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Wang Z, Chen H, Chen Q, Zhu Y, Li M, Zhou J, Shi L. Outcomes of 2-SSRS plus bevacizumab therapy strategy for brainstem metastases (BSM) over 2 cm 3: a multi-center study. Neurosurg Rev 2024; 47:137. [PMID: 38564039 DOI: 10.1007/s10143-024-02369-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/17/2024] [Accepted: 03/24/2024] [Indexed: 04/04/2024]
Abstract
Despite 2-staged stereotactic radiosurgery (2-SSRS) has been reported to provide patients with improved survival and limited toxicity, 2-SSRS for brainstem metastases (BSM) larger than 2 cm3 remains challenging. We tried to find out the effectiveness and safety of 2-SSRS plus bevacizumab therapy for BSMs over 2 cm3 and prognostic factors that related to the tumor local control. Patients that received 2-SSRS plus bevacizumab therapy from four gamma knife center were retrospectively studied from Jan 2014 to December 2023. Patients' domestic characteristics and the tumor features were evaluated before and after the treatment. Cox regression model was used to find out prognostic factors for tumor local control. 53 patients with 63 lesions received the therapy. The median peri-tumor edema volume greatly reduced at the end of therapy (P < 0.01), the median tumor volume dramatically reduced (P < 0.01) and patients' KPS score improved significantly (P < 0.05) 3 months after the therapy. Patients' median OS was 12.8 months. The tumor local control rate at 3, 6, and 12 months was 98.4%, 93.4%, and 85.2%. The incidence side effects were mainly oral and nasal hemorrhage (5.7%, 3/53), and radiation necrosis (13.2%, 7/53). Patients with primary lung adenocarcinoma, therapeutic dose over 12 Gy at second-stage SRS, primary peri-tumor edema volume less than 2.3 cm³, primary tumor volume less than 3.7 cm³ would enjoy longer tumor local control. These results suggested that 2-SSRS plus bevacizumab therapy was effective and safe for BSMs over 2 cm3. However, it is important for patients with BSM to receive early diagnosis and treatment to achieve good tumor local control.
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Affiliation(s)
- Zheng Wang
- Cancer center, Gamma Knife Treatment Center, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, 310014, Zhejiang, China
| | - Haining Chen
- Gamma Knife Treatment Center, Anhui Provincial Hospital, The First Affiliated Hospital of University of Science and Technology of China, Hefei, 230001, China
| | - Qun Chen
- Gamma Knife Treatment Center, Jiangsu province hospital, The First affiliated Hospital of Nanjing Medical University, Nanjing, 210001, China
| | - Yucun Zhu
- Gamma Knife Treatment Center, Ming ji Hospital, Affiliated to Nanjing Medical University, Nanjing, 210001, China
| | - Min Li
- Cancer center, Gamma Knife Treatment Center, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, 310014, Zhejiang, China
| | - Jia Zhou
- Cancer center, Gamma Knife Treatment Center, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, 310014, Zhejiang, China
| | - Lingfei Shi
- Geriatric Medicine Center, Department of Geriatric medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, 310014, Zhejiang, China.
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Quashie EE, Li XA, Prior P, Awan M, Schultz C, Tai A. Obtaining organ-specific radiobiological parameters from clinical data for radiation therapy planning of head and neck cancers. Phys Med Biol 2023; 68:245015. [PMID: 37903437 DOI: 10.1088/1361-6560/ad07f5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/30/2023] [Indexed: 11/01/2023]
Abstract
Objective.Different radiation therapy (RT) strategies, e.g. conventional fractionation RT (CFRT), hypofractionation RT (HFRT), stereotactic body RT (SBRT), adaptive RT, and re-irradiation are often used to treat head and neck (HN) cancers. Combining and/or comparing these strategies requires calculating biological effective dose (BED). The purpose of this study is to develop a practical process to estimate organ-specific radiobiologic model parameters that may be used for BED calculations in individualized RT planning for HN cancers.Approach.Clinical dose constraint data for CFRT, HFRT and SBRT for 5 organs at risk (OARs) namely spinal cord, brainstem, brachial plexus, optic pathway, and esophagus obtained from literature were analyzed. These clinical data correspond to a particular endpoint. The linear-quadratic (LQ) and linear-quadratic-linear (LQ-L) models were used to fit these clinical data and extract relevant model parameters (alpha/beta ratio, gamma/alpha,dTand BED) from the iso-effective curve. The dose constraints in terms of equivalent physical dose in 2 Gy-fraction (EQD2) were calculated using the obtained parameters.Main results.The LQ-L and LQ models fitted clinical data well from the CFRT to SBRT with the LQ-L representing a better fit for most of the OARs. The alpha/beta values for LQ-L (LQ) were found to be 2.72 (2.11) Gy, 0.55 (0.30) Gy, 2.82 (2.90) Gy, 6.57 (3.86) Gy, 5.38 (4.71) Gy, and the dose constraint EQD2 were 55.91 (54.90) Gy, 57.35 (56.79) Gy, 57.54 (56.35) Gy, 60.13 (59.72) Gy and 65.66 (64.50) Gy for spinal cord, optic pathway, brainstem, brachial plexus, and esophagus, respectively. Additional two LQ-L parametersdTwere 5.24 Gy, 5.09 Gy, 7.00 Gy, 5.23 Gy, and 6.16 Gy, and gamma/alpha were 7.91, 34.02, 8.67, 5.62 and 4.95.Significance.A practical process was developed to extract organ-specific radiobiological model parameters from clinical data. The obtained parameters can be used for biologically based radiation planning such as calculating dose constraints of different fractionation regimens.
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Affiliation(s)
- Edwin E Quashie
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
- Department of Radiation Oncology, Brown University School of Medicine, Providence, RI 02903, United States of America
- Department of Radiation Oncology, Rhode Island Hospital, Providence, RI 02903, United States of America
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
| | - Phillip Prior
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
| | - Musaddiq Awan
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
| | - Christopher Schultz
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
| | - An Tai
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
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Begley SL, Goenka A, Schulder M. Brainstem Metastases Treated with Stereotactic Radiosurgery: Masked versus Framed Immobilization. World Neurosurg 2023; 175:e1158-e1165. [PMID: 37116783 DOI: 10.1016/j.wneu.2023.04.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Patients with brainstem metastases (BSMs) have minimal surgical options due to high-risk anatomy. To review our efficacy treating BSM using Gamma Knife stereotactic radiosurgery (SRS), we compared results on the basis of the utilization of mask-fixation (MF) or frame-fixation (FF). METHODS Data were retrospectively collected for 32 patients. Follow-up data for 49 lesions were analyzed for local control rate (LCR) and objective response rate (ORR). RESULTS Primary cancers included lung, breast, and melanoma; most lesions were pontine. MF was used in 18 patients. Average tumor volume was 0.99 cm3 (0.005-13.3 cm3). Thirty-nine lesions were treated with single-fraction 16 Gy. Ten lesions were treated in 3-5 fractions with mean dose of 22.5 Gy. Mean follow-up was 14.2 months (1.2-48.2 months). One-year LCR was 94.7%. ORR at last follow-up did not differ between MF and FF (P = 0.81). Average reduction of lesion volume at 6 and 12 months did not differ between MF and FF (64% vs. 45%, P = 0.77; 70% vs. 77%, P = 0.78). Failure occurred in a pontine colorectal cancer metastasis mask-immobilized for treatment with 14 Gy. CONCLUSIONS SRS for BSM achieved high LCR despite variability in tumor size and histology with no significant difference between MF and FF. Although trials have historically excluded patients with BSM, our data support SRS as a safe and efficacious treatment. This is the first study showing that MF provides equivalent, successful outcomes when compared with FF for patients with BSM.
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Affiliation(s)
- Sabrina L Begley
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, USA.
| | - Anuj Goenka
- Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York, USA
| | - Michael Schulder
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, USA
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Nicosia L, Navarria P, Pinzi V, Giraffa M, Russo I, Tini P, Giaj-Levra N, Alongi F, Minniti G. Stereotactic radiosurgery for the treatment of brainstem metastases: a multicenter retrospective study. Radiat Oncol 2022; 17:140. [PMID: 35945597 PMCID: PMC9364508 DOI: 10.1186/s13014-022-02111-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background Brainstem metastases (BSM) are associated with a poor prognosis and their management represents a therapeutic challenge. BSM are often inoperable and, in absence of randomized trials, the optimal radiation treatment of BSM remains to be defined. We evaluated the efficacy and toxicity of linear accelerator (linac)-based stereotactic radiosurgery (SRS) and hypofractionated steretotactic radiotherapy (HSRT) in the treatment of BSM in a series of patients treated in different clinical centers. Methods We conducted a multicentric retrospective study of patients affected by 1–2 BSM from different histologies who underwent SRS/HSRT. Freedom from local progression (FLP), cancer-specific survival (CSS), overall survival (OS), and treatment-related toxicity were evaluated. In addition, predictors of treatment response and survivals were evaluated. Results Between 2008 and 2021, 105 consecutive patients with 111 BMS who received SRS or HSRT for 1–2 BSM were evaluated. Median follow-up time was 10 months (range 3–130). One-year FLP rate was 90.4%. At the univariate analysis, tumor volume ≤ 0.4 cc, and concurrent targeted therapy were associated with longer FLP, with combined treatment that remained a significant independent predictor [0.058, HR 0.139 (95% CI 0.0182–1.064]. Median OS and CSS were 11 months and 14.6 months, respectively. At multivariate analysis, concurrent targeted therapy administration was significantly associated with longer OS [HR 0.514 (95%CI 0.302–0.875); p = 0.01]. Neurological death occurred in 30.4% of patients, although this was due to local progression in only 3 (2.8%) patients. Conclusion Linac-based SRS/HSRT offers excellent local control to patients with BSM, with low treatment-related toxicity and no apparent detrimental effects on OS. When treated with ablative intent, BSM are an uncommon cause of neurological death. The present results indicates that patients with BSM should not be excluded a priori from clinical trials.
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Affiliation(s)
- Luca Nicosia
- Advanced Radiation Oncology Department, Cancer Care Center, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy
| | - Piera Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Hospital-IRCCS, Rozzano, MI, Italy
| | - Valentina Pinzi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C Besta, Via Celoria 11, 20133, Milan, Italy
| | - Martina Giraffa
- UPMC Hillman Cancer Center, San Pietro Hospital FBF, Rome, Italy
| | - Ivana Russo
- UPMC Hillman Cancer Center, Villa Maria, Mirabella Eclano, AV, Italy
| | - Paolo Tini
- Department of Medicine, Surgery and Neurosciences, University of Siena, Policlinico Le Scotte, 53100, Siena, Italy
| | - Niccolò Giaj-Levra
- Advanced Radiation Oncology Department, Cancer Care Center, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy
| | - Filippo Alongi
- Advanced Radiation Oncology Department, Cancer Care Center, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy.,University of Brescia, Brescia, Italy
| | - Giuseppe Minniti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Policlinico Le Scotte, 53100, Siena, Italy. .,IRCCS Neuromed, 86077, Pozzilli, IS, Italy.
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5
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Zirone L, Bonanno E, Borzì GR, Cavalli N, D’Anna A, Galvagno R, Girlando A, Gueli AM, Pace M, Stella G, Marino C. HyperArc TM Dosimetric Validation for Multiple Targets Using Ionization Chamber and RT-100 Polymer Gel. Gels 2022; 8:481. [PMID: 36005082 PMCID: PMC9407338 DOI: 10.3390/gels8080481] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/25/2022] [Accepted: 07/28/2022] [Indexed: 11/16/2022] Open
Abstract
Multiple brain metastases single-isocenter stereotactic radiosurgery (SRS) treatment is increasingly employed in radiotherapy department. Before its use in clinical routine, it is recommended to perform end-to-end tests. In this work, we report the results of five HyperArcTM treatment plans obtained by both ionization chamber (IC) and polymer gel. The end-to-end tests were performed using a water equivalent Mobius Verification PhantomTM (MVP) and a 3D-printed anthropomorphic head phantom PseudoPatient® (PP) (RTsafe P.C., Athens, Greece); 2D and 3D dose distributions were evaluated on the PP phantom using polymer gel (RTsafe). Gels were read by 1.5T magnetic resonance imaging (MRI). Comparison between calculated and measured distributions was performed using gamma index passing rate evaluation by different criteria (5% 2 mm, 3% 2 mm, 5% 1 mm). Mean point dose differences of 1.01% [min −0.77%−max 2.89%] and 0.23% [min 0.01%−max 2.81%] were found in MVP and PP phantoms, respectively. For each target volume, the obtained results in terms of gamma index passing rate show an agreement >95% with 5% 2 mm and 3% 2 mm criteria for both 2D and 3D distributions. The obtained results confirmed that the use of a single isocenter for multiple lesions reduces the treatment time without compromising accuracy, even in the case of target volumes that are quite distant from the isocenter.
