Research Hospital–IRCCS Rozzano Italy
| | - Cheng‐Chia Lee
- Department of Neurosurgery Neurological InstituteTaipei Veteran General Hospital Taipei Taiwan
| | - Huai‐Che Yang
- Department of Neurosurgery Neurological InstituteTaipei Veteran General Hospital Taipei Taiwan
| | | | - Jason P. Sheehan
- Department of Neurological Surgery University of Virginia Charlottesville Virginia
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Akinduro OO, De Biase G, Goyal A, Meyer JH, Sandhu SJS, Kowalchuk RO, Trifiletti DM, Sheehan J, Merrell KW, Vora SA, Broderick DF, Clarke MJ, Bydon M, McClendon J, Kalani MA, Quiñones-Hinojosa A, Abode-Iyamah K. Focused versus conventional radiotherapy in spinal oncology: is there any difference in fusion rates and pseudoarthrosis? J Neurooncol 2022; 156:329-339. [PMID: 34993721 DOI: 10.1007/s11060-021-03915-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/26/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Radiotherapy is considered standard of care for adjuvant peri-operative treatment of many spinal tumors, including those with instrumented fusion. Unfortunately, radiation treatment has been linked to increased risk of pseudoarthrosis. Newer focused radiotherapy strategies with enhanced conformality could offer improved fusion rates for these patients, but this has not been confirmed. METHODS We performed a retrospective analysis of patients at three tertiary care academic institutions with primary and secondary spinal malignancies that underwent resection, instrumented fusion, and peri-operative radiotherapy. Two board certified neuro-radiologists used the Lenke fusion score to grade fusion status at 6 and 12-months after surgery. Secondary outcomes included clinical pseudoarthrosis, wound complications, the effect of radiation timing and radiobiological dose delivered, the use of photons versus protons, tumor type, tumor location, and use of autograft on fusion outcomes. RESULTS After review of 1252 spinal tumor patients, there were 60 patients with at least 6 months follow-up that were included in our analyses. Twenty-five of these patients received focused radiotherapy, 20 patients received conventional radiotherapy, and 15 patients were treated with protons. There was no significant difference between the groups for covariates such as smoking status, obesity, diabetes, intraoperative use of autograft, and use of peri-operative chemotherapy. There was a significantly higher rate of fusion for patients treated with focused radiotherapy compared to those treated with conventional radiotherapy at 6-months (64.0% versus 30.0%, Odds ratio: 4.15, p = 0.036) and 12-months (80.0% versus 42.1%, OR: 5.50, p = 0.022). There was a significantly higher rate of clinical pseudoarthrosis in the conventional radiotherapy cohort compared to patients in the focused radiotherapy cohort (19.1% versus 0%, p = 0.037). There was no difference in fusion outcomes for any of the secondary outcomes except for use of autograft. The use of intra-operative autograft was associated with an improved fusion at 12-months (66.7% versus 37.5%, OR: 3.33, p = 0.043). CONCLUSION Focused radiotherapy may be associated with an improved rate of fusion and clinical pseudoarthrosis when compared to conventional radiation delivery strategies in patients with spinal tumors. Use of autograft at the time of surgery may be associated with improved 12-month fusion rates. Further large-scale prospective and randomized controlled studies are needed to better stratify the effects of radiation delivery modality in these patients.
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Affiliation(s)
| | - Gaetano De Biase
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Anshit Goyal
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Jenna H Meyer
- Department of Neurosurgery, Mayo Clinic, Phoenix, AZ, USA
| | | | | | | | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | | | - Sujay A Vora
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | | | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
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Zaorsky NG, Wang X, Garrett SM, Lehrer EJ, Lin C, DeGraff DJ, Spratt DE, Trifiletti DM, Kishan AU, Showalter TN, Park HS, Yang JT, Chinchilli VM, Wang M. Pan-cancer analysis of prognostic metastatic phenotypes. Int J Cancer 2022; 150:132-141. [PMID: 34287840 PMCID: PMC8595638 DOI: 10.1002/ijc.33744] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/21/2021] [Accepted: 06/29/2021] [Indexed: 01/03/2023]
Abstract
Although cancer is highly heterogeneous, all metastatic cancer is considered American Joint Committee on Cancer (AJCC) Stage IV disease. The purpose of this project was to redefine staging of metastatic cancer. Internal validation of nationally representative patient data from the National Cancer Database (n = 461 357; 2010-2013), and external validation using the Surveillance, Epidemiology and End Results database (n = 106 595; 2014-2015) were assessed using the concordance index for evaluation of survival prediction. A Cox proportional hazards model was used for overall survival by considering identified phenotypes (latent classes) and other confounding variables. Latent class analysis was performed for phenotype identification, where Bayesian information criterion (BIC) and sample-size-adjusted BIC were used to select the optimal number of distinct clusters. Kappa coefficients assessed external cluster validation. Latent class analysis identified five metastatic phenotypes with differences in overall survival (P < .0001): (Stage IVA) nearly exclusive bone-only metastases (n = 59 049, 12.8%; median survival 12.7 months; common in lung, breast and prostate cancers); (IVB) predominant lung metastases (n = 62 491, 13.5%; 11.4 months; common in breast, stomach, kidney, ovary, uterus, thyroid, cervix and soft tissue cancers); (IVC) predominant liver/lung metastases (n = 130 014, 28.2%; 7.0 months; common in colorectum, pancreatic, lung, esophagus and stomach cancers); (IVD) bone/liver/lung metastases predominant over brain (n = 61 004, 13.2%; 5.9 months; common in lung and breast cancers); and (IVE) brain/lung metastases predominant over bone/liver (n = 148 799, 32.3%; 5.7 months; lung cancer and melanoma). Long-term survivors were identified, particularly in Stages IVA-B. A pan-cancer nomogram model to predict survival (STARS: site, tumor, age, race, sex) was created, validated and provides 13% better prognostication than AJCC: 1-month concordance index of 0.67 (95% confidence interval [CI]: 0.66-0.67) vs 0.61 (95% CI: 0.60-0.61). STARS is simple, uses easily accessible variables, better prognosticates survival outcomes and provides a platform to develop novel metastasis-directed clinical trials.
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Affiliation(s)
- Nicholas G. Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA,Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA,Corresponding author: Nicholas G. Zaorsky, MD MS, Department of Radiation Oncology, Penn State Cancer Institute and Department of Public Health Sciences, Penn State College of Medicine, ; , Twitter: @NicholasZaorsky
| | - Xi Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Sara M. Garrett
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA,Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Christine Lin
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA,Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - David J. DeGraff
- Division of Experimental Pathology, Department of Pathology and Laboratory Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Daniel E. Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | | | - Amar U. Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA
| | | | - Henry S. Park
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT
| | - Jonathan T. Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
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73
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Kim MM, Hattangadi-Gluth JA, Redmond KJ, Trifiletti DM, Soltys SG, Milano MT. Back to the Future: Charting the Direction of Lower Grade Glioma Trials With Lessons From the Present and Past. Int J Radiat Oncol Biol Phys 2022; 112:30-34. [PMID: 34919877 DOI: 10.1016/j.ijrobp.2021.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Jona A Hattangadi-Gluth
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, Florida
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
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Singh R, Didwania P, Lehrer EJ, Palmer JD, Trifiletti DM, Sheehan JP. Repeat stereotactic radiosurgery for locally recurrent brain metastases previously treated with stereotactic radiosurgery: A systematic review and meta-analysis of efficacy and safety. J Radiosurg SBRT 2022; 8:1-10. [PMID: 35387405 PMCID: PMC8930057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/11/2021] [Indexed: 01/03/2023]
Abstract
Objectives To perform a systematic review and meta-analysis of outcomes for patients with locally recurrent brain metastases treated with a repeat course of stereotactic radiosurgery (rSRS). Method Primary outcomes were 1-year local control(LC) and radionecrosis (RN). Secondary outcomes were 1-year overall survival (OS) and 1-year distant brain control (DBC). Weighted random effects meta-analyses utilizing the DerSimonian and Laird methods were conducted to characterize summary effect sizes. Mixed effects regression models were utilized to analyze potential correlations between prognostic factors and outcomes. Results In total, 347 patients with 462 brain metastases treated with rSRS were included. Estimated 1-year LC, OS, and DBC rates were 69.0% (95% CI: 61.0-77.0%), 49.7% (95% CI: 28.9-70.6%), and 41.6% (95% CI: 33.0-50.4%), respectively. The estimated RN rate was 16.1% (95% CI: 6.3-25.9%). Every 1 Gy increase in prescription dose was estimated to result in roughly 5% increase in 1-year LC (p = 0.14). Conclusions rSRS was well-tolerated with reasonable 1-year LC and OS. Dose escalation may result in improved LC.