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Affiliation(s)
- Lucia Zirone
- Medical Physics Department, Humanitas Istituto Clinico Catanese, 95045 Catania, Italy; (L.Z.); (E.B.); (G.R.B.); (N.C.); (M.P.); (C.M.)
| | - Elisa Bonanno
- Medical Physics Department, Humanitas Istituto Clinico Catanese, 95045 Catania, Italy; (L.Z.); (E.B.); (G.R.B.); (N.C.); (M.P.); (C.M.)
| | - Giuseppina Rita Borzì
- Medical Physics Department, Humanitas Istituto Clinico Catanese, 95045 Catania, Italy; (L.Z.); (E.B.); (G.R.B.); (N.C.); (M.P.); (C.M.)
| | - Nina Cavalli
- Medical Physics Department, Humanitas Istituto Clinico Catanese, 95045 Catania, Italy; (L.Z.); (E.B.); (G.R.B.); (N.C.); (M.P.); (C.M.)
| | - Alessia D’Anna
- Department of Physics and Astronomy E. Majorana, University of Catania, 95123 Catania, Italy; (A.D.); (R.G.); (A.M.G.)
| | - Rosaria Galvagno
- Department of Physics and Astronomy E. Majorana, University of Catania, 95123 Catania, Italy; (A.D.); (R.G.); (A.M.G.)
| | - Andrea Girlando
- Radiotherapy Department, Humanitas Istituto Clinico Catanese, 95045 Catania, Italy;
| | - Anna Maria Gueli
- Department of Physics and Astronomy E. Majorana, University of Catania, 95123 Catania, Italy; (A.D.); (R.G.); (A.M.G.)
| | - Martina Pace
- Medical Physics Department, Humanitas Istituto Clinico Catanese, 95045 Catania, Italy; (L.Z.); (E.B.); (G.R.B.); (N.C.); (M.P.); (C.M.)
| | - Giuseppe Stella
- Department of Physics and Astronomy E. Majorana, University of Catania, 95123 Catania, Italy; (A.D.); (R.G.); (A.M.G.)
| | - Carmelo Marino
- Medical Physics Department, Humanitas Istituto Clinico Catanese, 95045 Catania, Italy; (L.Z.); (E.B.); (G.R.B.); (N.C.); (M.P.); (C.M.)
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Lupattelli M, Tini P, Nardone V, Aristei C, Borghesi S, Maranzano E, Anselmo P, Ingrosso G, Deantonio L, di Monale E Bastia MB. Stereotactic radiotherapy for brain oligometastases. Rep Pract Oncol Radiother 2022; 27:15-22. [PMID: 35402029 PMCID: PMC8989457 DOI: 10.5603/rpor.a2021.0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/14/2021] [Indexed: 11/25/2022] Open
Abstract
Brain metastases, the most common metastases in adults, will develop in up to 40% of cancer patients, accounting for more than one-half of all intracranial tumors. They are most associated with breast and lung cancer, melanoma and, less frequently, colorectal and kidney carcinoma. Magnetic resonance imaging (MRI) is the gold standard for diagnosis. For the treatment plan, computed tomography (CT ) images are co-registered and fused with a gadolinium-enhanced T1-weighted MRI where tumor volume and organs at risk are contoured. Alternatively, plain and contrast-enhanced CT scans are co-registered. Single-fraction stereotactic radiotherapy (SRT ) is used to treat patients with good performance status and up to 4 lesions with a diameter of 30 mm or less that are distant from crucial brain function areas. Fractionated SRT (2–5 fractions) is used for larger lesions, in eloquent areas or in proximity to crucial or surgically inaccessible areas and to reduce treatment-related neurotoxicity. The single-fraction SRT dose, which depends on tumor diameter, impacts local control. Fractionated SRT may encompass different schedules. No randomized trial data compared the safety and efficacy of single and multiple fractions. Both single-fraction and fractionated SRT provide satisfactory local control rates, tolerance, a low risk of transient acute adverse events and of radiation necrosis the incidence of which correlated with the irradiated brain volume.
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Affiliation(s)
- Marco Lupattelli
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Italy
| | - Paolo Tini
- Unit of Radiation Oncology, University Hospital of Siena, Italy
| | - Valerio Nardone
- Unit of Radiation Oncology, Ospedale del Mare, Napoli, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Italy
| | - Simona Borghesi
- Radiation Oncology Unit of Arezzo-Valdarno, Azienda USL Toscana Sud Est, Italy
| | | | - Paola Anselmo
- Radiation Oncology Centre, S. Maria Hospital, Terni, Italy
| | - Gianluca Ingrosso
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Italy
| | - Letizia Deantonio
- Radiation Oncology Clinic, Oncology Institute of Southern Switzerland, Bellinzona-Lugano, Switzerland
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Ortiz M, Herbert J, Hika B, Biedermann G, Phillips L, Wexler A, Litofsky NS. Linac-based hypofractionated stereotactic radiotherapy for metastases involving the brainstem. J Clin Neurosci 2022; 98:235-239. [PMID: 35217503 DOI: 10.1016/j.jocn.2022.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 10/26/2021] [Accepted: 01/22/2022] [Indexed: 11/19/2022]
Abstract
The long-term efficacy and complications of hypofractionated stereotactic radiotherapy (hSRT) to metastases involving the brainstem are not well reported. Our objective is to review the results of metastases intrinsic to or abutting the brainstem treatedwith hSRT.Patients treated with hSRT in 5 fractions at our institution from 2016 to 2020 were retrospectively reviewed. Varian Eclipse v13.7 TPS was used for treatment planning. MRI images were fused with CT images acquired at the time of simulation, and contoured structures include the brainstem, the GTV, and a 2 mm margin was used to generate the PTV. MR imaging was performed at 3-month intervals. Survival was assessed at the last available follow-up; tumor control was assessed at 6 and 12 months and toxicity was assessed based on the Radiation Therapy Oncology Group grading system at regular follow-up. Twenty patients were treated with 5 fraction treatment dose plans ranging from 20 Gy - 31.25 Gy. GTV mean volume was 3.5 cc ± 4.3 cc (range 0.1 cc - 18.9 cc). The median overall survival was 6.5 months (range: 1 to 29 months). The twelve-month tumor control rate was 80%. Toxicity was generally mild, with only one patient demonstrating Grade 3 toxicity. Two patients had radiographic progression, but neither required surgical intervention. In our series, hSRT resulted in similar rates of survival, tumor control, and toxicity as compared with published single fraction series. Dose escalation of lesions adjacent to the brainstem can be considered and maybe more feasible with a hypofractionated regimen of 5 fractions.
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Affiliation(s)
- Michael Ortiz
- Division of Neurological Surgery, University of Missouri School of Medicine, Columbia, MO, USA.
| | - Joseph Herbert
- Division of Neurological Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Busha Hika
- Division of Neurological Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Gregory Biedermann
- Division of Radiation Oncology, University of Missouri School of Medicine, Columbia, MO, USA
| | - Leslie Phillips
- Division of Radiation Oncology, University of Missouri School of Medicine, Columbia, MO, USA
| | - Amelia Wexler
- Division of Radiation Oncology, University of Missouri School of Medicine, Columbia, MO, USA
| | - N Scott Litofsky
- Division of Neurological Surgery, University of Missouri School of Medicine, Columbia, MO, USA
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Magnetic Resonance-guided Laser Interstitial Thermal Therapy (MRgLITT) for Brainstem Pathologies. World Neurosurg 2022; 161:e80-e89. [PMID: 35033695 DOI: 10.1016/j.wneu.2022.01.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/09/2022] [Accepted: 01/09/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Magnetic Resonance-guided Laser interstitial thermal therapy (MRgLITT) is a minimally invasive and effective treatment option that can potentially treat deep-seated pathologies in cases where there are no safe open surgical corridors. In this report, we present our experience using MRgLITT for brainstem pathologies. METHODS A retrospective chart analysis was conducted of all patients who underwent MRgLITT for pathologies within or closely surrounding the brainstem between 2011 and 2020. The patients underwent stereotactic laser placement in the operating suite and were transported to the MRI suite for laser ablation with real-time monitoring. Demographics, operative parameters and complications were recorded. RESULTS A total of twelve patients underwent MRgLITT for brainstem pathologies. The average age of the patients was 47.6 years old, ranging from 4 to 75. Pathologies included both primary and metastatic intracranial tumors. The average pre-ablation volume of the targets was 2.4cm3 ±SEM=0.50. The average time of ablation was 324.3± 60.7 seconds and average post-ablation volume was 2.92±0.53 cm3. There was one perioperative mortality directly related to the procedure and seven cases of post-operative deficits. Two patients had recurrence after MRgLITT and opted to undergo additional alternative treatments. CONCLUSION The brainstem represents formidable territory even for minimally invasive procedures. The overall morbidity and mortality remains high, and the probability of achieving a meaningful outcome needs to be carefully assessed.
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Chatzikonstantinou G, Wolff R, Tselis N. Fractionated stereotactic radiotherapy as a primary or salvage treatment for large brainstem metastasis. J Cancer Res Ther 2022; 18:1604-1609. [DOI: 10.4103/jcrt.jcrt_426_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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10
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Global management of brain metastasis from renal cell carcinoma. Crit Rev Oncol Hematol 2022; 171:103600. [DOI: 10.1016/j.critrevonc.2022.103600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 12/28/2021] [Accepted: 01/17/2022] [Indexed: 11/20/2022] Open
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Chen WC, Baal UH, Baal JD, Pai JS, Boreta L, Braunstein SE, Raleigh DR. Efficacy and Safety of Stereotactic Radiosurgery for Brainstem Metastases: A Systematic Review and Meta-analysis. JAMA Oncol 2021; 7:1033-1040. [PMID: 33983393 DOI: 10.1001/jamaoncol.2021.1262] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Owing to the proximity to critical neurologic structures, treatment options for brainstem metastases (BSM) are limited, and BSM growth can cause acute morbidity or death. Stereotactic radiosurgery (SRS) is the only local therapy for BSM, but efficacy and safety of this approach are incompletely understood because patients with BSM are excluded from most clinical trials. Objective To perform a systematic review and comparative meta-analysis of SRS studies for BSM in the context of prospective trials of SRS or molecular therapy for nonbrainstem brain metastases (BM). Data Sources A comprehensive search of Pubmed/MEDLINE and Embase was performed on December 6, 2019. Study Selection English-language studies of SRS for BSM with at least 10 patients and reporting 1 or more outcomes of interest were included. Duplicate studies or studies with overlapping data sets were excluded. Studies were independently evaluated by 2 reviewers, and discrepancies were resolved by consensus. A total of 32 retrospective studies published between 1999 and 2019 were included in the analysis. Data Extraction and Synthesis Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify studies. Study quality was assessed using Methodological Index for Non-Randomized Studies criteria. Fixed and random-effects meta-analyses and meta-regressions were performed for the outcomes of interest. Main Outcomes and Measures Primary study outcomes included 1-year and 2-year local control and overall survival, objective response rate, symptom response rate, neurological death rate, and rate of grade 3 to 5 toxic effects as described in Common Terminology Criteria for Adverse Events, version 4.0. Results The 32 retrospective studies included in the analysis comprised 1446 patients with 1590 BSM that were treated with SRS (median [range] dose, 16 [11-39] Gy; median [range] fractions, 1 [1-13]). Local control at 1 year was 86% (95% CI, 83%-88%; I2 = 38%) in 1410 patients across 31 studies, objective response rate was 59% (95% CI, 47%-71%; I2 = 88%) in 642 patients across 17 studies, and symptom improvement was 55% (95% CI, 47%-63%; I2 = 41%) in 323 patients across 13 studies. Deaths from BSM progression after SRS were rare (19 of 703 [2.7%] deaths across 19 studies), and the neurologic death rate in patients with BSM (24%; 95% CI, 19%-31%; I2 = 62%) was equivalent to the neurologic death rate in patients with BM who were treated on prospective trials. The rate of treatment-related grade 3 to 5 toxic effects was 2.4% (95% CI, 1.5%-3.7%; I2 = 33%) in 1421 patients across 31 studies. These results compared favorably to trials of targeted or immunotherapy for BM, which had a wide objective response rate range from 17% to 56%. Conclusions and Relevance Results of this systematic review and meta-analysis show that SRS for BSM was associated with effectiveness and safety and was comparable to SRS for nonbrainstem BM, suggesting that patients with BSM should be eligible for clinical trials of SRS. In this analysis, patients treated with SRS for BSM rarely died from BSM progression and often experienced symptomatic improvement. Given the apparent safety and efficacy of SRS for BSM in the context of acute morbidity or death from BSM growth, consideration of SRS at the time of enrollment on emerging trials of targeted therapy for BM should be considered.
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Affiliation(s)
- William C Chen
- Department of Radiation Oncology, University of California, San Francisco
| | - Ulysis H Baal
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Joe D Baal
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Jon S Pai
- Department of Internal Medicine, University of Southern California, Los Angeles
| | - Lauren Boreta
- Department of Radiation Oncology, University of California, San Francisco
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California, San Francisco
| | - David R Raleigh
- Department of Radiation Oncology, University of California, San Francisco.,Department of Neurological Surgery, University of California, San Francisco
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12
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Brain Metastasis from Unknown Primary Tumour: Moving from Old Retrospective Studies to Clinical Trials on Targeted Agents. Cancers (Basel) 2020; 12:cancers12113350. [PMID: 33198246 PMCID: PMC7697886 DOI: 10.3390/cancers12113350] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/04/2020] [Accepted: 11/09/2020] [Indexed: 12/14/2022] Open
Abstract
Simple Summary Brain metastases (BMs) are the most common intracranial tumours in adults and occur up to 3–10 times more frequently than primary brain tumours. In up to 15% of patients with BM, the primary tumour cannot be identified. These cases are known as BM of cancer of unknown primary (CUP) (BM-CUP). The understanding of BM-CUP, despite its relative frequency and unfavourable outcome, is still incomplete and clear indications on management are missing. The aim of this review is to summarize current evidence on the diagnosis and treatment of BM-CUP. Abstract Brain metastases (BMs) are the most common intracranial tumours in adults and occur up to 3–10 times more frequently than primary brain tumours. BMs may be the cause of the neurological presenting symptoms in patients with otherwise previously undiagnosed cancer. In up to 15% of patients with BMs, the primary tumour cannot be identified. These cases are known as BM of cancer of unknown primary (CUP) (BM-CUP). CUP has an early and aggressive metastatic spread, poor response to chemotherapy, and poor prognosis. The pathogenesis of CUP seems to be characterized by a specific underlying pro-metastatic signature. The understanding of BM-CUP, despite its relative frequency and unfavourable outcome, is still incomplete and clear indications on management are missing. Advances in diagnostic tools, molecular characterization, and target therapy have shifted the paradigm in the approach to metastasis from CUP: while earlier studies stressed the importance of finding the primary tumour and deciding on treatment based on the primary diagnosis, most recent studies focus on the importance of identifying targetable molecular markers in the metastasis itself. The aim of this review is to summarize current evidence on BM-CUP, from the diagnosis and pathogenesis to the treatment, with a focus on available studies and ongoing clinical trials.
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13
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Lehrer EJ, Snyder MH, Desai BD, Li CE, Narayan A, Trifiletti DM, Schlesinger D, Sheehan JP. Clinical and radiographic adverse events after Gamma Knife radiosurgery for brainstem lesions: A dosimetric analysis. Radiother Oncol 2020; 147:200-209. [PMID: 32413528 DOI: 10.1016/j.radonc.2020.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/30/2020] [Accepted: 05/08/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To analyze the association between dosvolume relationships and adverse events in brainstem lesions treated with Gamma Knife radiosurgery (GKRS). METHODS Treatment plans were generated on BrainLab Elements and GammaPlan software. Dosimetric data were analyzed as continuous variables for patients who received GKRS to brain metastases or arteriovenous malformations (AVM) within or abutting the brainstem. Adverse events were classified as clinical and/or radiographic. Logistic and cox regression were used to assess the relationship between dosimetric variables and adverse events. RESULTS Sixty-one patients who underwent single fraction GKRS for brain metastases or AVM were retrospectively analyzed. Median age was 62 years (range: 12-92 years) and the median prescription dose was 18 Gy (range: 13-25 Gy). Median follow-up was 6months. Clinical and radiographic complications were seen in ten (16.4%) and 17 (27.9%) patients, respectively. On logistic regression, increasing D05% was found to be associated with an increased probability of developing a clinical complication post-GKRS (OR: 1.18; 95% CI: 1.01-1.39; p = 0.04). Furthermore, mean brainstem dose (HR: 1.43; 95% CI: 1.05-1.94; p < 0.02), D05% (HR: 1.09; 95% CI: 1.01-1.18; p = 0.03), and D95% (HR: 2.37; 95% CI: 0.99-5.67; p = 0.05) were associated with an increased hazard of experiencing post-GKRS complications over time. CONCLUSIONS Increasing D05% to the brainstem is associated with an increased risk of developing clinical complications. Clinicians may consider this parameter in addition to fractionated stereotactic radiation therapy when well-established dose constraints are not met in this patient population. Additional data are needed to further validate these findings.
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Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - M Harrison Snyder
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Bhargav D Desai
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Chelsea E Li
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Aditya Narayan
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | | | - David Schlesinger
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
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14
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Cohen JV, Wang N, Venur VA, Hadfield MJ, Cahill DP, Oh K, Brastianos PK. Neurologic complications of melanoma. Cancer 2020; 126:477-486. [DOI: 10.1002/cncr.32619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 09/28/2019] [Accepted: 10/08/2019] [Indexed: 11/12/2022]
Affiliation(s)
- Justine V. Cohen
- Division of Medical Oncology and Neuro‐Oncology Massachusetts General Hospital Cancer Center Boston Massachusetts
| | - Nancy Wang
- Division of Neuro‐Oncology Massachusetts General Hospital Cancer Center Boston Massachusetts
| | - Vyshak A. Venur
- Division of Neuro‐Oncology Massachusetts General Hospital Cancer Center Boston Massachusetts
| | - Matthew J. Hadfield
- Division of Internal Medicine University of Connecticut Hartford Connecticut
| | - Daniel P. Cahill
- Division of Neurosurgery Massachusetts General Hospital Boston Massachusetts
| | - Kevin Oh
- Division of Radiation Oncology Massachusetts General Hospital Boston Massachusetts
| | - Priscilla K. Brastianos
- Division of Medical Oncology and Neuro‐Oncology Massachusetts General Hospital Cancer Center Boston Massachusetts
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15
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Linac-Based Fractionated Stereotactic Radiotherapy with a Micro-Multileaf Collimator for Brainstem Metastasis. World Neurosurg 2019; 132:e680-e686. [DOI: 10.1016/j.wneu.2019.08.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/08/2019] [Accepted: 08/09/2019] [Indexed: 11/18/2022]
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16
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Winograd E, Rivers CI, Fenstermaker R, Fabiano A, Plunkett R, Prasad D. The case for radiosurgery for brainstem metastases. J Neurooncol 2019; 143:585-595. [DOI: 10.1007/s11060-019-03195-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/11/2019] [Accepted: 05/16/2019] [Indexed: 11/30/2022]
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17
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Sinclair G, Benmakhlouf H, Martin H, Maeurer M, Dodoo E. Adaptive hypofractionated gamma knife radiosurgery in the acute management of brainstem metastases. Surg Neurol Int 2019; 10:14. [PMID: 30783544 PMCID: PMC6367951 DOI: 10.4103/sni.sni_53_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 10/29/2018] [Indexed: 12/15/2022] Open
Abstract
Background: Intrinsic brainstem metastases are life-threatening neoplasms requiring rapid, effective intervention. Microsurgery is considered not feasible in most cases and systemic treatment seldom provides a successful outcome. In this context, radiation therapy remains the best option but adverse radiation effects (ARE) remain a major concern. A dose-adaptive gamma knife procedure coined as Rapid Rescue Radiosurgery (3R) offers the possibility to treat these lesions whilst reducing the risk of ARE evolvement. We report the results of 3R applied to a group of patients with brainstem metastases. Methods: Eight patients with nine brainstem metastases, having undergone three separate, dose-adapted gamma knife radiosurgery (GKRS) procedures over 7 days, were retrospectively analyzed in terms of tumor volume reduction, local control rates, and ARE-development under the period of treatment and at least 6 months after treatment completion. Results: Mean peripheral doses at GKRS 1, GKRS 2, and GKRS 3 were 7.4, 7.7, and 8.2 Gy (range 6–9 Gy) set at the 35–50% isodose lines. Mean tumor volume reduction between GKRS 1 and GKRS 3 was −15% and −56% at first follow-up. Four patients developed radiologic signs of ARE but remained clinically asymptomatic. One patient developed a local recurrence at 34 months. Mean survival from GKRS 1 was 13 months. Two patients were still alive at the time of paper submission (10 and 23 months from GKRS 1). Conclusions: In this study, 3R proved effective in terms of tumor volume reduction, rescue/preservation of neurological function, and limited ARE evolvement.
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Affiliation(s)
- Georges Sinclair
- Department of Neurosurgery, Karolinska University Hospital, Solna, Sweden
| | - Hamza Benmakhlouf
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Solna, Sweden
| | - Heather Martin
- Department of Neuroradiology, Karolinska University Hospital, Solna, Sweden
| | - Markus Maeurer
- Department of Laboratory Medicine (LABMED), Therapeutic Immunology Unit (TIM), Karolinska Institutet, Stockholm, Sweden.,Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institute, Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Solna, Sweden
| | - Ernest Dodoo
- Department of Neurosurgery, Karolinska University Hospital, Solna, Sweden
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18
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A retrospective dosimetry study of intensity-modulated radiotherapy for nasopharyngeal carcinoma: radiation-induced brainstem injury and dose-volume analysis. Radiat Oncol 2018; 13:194. [PMID: 30285884 PMCID: PMC6171220 DOI: 10.1186/s13014-018-1105-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 08/20/2018] [Indexed: 01/19/2023] Open
Abstract
Background Radiation therapy is the standard radical treatment for nasopharyngeal carcinoma (NPC) but also causes transient as well as long-term complications. Patients who develop severe radiation-induced brainstem injuries have a poor prognosis due to the lack of effective medical therapies. However, the relationship between brainstem injury and radiation volume dose is unknown. In this study, we found that radiation-induced brainstem injury was significantly associated with brainstem dose per unit volume. Methods A retrospective analysis was performed on a consecutive cohort of 327 patients with NPC receiving IMRT from May 2005 to December 2014. Dose-volume data and long-term outcome were analyzed. Results The median follow-up duration was 56 months (range, 3–141 months), and six with T4 and two with T3 patients had radiation-induced brainstem injuries. The 3-year and 5-year incidences were 2.2% and 2.8%, respectively. The latency period of brainstem injury ranged from 9 to 58 months, with a median period of 21 months. The Cox regression analysis showed that brainstem radiation toxicity was associated with the T4 stage, D2% of gross tumor volume of nasopharyngeal primary lesions and their direct extensions (GTVnx), Dmax (the maximum point dose), D1%, D0.1cc (the top dose delivered to a 0.1-ml volume), and D1cc (the top dose delivered to a 1-ml volume) of the brainstem (p < 0.05). Receiver operating characteristic (ROC) curves showed that GTVnx D2% and the Dmax, D1%, D0.1cc, and D1cc of the brainstem were significant predictors of brainstem injury. The area under the ROC curve for these five parameters was 0.724, 0.813, 0.818, 0.818, and 0.798, respectively (p < 0.001), and the cutoff points 77.26 Gy, 67.85 Gy, 60.13 Gy, 60.75 Gy, and 54.58 Gy, respectively, were deemed as the radiation dose limit. Conclusions Radiotherapy-induced brainstem injury was uncommon in patients with NPC who received definitive IMRT. Multiple dose-volume data may be the dose tolerance of radiation-induced brainstem injury.