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Affiliation(s)
- Raj Singh
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Prabhanjan Didwania
- Rady School of Management, University of California at San Diego, San Diego, CA, USA
| | - Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua D. Palmer
- Department of Radiation Oncology, The James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | | | - Jason P. Sheehan
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, VA, USA
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Chen CJ, Ding D, Lee CC, Kearns KN, Pomeraniec IJ, Cifarelli CP, Arsanious DE, Liscak R, Hanuska J, Williams BJ, Yusuf MB, Woo SY, Ironside N, Warnick RE, Trifiletti DM, Mathieu D, Mureb M, Benjamin C, Kondziolka D, Feliciano CE, Rodriguez-Mercado R, Cockroft KM, Simon S, Mackley HB, Zammar S, Patel NT, Padmanaban V, Beatson N, Saylany A, Lee J, Sheehan JP. Stereotactic Radiosurgery With Versus Without Embolization for Brain Arteriovenous Malformations. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa418_s087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ramos-Fresnedo A, Domingo RA, Sanchez-Garavito JE, Perez-Vega C, Akinduro OO, Jentoft ME, Vora SA, Brown PD, Porter AB, Bendok BR, Link MJ, Middlebrooks EH, Trifiletti DM, Chaichana KL, Quiñones-Hinojosa A, Sherman WJ. The impact of multiple lesions on progression-free survival of meningiomas: a 10-year multicenter experience. J Neurosurg 2021; 137:1-9. [PMID: 34798603 DOI: 10.3171/2021.8.jns211252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Multiple meningiomas (MMs) occur in as many as 18% of patients with meningioma, and data on progression-free survival (PFS) are scarce. The objective of this study was to explore the influence of the number of lesions and clinical characteristics on PFS in patients with WHO grade I meningiomas. METHODS The authors retrospectively reviewed the records of all adults diagnosed with a meningioma at their three main sites from January 2009 to May 2020. Progression was considered the time from diagnosis until radiographic growth of the originally resected meningioma. A secondary analysis was performed to evaluate the time of diagnosis until the time to second intervention (TTSI). Univariable and multivariable analyses were conducted to assess whether the number of lesions or any associated variables (age, sex, race, radiation treatment, tumor location, and extent of resection) had a significant impact on PFS and TTSI. RESULTS Eight hundred thirty-eight patients were included. Use of a log-rank test to evaluate PFS and TTSI between a single and multiple lesions showed a significantly shorter progression for MM (p < 0.001 and p < 0.001, respectively). Multivariable Cox regression analysis showed significantly inferior PFS on MM compared to a single lesion (hazard ratio [HR] 2.262, 95% confidence interval [CI] 1.392-3.677, p = 0.001) and a significantly inferior TTSI for patients with MM when compared to patients with a single meningioma (HR 2.377, 95% CI 1.617-3.494, p = 0.001). By testing the number of meningiomas as a continuous variable, PFS was significantly inferior for each additional meningioma (HR 1.350, 95% CI 1.074-1.698, p = 0.010) and TTSI was significantly inferior as well (HR 1.428, 95% CI 1.189-1.716, p < 0.001). African American patients had an inferior PFS when compared to non-Hispanic White patients (HR 3.472, 95% CI 1.083-11.129, p = 0.036). CONCLUSIONS The PFS of meningiomas appears to be influenced by the number of lesions present. Patients with MM also appear to be more prone to undergoing a second intervention for progressive disease. Hence, a closer follow-up may be warranted in patients who present with multiple lesions. These results show a decreased PFS for each additional lesion present, as well as a shorter PFS for MM compared to a single lesion. When assessing associated risk factors, African American patients showed an inferior PFS, whereas older age and adjuvant therapy with radiation showed an improved PFS.
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Affiliation(s)
| | | | - Jesus E Sanchez-Garavito
- Departments of1Neurosurgery
- 2Facultad de Ciencias de la Salud, Universidad Anahuac Mexico, Mexico City, Mexico
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Mehta GU, Lekovic GP, Slattery WH, Brackmann DE, Long H, Kano H, Kondziolka D, Mureb M, Bernstein K, Langlois AM, Mathieu D, Nabeel AM, Reda WA, Tawadros SR, Abdelkarim K, El-Shehaby AMN, Emad RM, Mohammed N, Urgosik D, Liscak R, Lee CC, Yang HC, Montazeripouragha A, Kaufmann AM, Joshi KC, Barnett GH, Trifiletti DM, Lunsford LD, Sheehan JP. Effect of Anatomic Segment Involvement on Stereotactic Radiosurgery for Facial Nerve Schwannomas: An International Multicenter Cohort Study. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa313_s078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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78
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Lehrer EJ, Stoltzfus KC, Jones BM, Gusani NJ, Walter V, Wang M, Trifiletti DM, Siva S, Louie AV, Zaorsky NG. Trends in Diagnosis and Treatment of Metastatic Cancer in the United States. Am J Clin Oncol 2021; 44:572-579. [PMID: 34560720 DOI: 10.1097/coc.0000000000000866] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Metastatic cancer has historically been considered fatal; however, there is a paucity of evidence characterizing the epidemiology of incidence, treatment, and outcomes in these patients. MATERIALS AND METHODS Incidence rates, annual percent change (APC), descriptive epidemiological statistics, and odds ratios for survival were calculated using registry data from the Surveillance, Epidemiology, and End Results (SEER) and the National Cancer Database (NCDB), 1998 to 2015. RESULTS There were a total of 1,055,860 patients with metastatic cancer. The most frequent primary cancers were lung (42.6%), colorectal (9.5%), and ovarian (5.5%). Metastatic lung and colorectal cancer incidence decreased, APC: -1.57 (P<0.001) and APC: -1.48 (P<0.001), respectively; metastatic pancreatic cancer incidence increased, APC: 0.62 (P=0.001). The use of local therapies decreased for almost all sites, and the use of systemic therapies increased across multiple sites: single-agent chemotherapy in kidney (2.54% increase/year), female breast (1.14% increase/year), and prostate cancer (1.08% increase/year); multiagent chemotherapy, most notably in pancreas (2.23% increase/year), uterus (1.81% increase/year), and colorectal cancer (1.54% increase/year). Increased utilization of immunotherapy was observed across the majority of sites, most notably in melanoma (2.14% increase/year). Patients diagnosed from 2006 to 2010 had 17.4% higher odds of surviving at least 60 months compared with 1998 to 2002. CONCLUSIONS In this study, metastatic disease has been shown to have unique epidemiological patterns, and survival has improved. Continued research on metastatic disease is important in understanding and addressing the distinct health concerns of this population.
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Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Brianna M Jones
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Niraj J Gusani
- Public Health Sciences
- Surgery, Penn State College of Medicine
- Section of Surgical Oncology, Baptist MD Anderson Cancer Center
| | - Vonn Walter
- Public Health Sciences
- Departments of Biochemistry and Molecular Biology
| | | | | | - Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre
- Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Vic., Australia
| | - Alexander V Louie
- Odette Cancer Centre-Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Nicholas G Zaorsky
- Public Health Sciences
- Radiation Oncology, Penn State Cancer Institute, Hershey, PA
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Chen H, Stoltzfus KC, Lehrer EJ, Horn SR, Siva S, Trifiletti DM, Meng MB, Verma V, Louie AV, Zaorsky NG. The Epidemiology of Lung Metastases. Front Med (Lausanne) 2021; 8:723396. [PMID: 34616754 PMCID: PMC8488106 DOI: 10.3389/fmed.2021.723396] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/11/2021] [Indexed: 12/31/2022] Open
Abstract
Introduction: Lung metastasis is usually associated with poor outcomes in cancer patients. This study was performed to characterize and analyze the population of patients with de novo (synchronous) lung metastases using the Surveillance, Epidemiology and End Results (SEER) database. Materials and Methods: Baseline characteristics of lung metastasis patients were obtained from SEER case listings. Incidence rates and counts of synchronous lung metastasis were also obtained using the SEER*Stat software. Survival outcomes were analyzed using univariate and multivariable Cox regressions, controlling for confounders. An alpha threshold of 0.05 was used for statistical significance and p-values were subject to correction for multiple comparisons. Results: The age-adjusted incidence rate of synchronous lung metastasis was 17.92 per 100,000 between 2010 and 2015. Synchronous lung metastases most commonly arose from primary lung cancers, colorectal cancers, kidney cancers, pancreatic cancers and breast cancers. During this time period, 4% of all cancer cases presented with synchronous lung metastasis. The percentage of patients presenting with synchronous lung metastasis ranged from 0.5% of all prostate cancers to 13% of all primary lung cancers. The percentage of all cancer cases presenting with synchronous lung metastasis increased over time. De novo metastatic patients with lung metastases had worse overall survival [hazard ratio = 1.22 (1.21–1.23), p < 0.001] compared to those with only extrapulmonary metastases, controlling for potential confounders. Conclusions: Synchronous lung metastasis occurs frequently and is an independent predictors of poor patient outcomes. As treatment for lung metastases becomes more complicated, patients with synchronous lung metastasis represent a high-risk population.