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19
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Patel A, Dong T, Ansari S, Cohen-Gadol A, Watson GA, Moraes FYD, Nakamura M, Murovic J, Chang SD, Hatiboglu MA, Chung C, Miller JC, Lautenschlaeger T. Toxicity of Radiosurgery for Brainstem Metastases. World Neurosurg 2018; 119:e757-e764. [PMID: 30096494 DOI: 10.1016/j.wneu.2018.07.263] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 07/28/2018] [Accepted: 07/30/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although stereotactic radiosurgery (SRS) is an effective modality in the treatment of brainstem metastases (BSM), radiation-induced toxicity remains a critical concern. To better understand how severe or life-threatening toxicity is affected by the location of lesions treated in the brainstem, a review of all available studies reporting SRS treatment for BSM was performed. METHODS Twenty-nine retrospective studies investigating SRS for BSM were reviewed. RESULTS The rates of grade 3 or greater toxicity, based on the Common Terminology Criteria for Adverse Events, varied from 0 to 9.5% (mean 3.4 ± 2.9%). Overall, the median time to toxicity after SRS was 3 months, with 90% of toxicities occurring before 9 months. A total of 1243 cases had toxicity and location data available. Toxicity rates for lesions located in the medulla were 0.8% (1/131), compared with midbrain and pons, respectively, 2.8% (8/288) and 3.0% (24/811). CONCLUSIONS Current data suggest that brainstem substructure location does not predict for toxicity and lesion volume within this cohort with median tumor volumes 0.04-2.8 cc does not predict for toxicity.
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Affiliation(s)
- Ajay Patel
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Tuo Dong
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA; Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shaheryar Ansari
- Goodman Campbell Brain and Spine and Department of Neurological Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Aaron Cohen-Gadol
- Goodman Campbell Brain and Spine and Department of Neurological Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Gordon A Watson
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA; Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Fabio Ynoe de Moraes
- Department of Radiation Oncology, University of Toronto - Princess Margaret Cancer Centre, Toronto, Canada
| | - Masaki Nakamura
- Department of Radiation Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Judith Murovic
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Steven D Chang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Mustafa Aziz Hatiboglu
- Department of Neurosurgery, Bezmialem Vakif University Vatan Caddesi, Fatih, Istanbul, Turkey
| | - Caroline Chung
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - James C Miller
- Goodman Campbell Brain and Spine and Department of Neurological Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Tim Lautenschlaeger
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA; Indiana University School of Medicine, Indianapolis, Indiana, USA.
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20
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Fokas E, Henzel M, Hamm K, Grund S, Engenhart-Cabillic R. Brain Metastases in Breast Cancer: Analysis of the Role of HER2 Status and Treatment in the Outcome of 94 Patients. TUMORI JOURNAL 2018; 98:768-74. [DOI: 10.1177/030089161209800615] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims and background We investigated the impact of human epidermal growth factor receptor 2 (HER2) and prognostic factors in the outcome of patients with breast cancer that developed brain metastases. Methods The data from 94 patients who received multidisciplinary therapy from 2001 to 2007 were retrospectively reviewed. Patients were assigned according to their HER2 status, and overall survival and time to brain metastases recurrence/progression were evaluated. The prognostic value of age, presence of extracerebral metastases, recursive partitioning analysis class, hormone therapy, systemic therapy and trastuzumab was assessed. Results The median overall survival and time to brain disease progression were 7.1 and 6.5 months, respectively. HER2 positivity (P = 0.006), treatment with trastuzumab (P = 0.025), chemotherapy (P = 0.011) and recursive partitioning analysis class I-II (P <0.001) were associated with prolonged survival on univariate analysis. On multivariate analysis, only recursive partitioning analysis class I-II (P <0.001) and triple-negative disease (P = 0.04) remained significant for overall survival, whereas time to brain metastases progression was only associated with recursive partitioning analysis class I-II (P = 0.001). The time from the diagnosis of primary disease to brain metastasis was slightly shorter in the HER2+ patients than in HER2– patients (36 vs 39 months). Intensified local treatment of brain metastasis incorporating whole-brain radiotherapy and/or radiosurgery and neurosurgery did not affect survival. Patients with triple-negative disease presented a significantly lower survival than the rest of the cohort (4 vs 8 months; P = 0.012). Conclusions Recursive partitioning analysis class I-II was found to be the strongest independent predictive factor. Treatment with trastuzumab in HER2+ patients appeared to improve overall survival, probably due to the better control of systemic metastatic disease, but did not maintain significance in multivariate analysis. The dismal prognosis of patients with triple-negative breast cancer highlights the need to develop novel therapies to improve the poor survival.
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Affiliation(s)
- Emmanouil Fokas
- Department of Radiotherapy and Radiation Oncology, Philipps University Marburg, Germany
| | - Martin Henzel
- Department of Radiotherapy and Radiation Oncology, Philipps University Marburg, Germany
| | - Klaus Hamm
- Department for Stereotactic Neurosurgery and Radiosurgery, HELIOS Klinikum Erfurt, Germany
| | - Steffen Grund
- Department of Radiotherapy and Radiation Oncology, Philipps University Marburg, Germany
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21
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Noh T, Walbert T. Brain metastasis: clinical manifestations, symptom management, and palliative care. HANDBOOK OF CLINICAL NEUROLOGY 2018; 149:75-88. [PMID: 29307363 DOI: 10.1016/b978-0-12-811161-1.00006-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Patients who have brain metastases can suffer from a medley of symptoms, including headaches, seizures, cognitive impairment, fatigue, and focal deficits. As therapies have evolved, so has the management of these symptoms as patients survive longer. This chapter focuses on the clinical presentation of brain metastases, the treatment of those symptoms, and palliation in end-of-life management. Brain metastases are the most common cerebral malignancy. They can present with various symptoms, which can have significant impact on patients' quality of life throughout the course of their disease. Most of these symptoms are related to direct brain compression from the tumor or from edema. The location of the metastases will determine the focal deficits incurred and most patients will be on a course of steroids tapered according to their clinical status. The chapter includes a list of potential side-effects and considerations for management. Palliative care is an essential and important part of approaching patients with metastases. Early and clear communication about end-of-life decision making is encouraged with multiple easily accessible tools. For patients near the end of life, comfort is the ultimate goal in providing a good quality of life.
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Affiliation(s)
- Thomas Noh
- Department of Neurosurgery, Henry Ford Health System, Detroit, MI, United States
| | - Tobias Walbert
- Department of Neurosurgery, Henry Ford Health System, Detroit, MI, United States; Department of Neurology, Henry Ford Health System, Detroit, MI, United States.
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Abstract
Stereotactic radiosurgery has revolutionized the management of brain metastases. It delivers focused, highly conformal, ionizing radiation to a tumor delineated using high-resolution imaging, with low toxicity to adjacent brain structures. Randomized controlled and prospective trials have demonstrated a survival advantage and high local control rates after stereotactic radiosurgery for metastatic disease to the central nervous system, including for up to 10 brain metastases. Its minimal-access nature makes it an attractive alternative to surgical resection. Furthermore, in addition to chemotherapy, newer targeted therapies and immunotherapies with improved side-effect profiles allow for the concurrent delivery of systemic therapy with radiosurgery, with possible additive or synergistic effects, expediting the treatment of both extracranial and intracranial disease. The modern management of brain metastasis patients should include consideration of routine staging and surveillance magnetic resonance imaging scans in patients with higher-stage cancer to detect intracranial metastases earlier and treat promptly with radiosurgery in order to prevent the development of neurologic symptoms and the need for surgical resection.
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Affiliation(s)
- Amparo Wolf
- Department of Neurosurgery, Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, New York University, New York, NY, United States
| | - Douglas Kondziolka
- Department of Neurosurgery, Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, New York University, New York, NY, United States.
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23
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Patel A, Mohammadi H, Dong T, Shiue KRY, Frye D, Le Y, Ansari S, Watson GA, Miller JC, Lautenschlaeger T. Brainstem metastases treated with Gamma Knife stereotactic radiosurgery: the Indiana University Health experience. CNS Oncol 2017; 7:15-23. [PMID: 29239214 PMCID: PMC6001560 DOI: 10.2217/cns-2017-0029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Brainstem metastases offer a unique challenge in cancer treatment, yet stereotactic radiosurgery (SRS) has proven to be an effective modality in treating these tumors. This report discusses the clinical outcomes of patients with brainstem metastases treated at Indiana University with Gamma Knife (GK) radiosurgery from 2008 to 2016. 19 brainstem metastases from 14 patients who had follow-up brain imaging were identified. Median tumor volume was 0.04 cc (range: 0.01–2.0 cc). Median prescribed dose was 17.5 Gy to the 50% isodose line (range: 14–22 Gy). Median survival after GK SRS treatment to brainstem lesion was 17.2 months (range: 2.8–45.6 months). The experience at Indiana University confirms the safety and efficacy of range of GK SRS prescription doses (14–22 Gy) to brainstem metastases.
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Affiliation(s)
- Ajay Patel
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Homan Mohammadi
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Tuo Dong
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | | | - Douglas Frye
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Yi Le
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Shaheryar Ansari
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Gordon A Watson
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - James C Miller
- Goodman Campbell Brain & Spine & Department of Neurological Surgery, Indiana University, Indianapolis, IN 46202, USA
| | - Tim Lautenschlaeger
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Sharma M, Jia X, Ahluwalia M, Barnett GH, Vogelbaum MA, Chao ST, Suh JH, Murphy ES, Yu JS, Angelov L, Mohammadi AM. First follow-up radiographic response is one of the predictors of local tumor progression and radiation necrosis after stereotactic radiosurgery for brain metastases. Cancer Med 2017; 6:2076-2086. [PMID: 28776956 PMCID: PMC5603831 DOI: 10.1002/cam4.1149] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/09/2017] [Accepted: 06/26/2017] [Indexed: 12/11/2022] Open
Abstract
Local progression (LP) and radiation necrosis (RN) occur in >20% of cases following stereotactic radiosurgery (SRS) for brain metastases (BM). Expected outcomes following SRS for BM include tumor control/shrinkage, local progression and radiation necrosis. 1427 patients with 4283 BM lesions were treated using SRS at Cleveland Clinic from 2000 to 2012. Clinical, imaging and radiosurgery data were collected from the database. Local tumor progression and RN were the primary end points and correlated with patient and tumor‐related variables. 5.7% of lesions developed radiographic RN and 3.6% showed local progression at 6 months. Absence of new extracranial metastasis (P < 0.001), response to SRS at first follow‐up scan (local progression versus stable size (P < 0.001), partial resolution versus complete resolution at first follow up [P = 0.009]), prior SRS to the same lesion (P < 0.001), IDL% (≤55; P < 0.001), maximum tumor diameter (>0.9 cm; P < 0.001) and MD/PD gradient index (≤1.8, P < 0.001) were independent predictors of high risk of local tumor progression. Absence of systemic metastases (P = 0.029), good neurological function at 1st follow‐up (P ≤ 0.001), no prior SRS to other lesion (P = 0.024), low conformity index (≤1.9) (P = 0.009), large maximum target diameter (>0.9 cm) (P = 0.003) and response to SRS (tumor progression vs. stable size following SRS [P < 0.001]) were independent predictors of high risk of radiographic RN. Complete tumor response at first follow‐up, maximum tumor diameter <0.9 cm, tumor volume <2.4 cc and no prior SRS to the index lesion are good prognostic factors with reduced risk of LP following SRS. Complete tumor response to SRS, poor neurological function at first follow‐up, prior SRS to other lesions and high conformity index are favorable factors for not developing RN. Stable or partial response at first follow‐up after SRS have same impact on local progression and RN compared to those with complete resolution or progression.
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Affiliation(s)
- Mayur Sharma
- Department of Neurosurgery, The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Xuefei Jia
- Department of Biostatistics, Cleveland Clinic, Cleveland, Ohio, 44195
| | - Manmeet Ahluwalia
- Department of Neurosurgery, The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Gene H Barnett
- Department of Neurosurgery, The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Michael A Vogelbaum
- Department of Neurosurgery, The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Samuel T Chao
- Cleveland Clinic, Department of Radiation Oncology, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - John H Suh
- Cleveland Clinic, Department of Radiation Oncology, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Erin S Murphy
- Cleveland Clinic, Department of Radiation Oncology, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Jennifer S Yu
- Cleveland Clinic, Department of Radiation Oncology, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Lilyana Angelov
- Department of Neurosurgery, The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
| | - Alireza M Mohammadi
- Department of Neurosurgery, The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, CA-50, Cleveland, Ohio, 44195
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The impact of different stereotactic radiation therapy regimens for brain metastases on local control and toxicity. Adv Radiat Oncol 2017; 2:391-397. [PMID: 29114607 PMCID: PMC5605319 DOI: 10.1016/j.adro.2017.05.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 03/04/2017] [Accepted: 05/30/2017] [Indexed: 11/24/2022] Open
Abstract
Purpose Stereotactic radiation therapy (SRT) enables focused, short course, high dose per fraction radiation delivery to brain tumors that are less ideal for single fraction treatment because of size, shape, or close proximity to sensitive structures. We sought to identify optimal SRT treatment regimens for maximizing local control while minimizing morbidity. Methods and materials We performed a retrospective review of patients treated with SRT for solid brain metastases using variable dose schedules between 2001 and 2011 at 3 academic hospitals. Endpoints included (1) local control, (2) acute toxicity (Common Toxicity Criteria for Adverse Events v3.0), and (3) symptomatic radionecrosis. Kaplan-Meier and a competing risks methodology were used to estimate the actuarial rate of local failure and assess the association of clinical and treatment covariates with time to local failure. Results A total of 156 patients was identified. Common tumor histologies included breast (21%), non-small cell lung (32%), melanoma (22%), small cell lung (9%), and renal cell carcinoma (6%). The majority of lesions were supratentorial (57%). Median target volume was 3.99 mL (range, 0.04-58.42). Median total SRT dose was 25 Gy (range, 12-36), median fractional dose was 5 Gy (range, 2.5-11), and median number of fractions was 5 (range, 2-10). Cumulative incidence of local progression at 3, 6, 12, 18, and 24 months was 11%, 22%, 29%, 34%, and 36%. Total prescription dose was the only factor significantly associated with time to local progression on univariate (P = .02) and multivariable analysis (P = .01, adjusted hazards ratio, 0.87). Five patients experienced seizures within 10 days of SRT and 5 patients developed radionecrosis. All patients with documented radionecrosis received prior radiation to the index lesion. Conclusions Our series of SRT for brain metastases found total prescription dose to be the only factor associated with local control. Both acute and long-term toxicity events from SRT were modest.
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Harris KB, Corbett MR, Mascarenhas H, Lee KS, Arastu H, Leinweber C, Ju AW. A Single-Institution Analysis of 126 Patients Treated with Stereotactic Radiosurgery for Brain Metastases. Front Oncol 2017; 7:90. [PMID: 28553615 PMCID: PMC5427066 DOI: 10.3389/fonc.2017.00090] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 04/24/2017] [Indexed: 11/13/2022] Open
Abstract
Background The objective of this study was to report our institutional experience with Gamma Knife® Radiosurgery (GKRS) in the treatment of patients with brain metastases. Methods Retrospectively collected demographic and clinical data on 126 patients with intracranial metastases were reviewed. The patients in our study underwent GKRS at Vidant Medical Center between 2009 and 2014. Kaplan–Meier curves were used to compare survival based on clinical characteristics for univariate analysis, and a Cox proportional hazards model was used for multivariate analysis. Results The median age of the patient population was 62 years. Medicare patients constituted 51% of our patient cohort and Medicaid patients 15%. The most common tumor histologies were non-small cell lung cancer (50%), breast cancer (12.7%), and melanoma (11.9%). The median overall survival time for all patients was 5.8 months. Patients with breast cancer had the longest median survival time of 9.15 months, while patients with melanoma had the shortest median survival time of 2.86 months. On univariate analysis, the following factors were predictors for improved overall survival, ECOG score 0 or 1 vs. 2 or greater (17.0 vs. 1.8 months, p < 0.001), controlled extracranial disease vs. progressive extracranial disease (17.4 vs. 4.6 months, p = 0.0001), recursive partitioning analysis Stage I vs. II–III (18.2 vs. 6.2 months, p < 0.007), multiple GKRS treatments (p = 0.002), prior brain metastasectomy (p = 0.012), and prior chemotherapy (p = 0.021). Age, ethnicity, gender, previous external beam radiation therapy, number of brain metastases, and hemorrhagic vs. non-hemorrhagic tumors were not predictors of longer median survival time. Number of metastatic brain lesions of 1–3 vs. ≥4 (p = 0.051) and insurance status of Medicare/Medicaid vs. commercial insurance approached significance (13.7 vs. 6.8 months, p = 0.08). On multivariate analysis, ECOG performance status 0–1 (p < 0.001), multiple GKRS treatments (p = 0.003), and control of extracranial disease (p = 0.001) remained significant predictors of survival. Conclusion ECOG score, control of extracranial disease, and multiple GKRS treatments are predictors of longer median survival following GKRS in our patient population. GKRS is an effective treatment for brain metastases, but these factors may be considered in patient selection for GKRS.
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Affiliation(s)
- Kevin B Harris
- Department of Radiation Oncology, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | | | | | | | - Hyder Arastu
- Department of Radiation Oncology, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Clinton Leinweber
- Department of Radiation Oncology, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Andrew W Ju
- Department of Radiation Oncology, East Carolina University Brody School of Medicine, Greenville, NC, USA
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Murray L, Menard C, Zadeh G, Au K, Bernstein M, Millar BA, Laperriere N, Chung C. Radiosurgery for brainstem metastases with and without whole brain radiotherapy: clinical series and literature review. ACTA ACUST UNITED AC 2016; 6:21-30. [PMID: 28367275 PMCID: PMC5357261 DOI: 10.1007/s13566-016-0281-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/09/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The objective of this study was to investigate outcomes for patients with brainstem metastases treated with stereotactic radiosurgery (SRS). METHODS Patients with brainstem metastases treated with SRS between April 2006 and June 2012 were identified from a prospective database. Patient and treatment-related factors were recorded. Kaplan-Meier analysis was used to calculate survival and freedom from local and distant brain progression. Univariate and multivariate Cox regression was used to identify factors important for overall survival. RESULTS In total, 44 patients received SRS for 48 brainstem metastases of whom 33 (75 %) also received whole brain radiotherapy (WBRT): 23 patients (52 %) WBRT prior to SRS, 6 (13.6 %) WBRT concurrently with SRS and 4 (9.0 %) WBRT after SRS. Eight patients received a second course of WBRT at further progression. Median target volume was 1.33 cc (range 0.04-12.17) and median prescribed marginal dose was 15 Gy (range 10-22). There were four cases of local failure, and 6-month and 1-year freedom from local failure was 84.6 and 76.9 %, respectively. Median overall survival (OS) was 5.4 months. There were four cases of radionecrosis, 2 (4.8 %) of which were symptomatic. The absence of external beam brain radiotherapy (predominantly WBRT) showed a trend towards improved OS on univariate analysis. Neither local nor distant brain failure significantly impacted OS. CONCLUSION This retrospective series of patients treated with SRS for brainstem metastases, largely in combination with at least one course of WBRT, demonstrates that this approach is safe and results in good local control. In this cohort, no variables significantly impacted OS, including intracranial control.
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Affiliation(s)
- Louise Murray
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Cynthia Menard
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, ON Canada
| | - Karolyn Au
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, ON Canada
| | - Mark Bernstein
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, ON Canada
| | - Barbara-Ann Millar
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Normand Laperriere
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Caroline Chung
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
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Garbe C, Peris K, Hauschild A, Saiag P, Middleton M, Bastholt L, Grob JJ, Malvehy J, Newton-Bishop J, Stratigos AJ, Pehamberger H, Eggermont AM. Diagnosis and treatment of melanoma. European consensus-based interdisciplinary guideline - Update 2016. Eur J Cancer 2016; 63:201-17. [PMID: 27367293 DOI: 10.1016/j.ejca.2016.05.005] [Citation(s) in RCA: 273] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 05/16/2016] [Indexed: 01/12/2023]
Abstract
Cutaneous melanoma (CM) is potentially the most dangerous form of skin tumour and causes 90% of skin cancer mortality. A unique collaboration of multi-disciplinary experts from the European Dermatology Forum, the European Association of Dermato-Oncology and the European Organisation of Research and Treatment of Cancer was formed to make recommendations on CM diagnosis and treatment, based on systematic literature reviews and the experts' experience. Diagnosis is made clinically using dermoscopy and staging is based upon the AJCC system. CMs are excised with 1-2 cm safety margins. Sentinel lymph node dissection is routinely offered as a staging procedure in patients with tumours >1 mm in thickness, although there is as yet no clear survival benefit for this approach. Interferon-α treatment may be offered to patients with stage II and III melanoma as an adjuvant therapy, as this treatment increases at least the disease-free survival and less clear the overall survival (OS) time. The treatment is however associated with significant toxicity. In distant metastasis, all options of surgical therapy have to be considered thoroughly. In the absence of surgical options, systemic treatment is indicated. For first-line treatment particularly in BRAF wild-type patients, immunotherapy with PD-1 antibodies alone or in combination with CTLA-4 antibodies should be considered. BRAF inhibitors like dabrafenib and vemurafenib in combination with the MEK inhibitors trametinib and cobimetinib for BRAF mutated patients should be offered as first or second line treatment. Therapeutic decisions in stage IV patients should be primarily made by an interdisciplinary oncology team ('Tumour Board').
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Affiliation(s)
- Claus Garbe
- Centre for Dermatooncology, Department of Dermatology, Eberhard Karls University, Tuebingen, Germany.
| | - Ketty Peris
- Institute of Dermatology, Catholic University, Rome, Italy
| | - Axel Hauschild
- Department of Dermatology, University Hospital Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Philippe Saiag
- University Department of Dermatology, Université de Versailles-Saint Quentin en Yvelines, APHP, Boulogne, France
| | - Mark Middleton
- NIHR Biomedical Research Centre, University of Oxford, UK
| | - Lars Bastholt
- Department of Oncology, Odense University Hospital, Denmark
| | | | - Josep Malvehy
- Melanoma Unit, Department of Dermatology, Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - Julia Newton-Bishop
- Section of Biostatistics and Epidemiology, Leeds Institute of Cancer and Pathology, University of Leeds, UK
| | - Alexander J Stratigos
- 1(st) Department of Dermatology, University of Athens School of Medicine, Andreas Sygros Hospital, Athens, Greece
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Trifiletti DM, Lee CC, Kano H, Cohen J, Janopaul-Naylor J, Alonso-Basanta M, Lee JYK, Simonova G, Liscak R, Wolf A, Kvint S, Grills IS, Johnson M, Liu KD, Lin CJ, Mathieu D, Héroux F, Silva D, Sharma M, Cifarelli CP, Watson CN, Hack JD, Golfinos JG, Kondziolka D, Barnett G, Lunsford LD, Sheehan JP. Stereotactic Radiosurgery for Brainstem Metastases: An International Cooperative Study to Define Response and Toxicity. Int J Radiat Oncol Biol Phys 2016; 96:280-288. [PMID: 27478166 DOI: 10.1016/j.ijrobp.2016.06.009] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 05/22/2016] [Accepted: 06/07/2016] [Indexed: 11/17/2022]
Abstract
PURPOSE To pool data across multiple institutions internationally and report on the cumulative experience of brainstem stereotactic radiosurgery (SRS). METHODS AND MATERIALS Data on patients with brainstem metastases treated with SRS were collected through the International Gamma Knife Research Foundation. Clinical, radiographic, and dosimetric characteristics were compared for factors prognostic for local control (LC) and overall survival (OS) using univariate and multivariate analyses. RESULTS Of 547 patients with 596 brainstem metastases treated with SRS, treatment of 7.4% of tumors resulted in severe SRS-induced toxicity (grade ≥3, increased odds with increasing tumor volume, margin dose, and whole-brain irradiation). Local control at 12 months after SRS was 81.8% and was improved with increasing margin dose and maximum dose. Overall survival at 12 months after SRS was 32.7% and impacted by age, gender, number of metastases, tumor histology, and performance score. CONCLUSIONS Our study provides additional evidence that SRS has become an option for patients with brainstem metastases, with an excellent benefit-to-risk ratio in the hands of experienced clinicians. Prior whole-brain irradiation increases the risk of severe toxicity in brainstem metastasis patients undergoing SRS.
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Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia.