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Affiliation(s)
- Hanbo Chen
- Department of Radiation Oncology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Kelsey C Stoltzfus
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, United States.,Department of Public Health Sciences, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Samantha R Horn
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, United States.,Department of Public Health Sciences, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Mao-Bin Meng
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, United States
| | - Alexander V Louie
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, United States.,Department of Public Health Sciences, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, United States
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80
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Kotecha R, Aboian M, Nabavizadeh SA, Parent EE, Trifiletti DM, Chao ST. Letter regarding "Contribution of PET imaging to radiotherapy planning and monitoring in glioma patients-a report of the PET/RANO group": 18F-fluciclovine and target volume delineation. Neuro Oncol 2021; 23:1408-1409. [PMID: 34081125 PMCID: PMC8328036 DOI: 10.1093/neuonc/noab097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Mariam Aboian
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Seyed Ali Nabavizadeh
- Department of Radiology, Hospital of University of Pennsylvania, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ephraim E Parent
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Samuel T Chao
- Department of Radiation Oncology, Rose Ella Burkhart Brain Tumor and Neuro-Oncology Center, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University Cleveland Clinic, Cleveland, Ohio, USA
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81
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Malouff TD, TerKonda SP, Knight D, Abu Dabrh AM, Perlman AI, Munipalli B, Dudenkov DV, Heckman MG, White LJ, Wert KM, Pascual JM, Rivera FA, Shoaei MM, Leak MA, Harrell AC, Trifiletti DM, Buskirk SJ. Physician Satisfaction With Telemedicine During the COVID-19 Pandemic: The Mayo Clinic Florida Experience. Mayo Clin Proc Innov Qual Outcomes 2021; 5:771-782. [PMID: 34226884 PMCID: PMC8245346 DOI: 10.1016/j.mayocpiqo.2021.06.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate physician perceptions and attitudes toward telemedicine use at a tertiary care academic institution in northeast Florida during the coronavirus disease 2019 pandemic. PATIENTS AND METHODS An anonymous 38-question cross-sectional survey was developed using Qualtrics survey software (Qualtrics) and e-mailed to all staff physicians from all specialty disciplines at Mayo Clinic in Florida. The survey was open from August 17, 2020, through September 1, 2020. Collected data included general demographic characteristics and employment information, attitude and experience with telemedicine use before and during the coronavirus disease 2019 pandemic, perception of patients' experience, and the effect of telemedicine on burnout. RESULTS The survey was distributed to 529 eligible physicians at our institution, with 103 physicians responding (20%). The distribution of specialties was 22% primary care specialties, 41% other internal medicine subspecialties, and 18% surgical specialties. Collectively, 63% found comparable quality of care when provided virtually (vs in-person) whereas 80% perceived telemedicine as cost-effective. A total of 76% of physicians felt that telemedicine increased flexibility and control over patient care activities, with 36% reporting improved work-life balance and 30% reporting improved burnout symptoms. Overall, 42% preferred using telemedicine over in-person visits when possible. CONCLUSION Physicians generally had positive attitudes regarding the adoption of telemedicine and perceived that the quality of health care delivery as generally comparable to in-person care. Future studies are needed to explore attitudes regarding telemedicine after the pandemic and how this virtual technology may be further used to improve physicians' professional and personal well-being.
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Affiliation(s)
| | - Sarvam P. TerKonda
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL
- Center for Connected Care, Mayo Clinic, Jacksonville, FL
| | - Dacre Knight
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL
| | | | - Adam I. Perlman
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Bala Munipalli
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL
| | | | - Michael G. Heckman
- Division of Biomedical Sciences and Informatics, Mayo Clinic, Jacksonville, FL
| | - Launia J. White
- Division of Biomedical Sciences and Informatics, Mayo Clinic, Jacksonville, FL
| | - Katey M. Wert
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL
| | - Jorge M. Pascual
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | | | | | | | - Anna C. Harrell
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL
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82
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Bunevicius A, Fribance S, Pikis S, Lee JYK, Buch LY, Moran M, Yang AI, Bernstein K, Mathieu D, Perron R, Liscak R, Simonova G, Patel S, Trifiletti DM, Martínez Álvarez R, Martínez Moreno N, Lee CC, Yang HC, Strickland BA, Zada G, Chang EL, Kondziolka D, Sheehan J. Stereotactic Radiosurgery for Differentiated Thyroid Cancer Brain Metastases: An International, Multicenter Study. Thyroid 2021; 31:1244-1252. [PMID: 33978475 DOI: 10.1089/thy.2020.0947] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: Brain metastases (BM) from differentiated thyroid cancer are rare. Stereotactic radiosurgery (SRS) is commonly used for the treatment of BMs; however, the experience with SRS for thyroid cancer BMs remains limited. The goal of this international, multi-centered study was to evaluate the efficacy and safety of SRS for thyroid cancer BMs. Methods: From 10 institutions participating in the International Radiosurgery Research Foundation, we pooled patients with established papillary or follicular thyroid cancer diagnosis who underwent SRS for histologically confirmed or radiologically suspected BMs. We investigated patient overall survival (OS), local tumor control, and adverse radiation events (AREs). Results: We studied 42 (52% men) patients who underwent SRS for 122 papillary (83%) or follicular (17%) thyroid cancer BMs. The mean age at SRS was 59.86 ± 12.69 years. The mean latency from thyroid cancer diagnosis to SRS for BMs was 89.05 ± 105.49 months. The median number of BMs per patient was 2 (range: 1-10 BMs). The median SRS treatment volume was 0.79 cm3 (range: 0.003-38.18 cm3), and the median SRS prescription dose was 20 Gy (range: 8-24 Gy). The median survival after SRS for BMs was 14 months (range: 3-58 months). The OS was significantly shorter in patients harboring ≥2 BMs, when compared with patients with one BM (Log-rank = 5.452, p = 0.02). Two or more BMs (odds ratio [OR] = 3.688; confidence interval [CI]: 1.143-11.904; p = 0.03) and lower Karnofsky performance score at the time of SRS (OR = 0.807; CI: 0.689-0.945; p = 0.008) were associated with shorter OS. During post-SRS imaging follow-up of 25.21 ± 30.49 months, local failure (progression and/or radiation necrosis) of BMs treated with SRS was documented in five (4%) BMs at 7.2 ± 7.3 months after the SRS. At the last imaging follow-up, the majority of patients with available imaging data had stable intracranial disease (33%) or achieved complete (26%) or partial (24%) response. There were no clinical AREs. Post-SRS peritumoral T2/fluid attenuated inversion recovery signal hyperintensity was noted in 7% BMs. Conclusion: The SRS allows durable local control of papillary and follicular thyroid cancer BMs in the vast majority of patients. Higher number of BMs and worse functional status at the time of SRS are associated with shorter OS in patients with thyroid cancer BMs. The SRS is safe and is associated with a low risk of AREs.
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Affiliation(s)
- Adomas Bunevicius
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Sarah Fribance
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Stylianos Pikis
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Love Y Buch
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Moran
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew I Yang
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kenneth Bernstein
- Department of Radiation Oncology and NYU Langone Health, New York University, New York, New York, USA
| | - David Mathieu
- Department of Neurological Surgery, Centre de recherche du CHUS, Université de Sherbrooke, Sherbrooke, Canada
| | - Rémi Perron
- Department of Neurological Surgery, Centre de recherche du CHUS, Université de Sherbrooke, Sherbrooke, Canada
| | - Roman Liscak
- Department of Neurological Surgery, Na Homolce Hospital, Prague, Czech Republic
| | - Gabriela Simonova
- Department of Neurological Surgery, Na Homolce Hospital, Prague, Czech Republic
| | - Samir Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Canada
| | | | - Roberto Martínez Álvarez
- Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, Madrid, Spain
| | - Nuria Martínez Moreno
- Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, Madrid, Spain
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Ben A Strickland
- Department of Neurosurgery and University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurosurgery and University of Southern California, Los Angeles, California, USA
| | - Eric L Chang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Health, New York University, New York, New York, USA
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
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83
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Malouff TD, Combs SE, Trifiletti DM. Editorial: Exploring the Potential of Particle Radiotherapy: Helium, Neutrons, Carbon, and Other Heavy Ions. Front Oncol 2021; 11:740974. [PMID: 34395297 PMCID: PMC8358599 DOI: 10.3389/fonc.2021.740974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Timothy D Malouff
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, FL, United States
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, FL, United States
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84
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Stoltzfus KC, Shen B, Tchelebi L, Trifiletti DM, Gusani NJ, Walter V, Wang M, Zaorsky NG. Authors' Reply: To the Letter to the Editor by Kessel et al. J Natl Compr Canc Netw 2021; 19:xliii-xliv. [PMID: 34340211 DOI: 10.6004/jnccn.2021.7068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Biyi Shen
- bPenn State College of Medicine, Hershey, Pennsylvania
| | | | | | - Niraj J Gusani
- bPenn State College of Medicine, Hershey, Pennsylvania.,dBaptist MD Anderson Cancer Center, Jacksonville, Florida
| | - Vonn Walter
- bPenn State College of Medicine, Hershey, Pennsylvania
| | - Ming Wang
- bPenn State College of Medicine, Hershey, Pennsylvania
| | - Nicholas G Zaorsky
- aPenn State Cancer Institute, Hershey, Pennsylvania.,bPenn State College of Medicine, Hershey, Pennsylvania
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85
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Abstract
BACKGROUND Chordoma is a rare primary bone tumour with a high propensity for local recurrence. Surgical resection is the mainstay of treatment, but complete resection is often morbid due to tumour location. Similarly, the dose of radiotherapy (RT) that surrounding healthy organs can tolerate is frequently below that required to provide effective tumour control. Therefore, clinicians have investigated different radiation delivery techniques, often in combination with surgery, aimed to improve the therapeutic ratio. OBJECTIVES To assess the effects and toxicity of proton and photon adjuvant radiotherapy (RT) in people with biopsy-confirmed chordoma. SEARCH METHODS We searched CENTRAL (2021, Issue 4); MEDLINE Ovid (1946 to April 2021); Embase Ovid (1980 to April 2021) and online registers of clinical trials, and abstracts of scientific meetings up until April 2021. SELECTION CRITERIA We included adults with pathologically confirmed primary chordoma, who were irradiated with curative intent, with protons or photons in the form of fractionated RT, SRS (stereotactic radiosurgery), SBRT (stereotactic body radiotherapy), or IMRT (intensity modulated radiation therapy). We limited analysis to studies that included outcomes of participants treated with both protons and photons. DATA COLLECTION AND ANALYSIS The primary outcomes were local control, mortality, recurrence, and treatment-related toxicity. We followed current standard Cochrane methodological procedures for data extraction, management, and analysis. We used the ROBINS-I tool to assess risk of bias, and GRADE to assess the certainty of the evidence. MAIN RESULTS We included six observational studies with 187 adult participants. We judged all studies to be at high risk of bias. Four studies were included in meta-analysis. We are uncertain if proton compared to photon therapy worsens or has no effect on local control (hazard ratio (HR) 5.34, 95% confidence interval (CI) 0.66 to 43.43; 2 observational studies, 39 participants; very low-certainty evidence). Median survival time ranged between 45.5 months and 66 months. We are uncertain if proton compared to photon therapy reduces or has no effect on mortality (HR 0.44, 95% CI 0.13 to 1.57; 4 observational studies, 65 participants; very low-certainty evidence). Median recurrence-free survival ranged between 3 and 10 years. We are uncertain whether proton compared to photon therapy reduces or has no effect on recurrence (HR 0.34, 95% CI 0.10 to 1.17; 4 observational studies, 94 participants; very low-certainty evidence). One study assessed treatment-related toxicity and reported that four participants on proton therapy developed radiation-induced necrosis in the temporal bone, radiation-induced damage to the brainstem, and chronic mastoiditis; one participant on photon therapy developed hearing loss, worsening of the seventh cranial nerve paresis, and ulcerative keratitis (risk ratio (RR) 1.28, 95% CI 0.17 to 9.86; 1 observational study, 33 participants; very low-certainty evidence). There is no evidence that protons led to reduced toxicity. There is very low-certainty evidence to show an advantage for proton therapy in comparison to photon therapy with respect to local control, mortality, recurrence, and treatment related toxicity. AUTHORS' CONCLUSIONS There is a lack of published evidence to confirm a clinical difference in effect with either proton or photon therapy for the treatment of chordoma. As radiation techniques evolve, multi-institutional data should be collected prospectively and published, to help identify persons that would most benefit from the available radiation treatment techniques.