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, People's Republic of China
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jonathan Cohen
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James Janopaul-Naylor
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - John Y K Lee
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gabriela Simonova
- Department of Radiation and Stereotactic Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Roman Liscak
- Department of Radiation and Stereotactic Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Amparo Wolf
- Department of Neurosurgery, New York University Lagone Medical Center, New York, New York
| | - Svetlana Kvint
- Department of Neurosurgery, New York University Lagone Medical Center, New York, New York
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Matthew Johnson
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Kang-Du Liu
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, People's Republic of China
| | - Chung-Jung Lin
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, People's Republic of China
| | - David Mathieu
- Division of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Québec, Canada
| | - France Héroux
- Division of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Québec, Canada
| | - Danilo Silva
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Mayur Sharma
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Christopher P Cifarelli
- Departments of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown, West Virginia
| | - Christopher N Watson
- Departments of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown, West Virginia
| | - Joshua D Hack
- Departments of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown, West Virginia
| | - John G Golfinos
- Department of Neurosurgery, New York University Lagone Medical Center, New York, New York
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Lagone Medical Center, New York, New York
| | - Gene Barnett
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia; Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Alongi F, Fiorentino A, Mancosu P, Navarria P, Giaj Levra N, Mazzola R, Scorsetti M. Stereotactic radiosurgery for intracranial metastases: linac-based and gamma-dedicated unit approach. Expert Rev Anticancer Ther 2016; 16:731-40. [DOI: 10.1080/14737140.2016.1190648] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Filippo Alongi
- Radiation Oncology Department, Sacro Cuore Hospital, Negrar, Italy
| | - Alba Fiorentino
- Radiation Oncology Department, Sacro Cuore Hospital, Negrar, Italy
| | - Pietro Mancosu
- Radiation Oncology Department, Istituto Clinico Humanitas, Milan, Italy
| | - Pierina Navarria
- Radiation Oncology Department, Istituto Clinico Humanitas, Milan, Italy
| | | | - Rosario Mazzola
- Radiation Oncology Department, Sacro Cuore Hospital, Negrar, Italy
| | - Marta Scorsetti
- Radiation Oncology Department, Istituto Clinico Humanitas, Milan, Italy
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Sinclair G, Bartek J, Martin H, Barsoum P, Dodoo E. Adaptive hypofractionated gamma knife radiosurgery for a large brainstem metastasis. Surg Neurol Int 2016; 7:S130-8. [PMID: 26958430 PMCID: PMC4765246 DOI: 10.4103/2152-7806.176138] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 12/28/2015] [Indexed: 11/24/2022] Open
Abstract
Background: To demonstrate how adaptive hypofractionated radiosurgery by gamma knife (GK) can be successfully utilized to treat a large brainstem metastasis - a novel approach to a challenging clinical situation. Case Description: A 42-year-old woman, diagnosed with metastatic nonsmall cell lung cancer in July 2011, initially treated with chemotherapy and tyrosine kinase inhibitors, developed multiple brain metastases March 2013, with subsequent whole brain radiotherapy, after which a magnetic resonance imaging (MRI) showed a significant volume regression of all brain metastases. A follow-up MRI in October 2013 revealed a growing brainstem lesion of 26 mm. Linear accelerator-based radiotherapy and microsurgery were judged contraindicated, why the decision was made to treat the patient with three separate radiosurgical sessions during the course of 1 week, with an 18% tumor volume reduction demonstrated after the last treatment. Follow-up MRI 2.5 months after her radiosurgical treatment showed a tumor volume reduction of 67% compared to the 1st day of treatment. Later on, the patient developed a radiation-induced perilesional edema although without major clinical implications. An MRI at 12 months and 18-fluoro-deoxyglucose positron emission tomography of the brain at 13 months showed decreased edema with no signs of tumor recurrence. Despite disease progression during the last months of her life, the patient's condition remained overall acceptable. Conclusion: GK-based stereotactic adaptive hypofractionation proved to be effective to achieve tumor control while limiting local adverse reactions. This surgical modality should be considered when managing larger brain lesions in critical areas.
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Affiliation(s)
- Georges Sinclair
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Jiri Bartek
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden; Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Heather Martin
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Pierre Barsoum
- Department of Medical Physics, Karolinska University Hospital, Stockholm, Sweden
| | - Ernest Dodoo
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
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Liu SH, Murovic J, Wallach J, Cui G, Soltys SG, Gibbs IC, Chang SD. CyberKnife radiosurgery for brainstem metastases: Management and outcomes and a review of the literature. J Clin Neurosci 2016; 25:105-10. [PMID: 26778047 DOI: 10.1016/j.jocn.2015.10.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 10/10/2015] [Indexed: 11/20/2022]
Abstract
To our knowledge this paper is the first to use recursive partitioning analysis (RPA) for brainstem metastasis (BSM) patient outcomes, after CyberKnife radiosurgery (CKRS; Accuray, Sunnyvale, CA, USA); nine similar previous publications used mainly Gamma Knife radiosurgery (Elekta AB, Stockholm, Sweden). Retrospective chart reviews from 2006-2013 of 949 CKRS-treated brain metastasis patients showed 54 BSM patients (5.7%): 35 RPA Class II (65%) and 19 Class III (35%). There were 30 women (56%) and 24 men (44%). The median age was 59 years (range 36-80) and median follow-up was 5 months (range 1-52). Twenty-three patients (43%) had lung carcinoma BSM and 12 (22%) had breast cancer BSM. Fifty-four RPA Class II and III BSM patients had a median overall survival (OS) of 5 months, and for each Class 8 and 2 months, respectively. Of 36 RPA Class II and III patients with available symptoms (n=31) and findings (n=33), improvement/stability occurred in the majority for symptoms (86%) and findings (92%). Of 35 cases, 28 (80%) achieved BSM local control (LC); 13/14 with breast histology (93%) and 10/13 with lung histology (77%). All six RPA Class II and III patients with controlled extracranial systemic disease (ESD) experienced LC. Median tumor volume was 0.14 cm(3); of 34 RPA Class II and III cases, 26 LC patients had a 0,13 cm(3) median tumor volume while it was 0.27 cm(3) in the eight local failures. Of 35 cases, single session equivalent dosages less than the median (n=13), at the 17.9 Gy median (n=5) and greater than the median (n=17) had BSM LC in 10 (77%), four (80%) and 14 cases (82%), respectively. Univariate analysis showed Karnofsky Performance Score, RPA Class and ESD-control predicted OS. CKRS is useful for RPA Class II and III BSM patients with effective clinical and local BSM control.
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Affiliation(s)
- Szu-Hao Liu
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, R225, Stanford, CA 94305-5327, USA
| | - Judith Murovic
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, R225, Stanford, CA 94305-5327, USA
| | - Jonathan Wallach
- Department of Radiation Oncology, Stanford University School of Medicine, 875 Blake Wilbur Drive, Stanford, CA 94305-5327, USA
| | - Guosheng Cui
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, R225, Stanford, CA 94305-5327, USA
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University School of Medicine, 875 Blake Wilbur Drive, Stanford, CA 94305-5327, USA
| | - Iris C Gibbs
- Department of Radiation Oncology, Stanford University School of Medicine, 875 Blake Wilbur Drive, Stanford, CA 94305-5327, USA
| | - Steven D Chang
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, R225, Stanford, CA 94305-5327, USA.
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Trifiletti DM, Lee CC, Shah N, Patel NV, Chen SC, Sheehan JP. How Does Brainstem Involvement Affect Prognosis in Patients with Limited Brain Metastases? Results of a Matched-Cohort Analysis. World Neurosurg 2015; 88:563-568. [PMID: 26555507 DOI: 10.1016/j.wneu.2015.10.089] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 10/22/2015] [Accepted: 10/24/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Although brainstem metastases are thought to portend an inferior prognosis compared to non-brainstem brain metastases, there is limited evidence to support this claim, particularly in the modern radiosurgical era. METHODS We collected the clinical data for 500 patients with brain metastases treated at our institution with stereotactic radiosurgery (SRS). All patients received SRS to at least one brain metastasis, and all brainstem metastases underwent SRS. After propensity score matching, clinical characteristics and overall survival were calculated and compared between groups. RESULTS Three hundred sixteen patients with brain metastases were analyzed after matching (143 with brainstem involvement and 173 without). Patients with brainstem metastases lived shorter after first SRS than patients without brainstem metastases did (median 4.4 and 6.5 months, respectively; P = 0.01), and they were more likely to have received whole brain irradiation (P = 0.003). Patients with a single metastasis did not survive longer than patients with multiple brain metastases if there was brainstem involvement (P = 0.45). The incidence of new extracranial disease and severe toxicity after SRS did not differ between groups. CONCLUSIONS The survival of patients with brain metastases is inferior after a metastatic lesion develops within the brainstem, despite favorable local control with brainstem SRS. The brainstem location should be considered a negative prognostic factor for survival after SRS, and it could result from the eloquence of this location. Future research could identify the clinically life-limiting component of brainstem metastases.
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Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA.
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Neil Shah
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA
| | - Nirav V Patel
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA
| | - Shao-Ching Chen
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
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Trifiletti DM, Lee CC, Winardi W, Patel NV, Yen CP, Larner JM, Sheehan JP. Brainstem metastases treated with stereotactic radiosurgery: safety, efficacy, and dose response. J Neurooncol 2015; 125:385-92. [PMID: 26341374 DOI: 10.1007/s11060-015-1927-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 09/01/2015] [Indexed: 11/28/2022]
Abstract
The safety and efficacy of stereotactic radiosurgery (SRS) in the brainstem is questioned by some over concern of violating historical brainstem SRS dose tolerance. Our purpose was to report on the clinical outcomes of patients treated at our institution with radiosurgery for brainstem metastases. Patients with metastatic tumors within or directly abutting the brainstem from 1992 to 2014 were analyzed. Patient and tumor characteristics, SRS parameters, and toxicity were recorded and analyzed for associations with local control and survival. Multivariate statistical analysis was performed using Cox proportional hazards modeling. One-hundred and eighty-nine (189) brainstem metastases from 161 patients were included in our analysis. Whole brain irradiation was administered prior to SRS in 52 % of patients. The median margin dose was 18 Gy prescribed to the 50 % isodose line. Median imaging follow up was 5.4 months and median survival was 5.5 months after SRS. At last follow up, local control was achieved in 87.3 % of brainstem lesions treated. There were 3 recorded events of grade 3-5 toxicity (1.8 %). On multivariate analysis, a margin dose ≥16 Gy was associated with improved local control (p = 0.049) and greater KPS score was associated with improved overall survival following SRS (p = 0.024). Patients with brainstem metastases who have limited intracranial disease and/or who have received whole brain irradiation should be considered for SRS. Margin doses of at least 16 Gy are associated with superior local control, and serious radiation toxicity in SRS for brainstem metastasis appears rare.
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Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia, 1240 Lee Street, Box 800383, Charlottesville, VA, 22908, USA.
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, ROC
| | - William Winardi
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Nirav V Patel
- Department of Radiation Oncology, University of Virginia, 1240 Lee Street, Box 800383, Charlottesville, VA, 22908, USA
| | - Chun-Po Yen
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, ROC
| | - James M Larner
- Department of Radiation Oncology, University of Virginia, 1240 Lee Street, Box 800383, Charlottesville, VA, 22908, USA
| | - Jason P Sheehan
- Department of Radiation Oncology, University of Virginia, 1240 Lee Street, Box 800383, Charlottesville, VA, 22908, USA.,Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, ROC
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Hsieh J, Elson P, Otvos B, Rose J, Loftus C, Rahmathulla G, Angelov L, Barnett GH, Weil RJ, Vogelbaum MA. Tumor progression in patients receiving adjuvant whole-brain radiotherapy vs localized radiotherapy after surgical resection of brain metastases. Neurosurgery 2015; 76:411-20. [PMID: 25599198 DOI: 10.1227/neu.0000000000000626] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Surgery followed by adjuvant radiotherapy is a well-established treatment paradigm for brain metastases. OBJECTIVE To examine the effect of postsurgical whole-brain radiotherapy (WBRT) or localized radiotherapy (LRT), including stereotactic radiosurgery and intraoperative radiotherapy, on the rate of recurrence both local and distal to the resection site in the treatment of brain metastases. METHODS We retrospectively identified patients who underwent surgery for brain metastasis at the Cleveland Clinic between 2004 and 2012. Institutional review board-approved chart review was conducted, and patients who had radiation before surgery, who had nonmetastatic lesions, or who lacked postadjuvant imaging were excluded. RESULTS The final analysis included 212 patients. One hundred fifty-six patients received WBRT, 37 received stereotactic radiosurgery only, and 19 received intraoperative radiotherapy. One hundred forty-six patients were deceased, of whom 60 (41%) died with no evidence of recurrence. Competing risks methodology was used to test the association between adjuvant modality and progression. Multivariable analysis revealed no significant difference in the rate of recurrence at the resection site (hazard ratio [HR] 1.46, P = .26) or of unresected, radiotherapy-treated lesions (HR 1.70, P = .41) for LRT vs WBRT. Patients treated with LRT had an increased hazard of the development of new lesions (HR 2.41, P < .001) and leptomeningeal disease (HR 2.45, P = .04). Median survival was 16.5 months and was not significantly different between groups. CONCLUSION LRT as adjuvant treatment to surgical resection of brain metastases is associated with an increased rate of development of new distant metastases and leptomeningeal disease compared with WBRT, but not with recurrence at the resection site or of unresected lesions treated with radiation.