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Affiliation(s)
- Iman El Sayed
- Department of Biomedical Informatics and Medical Statistics, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | | | - Eric J Lehrer
- Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, USA
| | | | - Sunil W Dutta
- Department of Radiation Oncology, Emory University, Atlanta, USA
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86
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Affiliation(s)
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
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87
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Tchelebi LT, Batchelder E, Wang M, Lehrer EJ, Drabick JJ, Sharma N, Machtay M, Trifiletti DM, Zaorsky NG. Radiotherapy and Receptor Tyrosine Kinase Inhibition for Solid Cancers (ROCKIT): A Meta-Analysis of 13 Studies. JNCI Cancer Spectr 2021; 5:pkab050. [PMID: 34350378 PMCID: PMC8328097 DOI: 10.1093/jncics/pkab050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/16/2021] [Accepted: 05/18/2021] [Indexed: 12/25/2022] Open
Abstract
Background We hypothesized that the addition of receptor tyrosine kinase inhibitors (RTKis, e.g., lapatinib, erlotinib, cetuximab, bevacizumab, panitumumab) to radiotherapy-based treatment for solid tumors does not increase overall survival but may increase toxicity. Methods Population, Intervention, Control, Outcome, Study Design; Preferred Reporting Items for Systematic Reviews and Meta-Analyses; and Meta-analysis of Observational Studies in Epidemiology methods were used to identify prospective randomized studies including patients with solid tumor cancers treated with radiotherapy with or without RTKis. Extracted variables included use of radiotherapy vs chemoradiotherapy, RTKi type (antibody vs small molecule), outcomes, and toxicities. The primary endpoint was overall survival; the secondary endpoint was grade 3+ toxicity. Random-effects meta-analyses were performed for each outcome measure. All statistical tests were 2-sided. Results A total of 405 studies met the initial search criteria, of which 13 prospective randomized trials of radiotherapy with or without RTKi met the inclusion criteria, encompassing 5678 patients. The trials included cancers of the head and neck (6 trials, 3295 patients), esophagus (3 trials, 762 patients), lung (2 trials, 550 patients), and brain (2 trials, 1542 patients). Three studies evaluated a small molecule and radiotherapy in 949 patients, and 10 studies evaluated antibodies and radiotherapy in 4729 patients. The addition of RTKis to radiotherapy-based treatment did not improve overall survival (hazard ratio = 1.02, 95% confidence interval = 0.90 to 1.15, P = .76) but increased grade 3+ toxicity (relative risk = 1.18, 95% confidence interval = 1.06 to 1.33, P = .009). Conclusions The addition of RTKis to radiotherapy does not improve survival and worsens toxicity.
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Affiliation(s)
- Leila T Tchelebi
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Emma Batchelder
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joseph J Drabick
- Department of Medical Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Navesh Sharma
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | - Mitchell Machtay
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA
| | | | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA.,Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
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88
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Singh R, Lehrer EJ, Wang M, Perlow HK, Zaorsky NG, Trifiletti DM, Bovi J, Navarria P, Scoccianti S, Gondi V, Brown PD, Palmer JD. Dose Escalated Radiation Therapy for Glioblastoma Multiforme: An International Systematic Review and Meta-Analysis of 22 Prospective Trials. Int J Radiat Oncol Biol Phys 2021; 111:371-384. [PMID: 33991621 DOI: 10.1016/j.ijrobp.2021.05.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/06/2021] [Accepted: 05/01/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Limited evidence is available on the utility of dose-escalated radiation therapy (DE-RT) with or without temozolomide (TMZ) versus standard-of-care radiation therapy (SoC-RT) for patients with newly diagnosed glioblastoma multiforme. We performed a systematic review/meta-analysis to compare overall survival (OS) and progression-free survival (PFS) between DE-RT and SoC-RT. METHODS AND MATERIALS We used a Population, Intervention, Control, Outcomes, Study Design/Preferred Reporting Items for Systematic Reviews and Meta-analyses/Meta-analysis of Observational Studies in Epidemiology selection criterion to identify studies. The primary and secondary outcomes were 1-year OS and 1-year PFS, respectively. Outcomes and comparisons were subdivided based on receipt of TMZ and MGMT status. DE-RT was defined based on equivalent dose calculations. Random effects meta-analyses using the Knapp-Hartung correction, arcsine transformation, and restricted maximum likelihood method were conducted. Meta-regression was used to compare therapeutic (eg, DE-RT or TMZ) and pathologic characteristics (eg, MGMT methylation status) using the Wald-type test. RESULTS Across 22 published studies, 2198 patients with glioblastoma multiforme were included; 507 received DE-RT. One-year OS after DE-RT alone was higher than SoC-RT alone (46.3% vs 23.4%; P = .02) as was 1-year PFS (17.9% vs 5.3%; P = .02). No significant difference in 1-year OS (73.2% vs 64.4%; P = .23) or 1-year PFS (44.5% vs 44.3%; P = .33) between DE-RT + TMZ and SoC-RT + TMZ was noted. No difference in 1-year OS was noted between DE-RT + TMZ and SoC-RT + TMZ in either MGMT methylated (83.2% vs 73.2%; P = .23) or MGMT unmethylated (72.6% vs 50.6%; P = .16) patients. CONCLUSIONS DE-RT alone resulted in superior PFS and OS versus SoC-RT alone. DE-RT + TMZ did not lead to improved outcomes versus SoC-RT + TMZ. No differential benefit based on MGMT status was found. Future studies are warranted to define which subgroups benefit most from DE-RT.
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Affiliation(s)
- Raj Singh
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ming Wang
- Department of Public Health Sciences, Penn State University, Hershey, Pennsylvania
| | - Haley K Perlow
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Nicholas G Zaorsky
- Department of Public Health Sciences, Penn State University, Hershey, Pennsylvania; Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
| | | | - Joseph Bovi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pierina Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Hospital-IRCCS, Rozzano (MI), Italy
| | - Silvia Scoccianti
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Joshua D Palmer
- Department of Radiation Oncology and Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, Virginia.