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Affiliation(s)
- Jason Hsieh
- *Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio; ‡Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio; §Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio; ¶Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio; ‖Department of Cancer Biology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; #Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania
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Stereotactic Radiosurgery for Metastases in Eloquent Central Brain Locations. Can J Neurol Sci 2015; 42:333-7. [DOI: 10.1017/cjn.2015.55] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractBackground: To examine stereotactic radiosurgery (SRS) following whole brain radiotherapy for metastases in eloquent, central brain locations: brainstem, thalamus, and basal ganglia. Methods: We conducted a retrospective review of patients with metastases in eloquent, central brain locations who were treated with SRS between January 2000 and April 2012. All patients had whole brain radiotherapy. Patients eligible for SRS had one to three brain metastases, metastasis size ≤4 cm, and Karnofsky performance status ≥70. Local progression-free survival and overall survival were calculated using the Kaplan-Meier method. Results: For 24 patients, the median age was 50 years (range, 36-73). Metastases by location were: 11 brainstem, 9 thalamus, and 5 basal ganglia. The median metastasis size was 15 mm (range, 2-33) and the median SRS dose prescription was 15 Gy (range, 12-24). The median local progression-free survival was 13.7 months and median overall survival was 16.4 months. Compared with a cohort of 188 patients with noneloquent brain metastases receiving a median dose of 24 Gy, overall survival of 10.8 months was not significantly different (p=0.16). The only symptomatic complication was grade 2 headache in 8.3%. Asymptomatic adverse radiologic events were radionecrosis in two (8.3%), peritumoural edema in four (16.7%), and hemorrhage in one patient (4.2%). Conclusions: Lower SRS marginal doses do not appear to compromise survival in patients with eloquently located brain metastases compared with higher doses for other brain metastases, with minimal symptomatic complications.
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Pinkham MB, Whitfield GA, Brada M. New developments in intracranial stereotactic radiotherapy for metastases. Clin Oncol (R Coll Radiol) 2015; 27:316-23. [PMID: 25662094 DOI: 10.1016/j.clon.2015.01.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 12/16/2014] [Accepted: 01/22/2015] [Indexed: 11/19/2022]
Abstract
Brain metastases are common and the prognosis for patients with multiple brain metastases treated with whole brain radiotherapy is limited. As systemic disease control continues to improve, the expectations of radiotherapy for brain metastases are growing. Stereotactic radiosurgery (SRS) as a high precision localised irradiation given in a single fraction prolongs survival in patients with a single brain metastasis and functional independence in those with up to three brain metastases. SRS technology has become commonplace and is available in many radiation oncology and neurosurgery departments. With increasing use there is a need for appropriate patient selection, refinement of dose-fractionation and safe integration of SRS with other treatment modalities. We review the evidence for current practice and new developments in the field, with a specific focus on patient-relevant outcomes.
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Affiliation(s)
- M B Pinkham
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK; School of Medicine, University of Queensland, Brisbane, Australia
| | - G A Whitfield
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK; The University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - M Brada
- University of Liverpool, Department of Clinical and Molecular Cancer Medicine and Academic Radiotherapy Unit, Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK.
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Voong KR, Farnia B, Wang Q, Luo D, McAleer MF, Rao G, Guha-Thakurta N, Likhacheva A, Ghia AJ, Brown PD, Li J. Gamma knife stereotactic radiosurgery in the treatment of brainstem metastases: The MD Anderson experience. Neurooncol Pract 2015; 2:40-47. [PMID: 26034640 DOI: 10.1093/nop/npu032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Brainstem metastases (BSMs) represent a significant treatment challenge. Stereotactic radiosurgery (SRS) is often used to treat BSM. We report our experience in the treatment of BSM with Gamma Knife SRS (GK_SRS). METHODS The records of 1962 patients with brain metastases treated with GK_SRS between 2009 and 2013 were retrospectively reviewed. Seventy-four patients with 77 BSMs and follow-up brain imaging were identified. Local control (LC), overall survival (OS), progression-free survival (PFS), and toxicity were assessed. RESULTS Median follow-up was 5.5 months (range, 0.2-48.5 months). Median tumor volume was 0.13 cm3 (range, 0.003-5.58 cm3). Median treatment dose was 16 Gy (range, 10-20 Gy) prescribed to 50% isodose line (range, 40%-86%). Crude LC was 94% (72/77). Kaplan-Meier estimate of median OS was 8.5 months (95% CI, 5.6-9.4 months). Symptomatic lesions and larger lesions, especially size ≥2 cm3, were associated with worse LC (HR = 8.70, P = .05; HR = 14.55, P = .02; HR = 62.81, P < .001) and worse OS (HR = 2.00, P = .02; HR = 2.14, P = .03; HR = 2.81, P = .008). Thirty-six percent of BSMs were symptomatic, of which 36% (10/28) resolved after SRS and 50% (14/28) had stable or improved symptoms. Actuarial median PFS was 3.9 months (95% CI, 2.7-4.9 months). Midbrain location was significant for worse PFS (HR = 2.29, P = .03). Toxicity was low (8%, 6/74), with size and midbrain location associated with increased toxicity (HR 1.57, P = .05; HR = 5.25, P = .045). CONCLUSIONS GK_SRS is associated with high LC (94%) and low toxicity (8%) for BSMs. Presence of symptoms or lesion size ≥ 2 cm3 was predictive of worse LC and OS.
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Affiliation(s)
- Khinh Ranh Voong
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Benjamin Farnia
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Qianghu Wang
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Dershan Luo
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Mary F McAleer
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Ganesh Rao
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Nandita Guha-Thakurta
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Anna Likhacheva
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Amol J Ghia
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Paul D Brown
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Jing Li
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
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DU C, Li Z, Wang Z, Wang L, Tian YU. Stereotactic aspiration combined with gamma knife radiosurgery for the treatment of cystic brainstem metastasis originating from lung adenosquamous carcinoma: A case report. Oncol Lett 2015; 9:1607-1613. [PMID: 25789009 PMCID: PMC4356421 DOI: 10.3892/ol.2015.2968] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 01/22/2015] [Indexed: 11/23/2022] Open
Abstract
Brainstem metastases have a poor prognosis and are difficult to manage. The present study describes the first case of histopathologically-confirmed brainstem metastasis originating from lung adenosquamous carcinoma, and discusses the outcomes of treatment by stereotactic aspiration combined with gamma knife radiosurgery (GKRS). A 59-year-old female presented with a cystic mass (15×12×13 mm; volume, 1.3 cm3) located in the pons, two years following surgical treatment for adenosquamous carcinoma of the lung. The patient received initial GKRS for the lesion in the pons with a total dose of 54.0 Gy, however, the volume of the mass subsequently increased to 3.9 cm3 over a period of three months. Computed tomography-guided stereotactic biopsy and aspiration of the intratumoral cyst were performed, yielding 2.0 cm3 of yellow-white fluid. Histology confirmed the diagnosis of adenosquamous carcinoma. Aspiration provided immediate symptomatic relief, and was followed one week later by repeat GKRS with a dose of 12.0 Gy. The patient survived for 12 months following the repeat GKRS; however, later succumbed to the disease after lapsing into a two-week coma. The findings of this case suggest that stereotactic aspiration of cysts may improve the effects of GKRS for the treatment of cystic brainstem metastasis; the decrease in tumor volume allowed a higher radiation dose to be administered with a lower risk of radiation-induced side effects. Therefore, stereotactic aspiration combined with GKRS may be an effective treatment for brainstem metastasis originating from adenosquamous carcinoma.
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Affiliation(s)
- Chao DU
- Department of Neurosurgery, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Zhaohui Li
- Department of Neurosurgery, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Zhijia Wang
- Department of Radiology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Liping Wang
- Department of Pathology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Y U Tian
- Department of Neurosurgery, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
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Lubrano V, Derrey S, Truc G, Mirabel X, Thariat J, Cupissol D, Sassolas B, Combemale P, Modiano P, Bedane C, Dygai-Cochet I, Lamant L, Mourrégot A, Rougé Bugat MÈ, Siegrist S, Tiffet O, Mazeau-Woynar V, Verdoni L, Planchamp F, Leccia MT. [Locoregional treatments of brain metastases for patients with metastatic cutaneous melanoma: French national guidelines]. Neurochirurgie 2014; 60:269-75. [PMID: 25241016 DOI: 10.1016/j.neuchi.2014.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 05/12/2014] [Accepted: 05/21/2014] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The management of metastatic cutaneous melanoma is changing, marked by innovative therapies. However, their respective use and place in the therapeutic strategy continue to be debated by healthcare professionals. OBJECTIVE The French national cancer institute has led a national clinical practice guideline project since 2008. It has carried out a review of these modalities of treatment and established recommendations. METHODS The clinical practice guidelines development process is based on systematic literature review and critical appraisal by experts. The recommendations are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines are reviewed by independent practitioners in cancer care delivery. RESULTS This article presents the results of bibliographic search, the conclusions of the literature and the recommendations concerning locoregional treatments of brain metastases for patients with metastatic cutaneous melanoma.
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Affiliation(s)
- V Lubrano
- Service de neurochirurgie, hôpital de Rangueil, CHU de Toulouse, 1, avenue du Professeur-Jean-Poulhès, TSA 50032, 31059 Toulouse, France
| | - S Derrey
- Département de neurochirurgie, hôpital Charles-Nicolle, 1, rue de Germont, 76000 Rouen, France
| | - G Truc
- Département de radiothérapie, centre Georges-François-Leclerc, 1, rue du Professeur-Marion, BP 77980, 21079 Dijon, France
| | - X Mirabel
- Département de radiothérapie-curiethérapie, centre Oscar-Lambret, 3, rue Frédéric-Combemale, BP 307, 59020 Lille, France
| | - J Thariat
- Pôle de radiothérapie, centre Antoine-Lacassagne, 33, avenue de Valombrose, 06189 Nice, France
| | - D Cupissol
- Service d'oncologie médicale, ICM, institut du cancer de Montpellier Val-d'Aurelle, 208, avenue des Apothicaires, parc Euromédecine, 34298 Montpellier, France
| | - B Sassolas
- Service de dermatologie, hôpital Cavale-Blanche, boulevard Tanguy-Prigent, 29609 Brest, France
| | - P Combemale
- Unité onco-dermatologie, centre Léon Bérard, 28, rue Laennec, 69008 Lyon, France
| | - P Modiano
- Service de dermatologie, hôpital Saint-Vincent-de-Paul, boulevard de Belfort, BP 387, 59020 Lille, France
| | - C Bedane
- Service de dermatologie, hôpital Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges, France
| | - I Dygai-Cochet
- Service de médecine nucléaire, centre Georges-François-Leclerc, 1, rue du Professeur-Marion, BP 77980, 21079 Dijon, France
| | - L Lamant
- Service d'anatomie pathologique, hôpital Purpan, place Baylac, 31059 Toulouse, France
| | - A Mourrégot
- Service de chirurgie oncologique, ICM, institut du cancer de Montpellier Val-d'Aurelle, 208, avenue des Apothicaires, parc Euromédecine, 34298 Montpellier, France
| | - M-È Rougé Bugat
- Cabinet médical, 59, rue de la Providence, 31500 Toulouse, France
| | - S Siegrist
- Cabinet médical, 3, rue Saint-Sigisbert, 57050 le Ban-Saint-Martin, France
| | - O Tiffet
- Service de chirurgie générale et thoracique, centre hospitalier universitaire, 42055 Saint-Étienne, France
| | - V Mazeau-Woynar
- Direction des recommandations et de la qualité de l'expertise, Institut national du cancer, 52, avenue André-Morizet, 92513 Boulogne-Billancourt, France
| | - L Verdoni
- Direction des recommandations et de la qualité de l'expertise, Institut national du cancer, 52, avenue André-Morizet, 92513 Boulogne-Billancourt, France
| | - F Planchamp
- Direction des recommandations et de la qualité de l'expertise, Institut national du cancer, 52, avenue André-Morizet, 92513 Boulogne-Billancourt, France.