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89
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Chen CJ, Ding D, Lee CC, Kearns KN, Pomeraniec IJ, Cifarelli CP, Arsanious DE, Liscak R, Hanuska J, Williams BJ, Yusuf MB, Woo SY, Ironside N, Warnick RE, Trifiletti DM, Mathieu D, Mureb M, Benjamin C, Kondziolka D, Feliciano CE, Rodriguez-Mercado R, Cockroft KM, Simon S, Mackley HB, Zammar S, Patel NT, Padmanaban V, Beatson N, Saylany A, Lee J, Sheehan JP. Stereotactic Radiosurgery With Versus Without Embolization for Brain Arteriovenous Malformations. Neurosurgery 2021; 88:313-321. [PMID: 33017465 DOI: 10.1093/neuros/nyaa418] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 07/02/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Prior comparisons of brain arteriovenous malformations (AVMs) treated using stereotactic radiosurgery (SRS) with or without embolization were inherently flawed, due to differences in the pretreatment nidus volumes. OBJECTIVE To compare the outcomes of embolization and SRS, vs SRS alone for AVMs using pre-embolization malformation features. METHODS We retrospectively reviewed International Radiosurgery Research Foundation AVM databases from 1987 to 2018. Patients were categorized into the embolization and SRS (E + SRS) or SRS alone (SRS-only) cohorts. The 2 cohorts were matched in a 1:1 ratio using propensity scores. Primary outcome was defined as AVM obliteration. Secondary outcomes were post-SRS hemorrhage, all-cause mortality, radiologic and symptomatic radiation-induced changes (RIC), and cyst formation. RESULTS The matched cohorts each comprised 101 patients. Crude AVM obliteration rates were similar between the matched E + SRS vs SRS-only cohorts (48.5% vs 54.5%; odds ratio = 0.788, P = .399). Cumulative probabilities of obliteration at 3, 4, 5, and 6 yr were also similar between the E + SRS (33.0%, 46.4%, 56.2%, and 60.8%, respectively) and SRS-only (32.9%, 46.2%, 56.0%, and 60.6%, respectively) cohorts (subhazard ratio (SHR) = 1.005, P = .981). Cumulative probabilities of radiologic RIC at 3, 4, 5, and 6 yr were lower in the E + SRS (25.0%, 25.7%, 26.7%, and 26.7%, respectively) vs SRS-only (45.3%, 46.2%, 47.8%, and 47.8%, respectively) cohort (SHR = 0.478, P = .004). Symptomatic and asymptomatic embolization-related complication rates were 8.3% and 18.6%, respectively. Rates of post-SRS hemorrhage, all-cause mortality, symptomatic RIC, and cyst formation were similar between the matched cohorts. CONCLUSION This study refutes the prevalent notion that AVM embolization negatively affects the likelihood of obliteration after SRS.
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Affiliation(s)
- Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Kathryn N Kearns
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - I Jonathan Pomeraniec
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | | | - David E Arsanious
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia
| | - Roman Liscak
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jaromir Hanuska
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Brian J Williams
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | - Mehran B Yusuf
- Department of Radiation Oncology, University of Louisville, Louisville, Kentucky
| | - Shiao Y Woo
- Department of Radiation Oncology, University of Louisville, Louisville, Kentucky
| | - Natasha Ironside
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Ronald E Warnick
- Department of Neurosurgery, The Jewish Hospital, Cincinnati, Ohio
| | | | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Canada
| | - Monica Mureb
- Department of Neurosurgery, New York University, New York, New York
| | | | | | - Caleb E Feliciano
- Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Kevin M Cockroft
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Scott Simon
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Heath B Mackley
- Department of Radiation Oncology, Pennsylvania State University, Hershey, Pennsylvania
| | - Samer Zammar
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Neel T Patel
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Varun Padmanaban
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Nathan Beatson
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anissa Saylany
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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90
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Chen CJ, Ding D, Lee CC, Kearns KN, Pomeraniec IJ, Cifarelli CP, Arsanious DE, Liscak R, Hanuska J, Williams BJ, Yusuf MB, Woo SY, Ironside N, Warnick RE, Trifiletti DM, Mathieu D, Mureb M, Benjamin C, Kondziolka D, Feliciano CE, Rodriguez-Mercado R, Cockroft KM, Simon S, Mackley HB, Zammar SG, Patel NT, Padmanaban V, Beatson N, Saylany A, Lee J, Sheehan JP. Embolization of Brain Arteriovenous Malformations With Versus Without Onyx Before Stereotactic Radiosurgery. Neurosurgery 2021; 88:366-374. [PMID: 32860409 DOI: 10.1093/neuros/nyaa370] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/24/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Embolization of brain arteriovenous malformations (AVMs) using ethylene-vinyl alcohol copolymer (Onyx) embolization may influence the treatment effects of stereotactic radiosurgery (SRS) differently than other embolysates. OBJECTIVE To compare the outcomes of pre-SRS AVM embolization with vs without Onyx through a multicenter, retrospective matched cohort study. METHODS We retrospectively reviewed International Radiosurgery Research Foundation AVM databases from 1987 to 2018. Embolized AVMs treated with SRS were selected and categorized based on embolysate usage into Onyx embolization (OE + SRS) or non-Onyx embolization (NOE + SRS) cohorts. The 2 cohorts were matched in a 1:1 ratio using de novo AVM features for comparative analysis of outcomes. RESULTS The matched cohorts each comprised 45 patients. Crude AVM obliteration rates were similar between the matched OE + SRS vs NOE + SRS cohorts (47% vs 51%; odds ratio [OR] = 0.837, P = .673). Cumulative probabilities of obliteration were also similar between the OE + SRS vs NOE + SRS cohorts (subhazard ratio = 0.992, P = .980). Rates of post-SRS hemorrhage, all-cause mortality, radiation-induced changes, cyst formation, and embolization-associated complications were similar between the matched cohorts. Sensitivity analysis for AVMs in the OE + SRS cohort embolized with Onyx alone revealed a higher rate of asymptomatic embolization-associated complications in this subgroup compared to the NOE + SRS cohort (36% vs 15%; OR = 3.297, P = .034), but the symptomatic complication rates were similar. CONCLUSION Nidal embolization using Onyx does not appear to differentially impact the outcomes of AVM SRS compared with non-Onyx embolysates. The embolic agent selected for pre-SRS AVM embolization should reflect both the experience of the neurointerventionalist and target of endovascular intervention.
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Affiliation(s)
- Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kathryn N Kearns
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - I Jonathan Pomeraniec
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | | | - David E Arsanious
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia
| | - Roman Liscak
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jaromir Hanuska
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Brian J Williams
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | - Mehran B Yusuf
- Department of Radiation Oncology, University of Louisville, Louisville, Kentucky
| | - Shiao Y Woo
- Department of Radiation Oncology, University of Louisville, Louisville, Kentucky
| | - Natasha Ironside
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Ronald E Warnick
- Department of Neurosurgery, The Jewish Hospital, Cincinnati, Ohio
| | | | - David Mathieu
- Department of Neurosurgery, Centre de Recherche du CHUS, Université de Sherbrooke, Sherbrooke, Canada
| | - Monica Mureb
- Department of Neurosurgery, New York University, New York, New York
| | | | | | - Caleb E Feliciano
- Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Kevin M Cockroft
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Scott Simon
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Heath B Mackley
- Department of Radiation Oncology, Pennsylvania State University, Hershey, Pennsylvania
| | - Samer G Zammar
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Neel T Patel
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Varun Padmanaban
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Nathan Beatson
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anissa Saylany
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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91
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Mehta GU, Lekovic GP, Slattery WH, Brackmann DE, Long H, Kano H, Kondziolka D, Mureb M, Bernstein K, Langlois AM, Mathieu D, Nabeel AM, Reda WA, Tawadros SR, Abdelkarim K, El-Shehaby AMN, Emad RM, Mohammed N, Urgosik D, Liscak R, Lee CC, Yang HC, Montazeripouragha A, Kaufmann AM, Joshi KC, Barnett GH, Trifiletti DM, Lunsford LD, Sheehan JP. Effect of Anatomic Segment Involvement on Stereotactic Radiosurgery for Facial Nerve Schwannomas: An International Multicenter Cohort Study. Neurosurgery 2021; 88:E91-E98. [PMID: 32687577 DOI: 10.1093/neuros/nyaa313] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 05/13/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Facial nerve schwannomas are rare, challenging tumors to manage due to their nerve of origin. Functional outcomes after stereotactic radiosurgery (SRS) are incompletely defined. OBJECTIVE To analyze the effect of facial nerve segment involvement on functional outcome for these tumors. METHODS Patients who underwent single-session SRS for facial nerve schwannomas with at least 3 mo follow-up at 11 participating centers were included. Preoperative and treatment variables were recorded. Outcome measures included radiological tumor response and neurological function. RESULTS A total of 63 patients (34 females) were included in the present study. In total, 75% had preoperative facial weakness. Mean tumor volume and margin dose were 2.0 ± 2.4 cm3 and 12.2 ± 0.54 Gy, respectively. Mean radiological follow-up was 45.5 ± 38.9 mo. Progression-free survival at 2, 5, and 10 yr was 98.1%, 87.2%, and 87.2%, respectively. The cumulative proportion of patients with regressing tumors at 2, 5, and 10 yr was 43.1%, 63.6%, and 63.6%, respectively. The number of involved facial nerve segments significantly predicted tumor progression (P = .04). Facial nerve function was stable or improved in 57 patients (90%). Patients with involvement of the labyrinthine segment of the facial nerve were significantly more likely to have an improvement in facial nerve function after SRS (P = .03). Hearing worsened in at least 6% of patients. Otherwise, adverse radiation effects included facial twitching (3 patients), facial numbness (2 patients), and dizziness (2 patients). CONCLUSION SRS for facial nerve schwannomas is effective and spares facial nerve function in most patients. Some patients may have functional improvement after treatment, particularly if the labyrinthine segment is involved.
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Affiliation(s)
- Gautam U Mehta
- Division of Neurosurgery, House Ear Institute, Los Angeles, California
| | - Gregory P Lekovic
- Division of Neurosurgery, House Ear Institute, Los Angeles, California
| | | | | | - Hao Long
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hideyuki Kano
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University School of Medicine, New York, New York
| | - Monica Mureb
- Department of Neurosurgery, New York University School of Medicine, New York, New York
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York
| | - Anne-Marie Langlois
- Department of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Canada
| | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Canada
| | - Ahmed M Nabeel
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt.,Neurosurgery Department, Benha University, Qalubya, Egypt
| | - Wael A Reda
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt.,Neurosurgery Department, Ain Shams University, Cairo, Egypt
| | - Sameh R Tawadros
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt.,Neurosurgery Department, Ain Shams University, Cairo, Egypt
| | - Khaled Abdelkarim
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt.,Clinical Oncology Department, Ain Shams University, Cairo, Egypt
| | - Amr M N El-Shehaby
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt.,Neurosurgery Department, Ain Shams University, Cairo, Egypt
| | - Reem M Emad
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt.,Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Nasser Mohammed
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Dusan Urgosik
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Roman Liscak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurologic Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurologic Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | | | | | - Krishna C Joshi
- Department of Neuro-oncology, Cleveland Clinic, Cleveland, Ohio
| | - Gene H Barnett
- Department of Neuro-oncology, Cleveland Clinic, Cleveland, Ohio
| | | | - L Dade Lunsford
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
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92
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Redmond KJ, Milano MT, Kim MM, Trifiletti DM, Soltys SG, Hattangadi-Gluth JA. Reducing Radiation-Induced Cognitive Toxicity: Sparing the Hippocampus and Beyond. Int J Radiat Oncol Biol Phys 2021; 109:1131-1136. [PMID: 33714520 DOI: 10.1016/j.ijrobp.2021.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 01/03/2021] [Indexed: 12/25/2022]
Affiliation(s)
- Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland.
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, Florida
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Jona A Hattangadi-Gluth
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
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93
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Malouff TD, Seneviratne DS, Ebner DK, Stross WC, Waddle MR, Trifiletti DM, Krishnan S. Boron Neutron Capture Therapy: A Review of Clinical Applications. Front Oncol 2021; 11:601820. [PMID: 33718149 PMCID: PMC7952987 DOI: 10.3389/fonc.2021.601820] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/27/2021] [Indexed: 01/22/2023] Open
Abstract
Boron neutron capture therapy (BNCT) is an emerging treatment modality aimed at improving the therapeutic ratio for traditionally difficult to treat tumors. BNCT utilizes boronated agents to preferentially deliver boron-10 to tumors, which, after undergoing irradiation with neutrons, yields litihium-7 and an alpha particle. The alpha particle has a short range, therefore preferentially affecting tumor tissues while sparing more distal normal tissues. To date, BNCT has been studied clinically in a variety of disease sites, including glioblastoma multiforme, meningioma, head and neck cancers, lung cancers, breast cancers, hepatocellular carcinoma, sarcomas, cutaneous malignancies, extramammary Paget's disease, recurrent cancers, pediatric cancers, and metastatic disease. We aim to provide an up-to-date and comprehensive review of the studies of each of these disease sites, as well as a review on the challenges facing adoption of BNCT.
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Affiliation(s)
- Timothy D Malouff
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | | | - Daniel K Ebner
- Warren Alpert Medical School, Brown University, Providence, RI, United States
| | - William C Stross
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Mark R Waddle
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Sunil Krishnan
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
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94
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Trifiletti DM, Ruiz-Garcia H, Quinones-Hinojosa A, Ramakrishna R, Sheehan JP. The evolution of stereotactic radiosurgery in neurosurgical practice. J Neurooncol 2021; 151:451-459. [PMID: 33611711 DOI: 10.1007/s11060-020-03392-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 01/06/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Stereotactic radiosurgery (SRS) was born in an attempt to treat complex intracranial pathologies in a fashion whereby open surgery would create unnecessary or excessive risk. To create this innovation, it was necessary to harness advances in other fields such as engineering, physics, radiology, and computer science. METHODS We review the history of SRS to provide context to today's current state, as well as guide future advancement in the field. RESULTS Since time of Lars Leksell, the young Swedish neurosurgeon who pioneered the development of the SRS, the collegial and essential partnership between neurosurgeons, radiation oncologists and physicists has given rise to radiosurgery as a prominent and successful tool in neurosurgical practice. CONCLUSION We examine how neurosurgeons have helped foster the SRS evolution and how this evolution has impacted neurosurgical practice as well as that of radiation oncology and neuro-oncology.
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Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA. .,Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA.
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA.,Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Rohan Ramakrishna
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
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95
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Stoltzfus KC, Shen B, Tchelebi L, Trifiletti DM, Gusani NJ, Walter V, Wang M, Zaorsky NG. Impact of Facility Surgical Volume on Survival in Patients With Cancer. J Natl Compr Canc Netw 2021; 19:495-503. [PMID: 33561825 DOI: 10.6004/jnccn.2020.7644] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 08/19/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Increased facility surgical treatment volume is sometimes associated with improved survival in patients with cancer; however, published studies evaluating volume are heterogeneous and disparate in their patient inclusion and definition of volume. The purpose of this work was to evaluate uniformly the impact of surgical facility volume on survival in patients with cancer. METHODS The National Cancer Database was searched for patients diagnosed in 2004 through 2013 with the 12 cancers most commonly treated surgically. Facilities were stratified by 4 categories using the overall population (low, intermediate, high, and very high), each including 25% of patients, and then stratified by each individual disease site. Five-year postsurgery survival was estimated using both the Kaplan-Meier method and corresponding log-rank tests for group comparisons. Cox proportional hazard models were used to evaluate the effects of facility volume on 5-year postsurgery survival further, adjusted for multiple covariates. RESULTS A total of 3,923,618 patients who underwent surgery were included from 1,139 facilities. Of these, 40.4% had breast cancer, 12.8% prostate cancer, and 10.0% colon cancer. Most patients were female (65.0%), White (86.4%), and privately insured (51.6%) with stage 0-III disease (64.8%). For all cancers, the risk of death for patients undergoing surgery at very high-volume facilities was 88% of that for those treated at low-volume facilities. Hazard ratios (HRs) were greatest (very high vs low volume) for cancer of the prostate (HR, 0.66; 95% CI, 0.63-0.69), pancreas (HR, 0.75; 95% CI, 0.71-0.78), and esophagus (HR, 0.78; 95% CI, 0.73-0.83), and for melanoma (HR, 0.81; 95% CI, 0.78-0.84); differences were smallest for uterine and non-small cell lung cancers. Overall survival differences were greatest for cancers of the brain, pancreas, and esophagus. CONCLUSIONS Patients treated surgically at higher-volume facilities consistently had improved overall survival compared with those treated at low-volume centers, although the magnitude of difference was cancer-specific.
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Affiliation(s)
| | - Biyi Shen
- 2Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Leila Tchelebi
- 1Department of Radiation Oncology, Penn State Cancer Institute, and
| | | | - Niraj J Gusani
- 2Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania.,4Department of Surgery, Penn State College of Medicine, Hershey, Pennsylvania.,5Section of Surgical Oncology, Baptist MD Anderson Cancer Center, Jacksonville, Florida; and
| | - Vonn Walter
- 2Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania.,6Department of Biochemistry and Molecular Biology, Penn State College of Medicine, Hershey, Pennsylvania
| | - Ming Wang
- 2Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Nicholas G Zaorsky
- 1Department of Radiation Oncology, Penn State Cancer Institute, and.,2Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
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96
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Kowalchuk RO, Shepard MJ, Sheehan K, Sheehan D, Faramand A, Niranjan A, Kano H, Gurewitz J, Bernstein K, Liscak R, Guseynova K, Grills IS, Parzen JS, Cifarelli CP, Rehman AA, Atik A, Bakhsheshian J, Zada G, Chang E, Giannotta S, Speckter H, Wu HM, Kondziolka D, Mathieu D, Lee CC, Warnick RE, Lunsford LD, Trifiletti DM, Sheehan JP. Treatment of WHO Grade 2 Meningiomas With Stereotactic Radiosurgery: Identification of an Optimal Group for SRS Using RPA. Int J Radiat Oncol Biol Phys 2021; 110:804-814. [PMID: 33548341 DOI: 10.1016/j.ijrobp.2021.01.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/12/2021] [Accepted: 01/23/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE This study assesses a large multi-institutional database to present the outcomes of World Health Organization grade 2 meningiomas treated with stereotactic radiosurgery (SRS). We also compare the 3-year progression-free survival (PFS) to that reported in the Radiation Therapy Oncology Group 0539 phase 2 cooperative group meningioma trial. METHODS AND MATERIALS From an international, multicenter group, data were collected for grade 2 meningioma patients treated with SRS for demonstrable tumor from 1994 to 2019. Statistical methods used included the Kaplan-Meier method, Cox proportional hazards analysis, and recursive partitioning analysis. RESULTS Two hundred thirty-three patients treated at 12 institutions were included. Patients presented at a median age of 60 years (range, 13-90), and many had at least 2 prior resections (30%) or radiation therapy (22%). Forty-eight percent of patients had prior gross total resection. At SRS, the median treatment volume was 6.1 cm3 (0.1-97.6). A median 15 Gy (10-30) was delivered to a median percent isodose of 50 (30-80), most commonly in 1 fraction (95%). A model was developed using recursive partitioning analysis, with one point attributed to age >50 years, treatment volume >11.5 cm3, and prior radiation therapy or multiple surgeries. The good-prognostic group (score, 0-1) had improved PFS (P < .005) and time to local failure (P < .005) relative to the poor-prognostic group (score, 2-3). Age >50 years (hazard ratio = 1.85 [95% confidence interval, 1.09-3.14]) and multiple prior surgeries (hazard ratio = 1.80 [1.09-2.99]) also portended reduced PFS in patients without prior radiation therapy. Two hundred eighteen of 233 patients in this study qualified for the high-risk group of Radiation Therapy Oncology Group 0539, and they demonstrated similar outcomes (3-year PFS: 53.9% vs 58.8%). The good-prognostic group of SRS patients demonstrated slightly improved outcomes (3-year PFS: 63.1% vs 58.8%). CONCLUSIONS SRS should be considered in carefully selected patients with atypical meningiomas. We suggest the use of our good-prognostic group to optimize patient selection, and we strongly encourage the initiation of a clinical trial to prospectively validate these outcomes.
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Affiliation(s)
- Roman O Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
| | - Matthew J Shepard
- Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Kimball Sheehan
- Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Darrah Sheehan
- Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Andrew Faramand
- Center of Image Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ajay Niranjan
- Center of Image Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hideyuki Kano
- Center of Image Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jason Gurewitz
- Department of Neurosurgery, NYU Langone Health System, New York, New York
| | - Kenneth Bernstein
- Department of Medical Physics, NYU Langone Health System, New York, New York
| | - Roman Liscak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Khumar Guseynova
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Jacob S Parzen
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | | | - Azeem A Rehman
- Department of Neurologic Surgery, West Virginia University, Morgantown, West Virginia
| | - Ahmet Atik
- Department of Neurologic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Joshua Bakhsheshian
- Department of Neurologic Surgery, University of Southern California, Los Angeles, California
| | - Gabriel Zada
- Department of Neurologic Surgery, University of Southern California, Los Angeles, California
| | - Eric Chang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California
| | - Steven Giannotta
- Department of Neurologic Surgery, University of Southern California, Los Angeles, California
| | - Herwin Speckter
- Centro Gamma Knife Dominicano, CEDIMAT, Plaza de la Salud, Santo Domingo, Dominican Republic
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veteran General Hospital, Taipei, Taiwan; National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Health System, New York, New York
| | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Québec, Canada
| | - Cheng-Chia Lee
- National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Neurosurgery, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Ronald E Warnick
- Department of Neurologic Surgery, Mayfield Clinic, Cincinnati, Ohio
| | - L Dade Lunsford
- Center of Image Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Daniel M Trifiletti
- Mayo Clinic, Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Jason P Sheehan
- Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia
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Ruiz-Garcia H, Trifiletti DM, Mohammed N, Hung YC, Xu Z, Chytka T, Liscak R, Tripathi M, Arsanious D, Cifarelli CP, Caceres MP, Mathieu D, Speckter H, Lekovic GP, Mehta GU, Sheehan JP. Convexity Meningiomas in Patients with Neurofibromatosis Type 2: Long-Term Outcomes After Gamma Knife Radiosurgery. World Neurosurg 2021; 146:e678-e684. [PMID: 33152493 PMCID: PMC7988886 DOI: 10.1016/j.wneu.2020.10.153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Convexity meningiomas are common tumors requiring treatment in patients with neurofibromatosis type 2 (NF2). Although different therapeutic options are described for sporadic convexity meningioma, much less is known about these lesions in patients with NF2 despite their distinct biology and need for multiple treatments. We analyzed the value of Gamma Knife radiosurgery (GKRS) as definitive treatment for convexity meningiomas in patients with NF2. METHODS This international multicenter retrospective study was approved by the International Radiosurgery Research Foundation. Patients with NF2 with at least 1 convexity meningioma and 6-month follow-up after primary GKRS were included. RESULTS Inclusion criteria were met by 18 patients with NF2. A total of 120 convexity meningiomas (median treatment volume, 0.66 cm3 [range, 0.10-21.20 cm3]) were analyzed. Median follow-up after initial GKRS was 15.6 years (range, 0.6-25.5 years). Median age at GKRS was 32.5 years (range, 16-53 years). Median number of meningiomas per patient was 13 (range, 1-27), and median number of convexity lesions receiving GKRS per patient was 3.5 (range, 1-27). One case of tumor progression was reported 24 years after GKRS, leading to actuarial progression-free survival rates of 100% at 2, 5, and 10 years. No malignant transformation or death due to meningioma or radiosurgery was recorded. CONCLUSIONS GKRS is safe and effective as definitive treatment of small to medium-sized convexity meningiomas in patients with NF2. Despite concerns about the particular mutational burden of these tumors, no malignant transformation manifested after treatment. GKRS represents a minimally invasive option that offers long-term tumor control to this specific group of patients.
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Affiliation(s)
- Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA; Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA; Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Nasser Mohammed
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Yi-Chieh Hung
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Tomas Chytka
- Department of Neurological Surgery, Na Homolce Hospital, Prague, Czech Republic
| | - Roman Liscak
- Department of Neurological Surgery, Na Homolce Hospital, Prague, Czech Republic
| | - Manjul Tripathi
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - David Arsanious
- Department of Neurological Surgery, West Virginia University, Morgantown, Virginia, USA
| | | | - Marco Perez Caceres
- Department of Neurological Surgery, Centre de recherche du CHUS, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - David Mathieu
- Department of Neurological Surgery, Centre de recherche du CHUS, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Herwin Speckter
- Dominican Gamma Knife Center and CEDIMAT Hospital, Santo Domingo, Dominican Republic
| | | | | | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA.
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98
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Rusthoven CG, Yamamoto M, Bernhardt D, Smith DE, Gao D, Serizawa T, Yomo S, Aiyama H, Higuchi Y, Shuto T, Akabane A, Sato Y, Niranjan A, Faramand AM, Lunsford LD, McInerney J, Tuanquin LC, Zacharia BE, Chiang V, Singh C, Yu JB, Braunstein S, Mathieu D, Touchette CJ, Lee CC, Yang HC, Aizer AA, Cagney DN, Chan MD, Kondziolka D, Bernstein K, Silverman JS, Grills IS, Siddiqui ZA, Yuan JC, Sheehan JP, Cordeiro D, Nosaki K, Seto T, Deibert CP, Verma V, Day S, Halasz LM, Warnick RE, Trifiletti DM, Palmer JD, Attia A, Li B, Cifarelli CP, Brown PD, Vargo JA, Combs SE, Kessel KA, Rieken S, Patel S, Guckenberger M, Andratschke N, Kavanagh BD, Robin TP. Evaluation of First-line Radiosurgery vs Whole-Brain Radiotherapy for Small Cell Lung Cancer Brain Metastases: The FIRE-SCLC Cohort Study. JAMA Oncol 2021; 6:1028-1037. [PMID: 32496550 DOI: 10.1001/jamaoncol.2020.1271] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Although stereotactic radiosurgery (SRS) is preferred for limited brain metastases from most histologies, whole-brain radiotherapy (WBRT) has remained the standard of care for patients with small cell lung cancer. Data on SRS are limited. Objective To characterize and compare first-line SRS outcomes (without prior WBRT or prophylactic cranial irradiation) with those of first-line WBRT. Design, Setting, and Participants FIRE-SCLC (First-line Radiosurgery for Small-Cell Lung Cancer) was a multicenter cohort study that analyzed SRS outcomes from 28 centers and a single-arm trial and compared these data with outcomes from a first-line WBRT cohort. Data were collected from October 26, 2017, to August 15, 2019, and analyzed from August 16, 2019, to November 6, 2019. Interventions SRS and WBRT for small cell lung cancer brain metastases. Main Outcomes and Measures Overall survival, time to central nervous system progression (TTCP), and central nervous system (CNS) progression-free survival (PFS) after SRS were evaluated and compared with WBRT outcomes, with adjustment for performance status, number of brain metastases, synchronicity, age, sex, and treatment year in multivariable and propensity score-matched analyses. Results In total, 710 patients (median [interquartile range] age, 68.5 [62-74] years; 531 men [74.8%]) who received SRS between 1994 and 2018 were analyzed. The median overall survival was 8.5 months, the median TTCP was 8.1 months, and the median CNS PFS was 5.0 months. When stratified by the number of brain metastases treated, the median overall survival was 11.0 months (95% CI, 8.9-13.4) for 1 lesion, 8.7 months (95% CI, 7.7-10.4) for 2 to 4 lesions, 8.0 months (95% CI, 6.4-9.6) for 5 to 10 lesions, and 5.5 months (95% CI, 4.3-7.6) for 11 or more lesions. Competing risk estimates were 7.0% (95% CI, 4.9%-9.2%) for local failures at 12 months and 41.6% (95% CI, 37.6%-45.7%) for distant CNS failures at 12 months. Leptomeningeal progression (46 of 425 patients [10.8%] with available data) and neurological mortality (80 of 647 patients [12.4%] with available data) were uncommon. On propensity score-matched analyses comparing SRS with WBRT, WBRT was associated with improved TTCP (hazard ratio, 0.38; 95% CI, 0.26-0.55; P < .001), without an improvement in overall survival (median, 6.5 months [95% CI, 5.5-8.0] for SRS vs 5.2 months [95% CI, 4.4-6.7] for WBRT; P = .003) or CNS PFS (median, 4.0 months for SRS vs 3.8 months for WBRT; P = .79). Multivariable analyses comparing SRS and WBRT, including subset analyses controlling for extracranial metastases and extracranial disease control status, demonstrated similar results. Conclusions and Relevance Results of this study suggest that the primary trade-offs associated with SRS without WBRT, including a shorter TTCP without a decrease in overall survival, are similar to those observed in settings in which SRS is already established.
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Affiliation(s)
- Chad G Rusthoven
- University of Colorado School of Medicine, Department of Radiation Oncology, Aurora
| | | | - Denise Bernhardt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Derek E Smith
- University of Colorado Cancer Center, Biostatistics Core, Aurora
| | - Dexiang Gao
- University of Colorado Cancer Center, Biostatistics Core, Aurora
| | - Toru Serizawa
- Tokyo Gamma Unit Center, Tsukiji Neurological Clinic, Tokyo, Japan
| | - Shoji Yomo
- Aizawa Comprehensive Cancer Center, Division of Radiation Oncology, Aizawa Hospital, Matsumoto, Japan
| | | | - Yoshinori Higuchi
- Chiba University Graduate School of Medicine, Department of Neurological Surgery, Chiba, Japan
| | - Takashi Shuto
- Yokohama Rosai Hospital, Department of Neurosurgery, Yokohama, Japan
| | - Atsuya Akabane
- Gamma Knife Center, NTT Medical Center Tokyo, Tokyo, Japan
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Ajay Niranjan
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew M Faramand
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James McInerney
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Leonard C Tuanquin
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Brad E Zacharia
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Veronica Chiang
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Charu Singh
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - James B Yu
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Steve Braunstein
- Department of Radiation Oncology, University of California, San Francisco, San Francisco
| | - David Mathieu
- Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Quebec, Canada
| | - Charles J Touchette
- Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Quebec, Canada
| | - Cheng-Chia Lee
- Taipei Veterans General Hospital, Department of Neurosurgery, Neurological Institute, Taipei, Taiwan
| | - Huai-Che Yang
- Taipei Veterans General Hospital, Department of Neurosurgery, Neurological Institute, Taipei, Taiwan
| | - Ayal A Aizer
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Daniel N Cagney
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York
| | - Kenneth Bernstein
- Department of Neurosurgery, New York University Langone Medical Center, New York
| | - Joshua S Silverman
- Department of Neurosurgery, New York University Langone Medical Center, New York
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Zaid A Siddiqui
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Justin C Yuan
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville
| | - Diogo Cordeiro
- Department of Neurological Surgery, University of Virginia, Charlottesville
| | - Kename Nosaki
- National Hospital Organization Kyushu Cancer Center, Department of Thoracic Oncology, Fukuoka, Japan
| | - Takahashi Seto
- National Hospital Organization Kyushu Cancer Center, Department of Thoracic Oncology, Fukuoka, Japan
| | | | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Samuel Day
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle
| | - Lia M Halasz
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle
| | - Ronald E Warnick
- Department of Neurosurgery, Jewish Hospital-Mercy Health, Cincinnati, Ohio
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Jacksonville, Jacksonville, Florida
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University, Columbus
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University, Nashville, Tennessee
| | - Benjamin Li
- Department of Radiation Oncology, Vanderbilt University, Nashville, Tennessee
| | | | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - John A Vargo
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Neurosurgery, West Virginia University, Morgantown
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany
| | - Kerstin A Kessel
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Samir Patel
- Department of Radiation Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, The University of Zurich, Zurich, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, The University of Zurich, Zurich, Switzerland
| | - Brian D Kavanagh
- University of Colorado School of Medicine, Department of Radiation Oncology, Aurora
| | - Tyler P Robin
- University of Colorado School of Medicine, Department of Radiation Oncology, Aurora
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Lehrer EJ, Prabhu AV, Sindhu KK, Lazarev S, Ruiz-Garcia H, Peterson JL, Beltran C, Furutani K, Schlesinger D, Sheehan JP, Trifiletti DM. Proton and Heavy Particle Intracranial Radiosurgery. Biomedicines 2021; 9:31. [PMID: 33401613 PMCID: PMC7823941 DOI: 10.3390/biomedicines9010031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 12/23/2020] [Accepted: 12/30/2020] [Indexed: 12/25/2022] Open
Abstract
Stereotactic radiosurgery (SRS) involves the delivery of a highly conformal ablative dose of radiation to both benign and malignant targets. This has traditionally been accomplished in a single fraction; however, fractionated approaches involving five or fewer treatments have been delivered for larger lesions, as well as lesions in close proximity to radiosensitive structures. The clinical utilization of SRS has overwhelmingly involved photon-based sources via dedicated radiosurgery platforms (e.g., Gamma Knife® and Cyberknife®) or specialized linear accelerators. While photon-based methods have been shown to be highly effective, advancements are sought for improved dose precision, treatment duration, and radiobiologic effect, among others, particularly in the setting of repeat irradiation. Particle-based techniques (e.g., protons and carbon ions) may improve many of these shortcomings. Specifically, the presence of a Bragg Peak with particle therapy at target depth allows for marked minimization of distal dose delivery, thus mitigating the risk of toxicity to organs at risk. Carbon ions also exhibit a higher linear energy transfer than photons and protons, allowing for greater relative biological effectiveness. While the data are limited, utilization of proton radiosurgery in the setting of brain metastases has been shown to demonstrate 1-year local control rates >90%, which are comparable to that of photon-based radiosurgery. Prospective studies are needed to further validate the safety and efficacy of this treatment modality. We aim to provide a comprehensive overview of clinical evidence in the use of particle therapy-based radiosurgery.
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Affiliation(s)
- Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.J.L.); (K.K.S.); (S.L.)
| | - Arpan V. Prabhu
- Department of Radiation Oncology, UAMS Winthrop P. Rockefeller Cancer Institute University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Kunal K. Sindhu
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.J.L.); (K.K.S.); (S.L.)
| | - Stanislav Lazarev
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.J.L.); (K.K.S.); (S.L.)
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
| | - Jennifer L. Peterson
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
| | - Chris Beltran
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
| | - Keith Furutani
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
| | - David Schlesinger
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA 22903, USA; (D.S.); (J.P.S.)
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA 22903, USA; (D.S.); (J.P.S.)
| | - Daniel M. Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
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100
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Murphy ES, Parsai S, Kano H, Sheehan JP, Martinez-Alvarez R, Martinez-Moreno N, Kondziolka D, Simonova G, Liscak R, Mathieu D, Lee CC, Yang HC, Lee JY, McShane BJ, Fang F, Trifiletti DM, Sharma M, Barnett GH. Outcomes of stereotactic radiosurgery for pilocytic astrocytoma: an international multiinstitutional study. J Neurosurg 2021:1-9. [PMID: 31783364 DOI: 10.3171/2019.9.jns191335] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 09/13/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVEThe current standard initial therapy for pilocytic astrocytoma is maximal safe resection. Radiation therapy is considered for residual, recurrent, or unresectable pilocytic astrocytomas. However, the optimal radiation strategy has not yet been established. Here, the authors describe the outcomes of stereotactic radiosurgery (SRS) for pilocytic astrocytoma in a large multiinstitutional cohort.METHODSAn institutional review board–approved multiinstitutional database of patients treated with Gamma Knife radiosurgery (GKRS) between 1990 and 2016 was queried. Data were gathered from 9 participating International Radiosurgery Research Foundation (IRRF) centers. Patients with a histological diagnosis of pilocytic astrocytoma treated using a single session of GKRS and with at least 6 months of follow-up were included in the analysis.RESULTSA total of 141 patients were analyzed in the study. The median patient age was 14 years (range 2–84 years) at the time of GKRS. The median follow-up was 67.3 months. Thirty-nine percent of patients underwent SRS as the initial therapy, whereas 61% underwent SRS as salvage treatment. The median tumor volume was 3.45 cm3. The tumor location was the brainstem in 30% of cases, with a nonbrainstem location in the remainder. Five- and 10-year overall survival rates at the last follow-up were 95.7% and 92.5%, respectively. Five- and 10-year progression-free survival (PFS) rates were 74.0% and 69.7%, respectively. On univariate analysis, an age < 18 years, tumor volumes < 4.5 cm3, and no prior radiotherapy or chemotherapy were identified as positive prognostic factors for improved PFS. On multivariate analysis, only prior radiotherapy was significant for worse PFS.CONCLUSIONSThis represents the largest study of single-session GKRS for pilocytic astrocytoma to date. Favorable long-term PFS and overall survival were observed with GKRS. Further prospective studies should be performed to evaluate appropriate radiosurgery dosing, timing, and sequencing of treatment along with their impact on toxicity and the quality of life of patients with pilocytic astrocytoma.
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Affiliation(s)
- Erin S. Murphy
- 1Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
- 13Rose-Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland, Ohio
| | - Shireen Parsai
- 1Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Hideyuki Kano
- 2Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jason P. Sheehan
- 3Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Roberto Martinez-Alvarez
- 4Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, Madrid, Spain
| | - Nuria Martinez-Moreno
- 4Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, Madrid, Spain
| | - Douglas Kondziolka
- 5Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Gabriela Simonova
- 6Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Roman Liscak
- 6Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - David Mathieu
- 7Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Québec, Canada
| | - Cheng-Chia Lee
- 8Department of Neurosurgery, Neurologic Institute, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - Huai-Che Yang
- 8Department of Neurosurgery, Neurologic Institute, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - John Y. Lee
- 9Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brendan J. McShane
- 9Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fang Fang
- 10Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | | | - Mayur Sharma
- 12Department of Neurosurgery, University of Louisville, Kentucky; and
| | - Gene H. Barnett
- 13Rose-Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland, Ohio
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