| | - M-T Leccia
- Clinique de dermatolo-vénéréologie, photobiologie et allergologie, pôle pluridisciplinaire de médecine, hôpital Michallon, 38043 Grenoble, France
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Lu A, Patel A, Kuzmik G, Atsina KK, Bronen R, Jabbour P, Hasan D, Vortmeyer A, Welch B, Bulsara K. Brainstem melanomas presenting as a cavernous malformation. Neurochirurgie 2014; 60:184-7. [DOI: 10.1016/j.neuchi.2014.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 01/16/2014] [Accepted: 02/19/2014] [Indexed: 11/26/2022]
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Local control after fractionated stereotactic radiation therapy for brain metastases. J Neurooncol 2014; 120:339-46. [DOI: 10.1007/s11060-014-1556-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 07/05/2014] [Indexed: 10/25/2022]
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Gamma knife treatment of brainstem metastases. Int J Mol Sci 2014; 15:9748-61. [PMID: 24886816 PMCID: PMC4100118 DOI: 10.3390/ijms15069748] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Revised: 05/01/2014] [Accepted: 05/05/2014] [Indexed: 11/16/2022] Open
Abstract
The management of brainstem metastases is challenging. Surgical treatment is usually not an option, and chemotherapy is of limited utility. Stereotactic radiosurgery has emerged as a promising palliative treatment modality in these cases. The goal of this study is to assess our single institution experience treating brainstem metastases with Gamma Knife radiosurgery (GKRS). This retrospective chart review studied 41 patients with brainstem metastases treated with GKRS. The most common primary tumors were lung, breast, renal cell carcinoma, and melanoma. Median age at initial treatment was 59 years. Nineteen (46%) of the patients received whole brain radiation therapy (WBRT) prior to or concurrent with GKRS treatment. Thirty (73%) of the patients had a single brainstem metastasis. The average GKRS dose was 17 Gy. Post-GKRS overall survival at six months was 42%, at 12 months was 22%, and at 24 months was 13%. Local tumor control was achieved in 91% of patients, and there was one patient who had a fatal brain hemorrhage after treatment. Karnofsky performance score (KPS) >80 and the absence of prior WBRT were predictors for improved survival on multivariate analysis (HR 0.60 (p = 0.02), and HR 0.28 (p = 0.02), respectively). GKRS was an effective treatment for brainstem metastases, with excellent local tumor control.
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Smith TR, Lall RR, Lall RR, Abecassis IJ, Arnaout OM, Marymont MH, Swanson KR, Chandler JP. Survival after surgery and stereotactic radiosurgery for patients with multiple intracranial metastases: results of a single-center retrospective study. J Neurosurg 2014; 121:839-45. [PMID: 24857242 DOI: 10.3171/2014.4.jns13789] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Patients with systemic cancer and a single brain metastasis who undergo treatment with resection plus radiotherapy live longer and have a better quality of life than those treated with radiotherapy alone. Historically, whole-brain radiotherapy (WBRT) has been the mainstay of radiation therapy; however, it is associated with significant delayed neurocognitive sequelae. In this study, the authors looked at survival in patients with single and multiple intracranial metastases who had undergone surgery and adjuvant stereotactic radiosurgery (SRS) to the tumor bed and synchronous lesions. METHODS The authors retrospectively reviewed the records from an 8-year period at a single institution for consecutive patients with brain metastases treated via complete resection of dominant lesions and adjuvant radiosurgery. The cohort was analyzed for time to local progression, synchronous lesion progression, new intracranial lesion development, systemic progression, and overall survival. The Kaplan-Meier method (stratified by age, sex, tumor histology, and number of intracranial lesions prior to surgery) was used to calculate both progression-free and overall survival. A Cox proportional-hazards regression model was also fitted with the number of intracranial lesions as the predictor and survival as the outcome controlling for disease severity, age, sex, and primary histology. RESULTS The median overall follow-up among the 150-person cohort eligible for analysis was 17 months. Patients had an average age of 46.2 years (range 16-82 years), and 62.7% were female. The mean (± standard deviation) number of intracranial lesions per patient was 2.5 ± 2.3. The mean time between surgery and stereotactic radiosurgery (SRS) was 3.2 ± 4.1 weeks. Primary cancers included lung cancer (43.3%), breast cancer (21.3%), melanoma (10.0%), renal cell carcinoma (6.7%), and colon cancer (6.7%). The average number of isocenters per treated lesion was 7.6 ± 6.6, and the average treatment dose was 17.8 ± 2.8 Gy. One-year survival for patients in this cohort was 52%, and the 1-year local control rate was 77%. The median (±standard error) overall survival was 13.2 ± 1.9 months. There was no difference in survival between patients with a single lesion and those with multiple lesions (p = 0.319) after controlling for age, sex, and histology of primary tumor. Patients with primary breast histology had the greatest overall median survival (22.9 ± 6.2 months); patients with colorectal cancer had the shortest overall median survival (5.3 ± 1.8 months). The most common cause of death in this series was systemic progression (79%). CONCLUSIONS These results confirm that 1-year survival for patients with multiple intracranial metastases treated with resection followed by SRS to both the tumor bed and synchronous lesions is similar to established outcomes for patients with a single intracranial metastasis.
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Hundsberger T, Tonder M, Hottinger A, Brügge D, Roelcke U, Putora PM, Stupp R, Weller M. Clinical management and outcome of histologically verified adult brainstem gliomas in Switzerland: a retrospective analysis of 21 patients. J Neurooncol 2014; 118:321-328. [PMID: 24736829 DOI: 10.1007/s11060-014-1434-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Accepted: 03/31/2014] [Indexed: 12/25/2022]
Abstract
Because of low incidence, mixed study populations and paucity of clinical and histological data, the management of adult brainstem gliomas (BSGs) remains non-standardized. We here describe characteristics, treatment and outcome of patients with exclusively histologically confirmed adult BSGs. A retrospective chart review of adults (age >18 years) was conducted. BSG was defined as a glial tumor located in the midbrain, pons or medulla. Characteristics, management and outcome were analyzed. Twenty one patients (17 males; median age 41 years) were diagnosed between 2004 and 2012 by biopsy (n = 15), partial (n = 4) or complete resection (n = 2). Diagnoses were glioblastoma (WHO grade IV, n = 6), anaplastic astrocytoma (WHO grade III, n = 7), diffuse astrocytoma (WHO grade II, n = 6) and pilocytic astrocytoma (WHO grade I, n = 2). Diffuse gliomas were mainly located in the pons and frequently showed MRI contrast enhancement. Endophytic growth was common (16 vs. 5). Postoperative therapy in low-grade (WHO grade I/II) and high-grade gliomas (WHO grade III/IV) consisted of radiotherapy alone (three in each group), radiochemotherapy (2 vs. 6), chemotherapy alone (0 vs. 2) or no postoperative therapy (3 vs. 1). Median PFS (24.1 vs. 5.8 months; log-rank, p = 0.009) and mOS (30.5 vs. 11.5 months; log-rank, p = 0.028) was significantly better in WHO grade II than in WHO grade III/IV tumors. Second-line therapy considerably varied. Histologically verification of adult BSGs is feasible and has an impact on postoperative treatment. Low-grade gliomas can simple be followed or treated with radiotherapy alone. Radiochemotherapy with temozolomide can safely be prescribed for high-grade gliomas without additional CNS toxicities.
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Affiliation(s)
- Thomas Hundsberger
- Department of Neurology, Cantonal Hospital St. Gallen, Rorschacherstr. 95, 9007, St. Gallen, Switzerland.
- Department of Hematology and Oncology, Cantonal Hospital St. Gallen, Rorschacherstr. 95, 9007, St. Gallen, Switzerland.
| | - Michaela Tonder
- Department of Neurology, and Brain Tumor Center, University Hospital Zurich, Zurich, Switzerland
| | - Andreas Hottinger
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Detlef Brügge
- Department of Radiation Oncology, Cantonal Hospital St Gallen, St. Gallen, Switzerland
| | - Ulrich Roelcke
- Department of Neurology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Paul Martin Putora
- Department of Radiation Oncology, Cantonal Hospital St Gallen, St. Gallen, Switzerland
| | - Roger Stupp
- Department of Oncology, and Brain Tumor Center, University Hospital Zurich, Zurich, Switzerland
| | - Michael Weller
- Department of Neurology, and Brain Tumor Center, University Hospital Zurich, Zurich, Switzerland
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Local control and toxicity outcomes in brainstem metastases treated with single fraction radiosurgery: is there a volume threshold for toxicity? J Neurooncol 2014; 117:167-74. [PMID: 24504497 DOI: 10.1007/s11060-014-1373-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 01/18/2014] [Indexed: 10/25/2022]
Abstract
Gamma Knife Radiosurgery (GKRS) has been reported in the treatment of brainstem metastases while dose volume toxicity thresholds remain mostly undefined. A retrospective review of 52 brainstem metastases in 44 patients treated with GKRS was completed. A median dose of 18 Gy (range 10-22 Gy) was prescribed to the tumor margin (median 50 % isodose). 25 patients had undergone previous whole brain radiation therapy. Toxicity was graded by the LENT-SOMA scale. Mean and median follow-up was 10 and 6 months. Only 3 of the 44 patients are living. Multiple brain metastases were treated in 75 % of patients. Median size of lesions was 0.134 cc, (range 0.013-6.600 cc). Overall survival rate at 1 year was 32 % (95 % CI 51.0-20.1 %) with a median survival time of 6 months (95 % CI 5.0-16.5). Local control rate at 6 months and 1 year was 88 % (95 % CI 70-95 %) and 74 % (95 % CI 52-87 %). Cause of death was neurologic in 17 patients, non-neurologic in 20 patients, and unknown in four. Four patients experienced treatment related toxicities. Univariate analysis of tumor volume revealed that volume greater than 1.0 cc predicted for toxicity. A strategy of using lower marginal doses with GKRS to brain stem metastases appears to lead to a lower local control rate than seen with lesions treated within the standard dose range in other locations. Tumor size greater than 1.0 cc predicted for treatment-related toxicity.
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Jung EW, Rakowski JT, Delly F, Jagannathan J, Konski AA, Guthikonda M, Kim H, Mittal S. Gamma Knife radiosurgery in the management of brainstem metastases. Clin Neurol Neurosurg 2013; 115:2023-8. [PMID: 23870233 DOI: 10.1016/j.clineuro.2013.06.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Revised: 06/15/2013] [Accepted: 06/19/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Metastases to the brainstem portend a poor prognosis and present a challenge in clinical management. Surgical resection is rarely a viable option. METHODS Post-treatment MRI scans of patients with brainstem metastases treated with radiosurgery were used to determine local control and disease progression. Median survival was calculated using Kaplan-Meier analysis. Univariate and multivariate analyses were performed using log-rank test and Cox proportional hazards model, respectively. RESULTS Thirty-two consecutive patients with brainstem metastasis underwent Gamma Knife radiosurgery. Median age was 50 years. Median tumor volume was 0.71 cm3 and median tumor margin dose was 13 Gy. Seventeen of 32 patients received WBRT prior to stereotactic radiosurgery. Median survival was 5.2 months. There was a statistically significant difference in survival based on RTOG recursive partition analysis (RPA) class. Median survival of patients categorized as RPA class I was 19.2 months, RPA class II was 8.4 months, and RPA class III was 1.9 months. The overall local tumor control rate was 87.5%. There were no acute complications following stereotactic radiosurgery and no evidence of radiation necrosis noted on post-treatment MRI scans. CONCLUSION Stereotactic radiosurgery is an effective treatment for brainstem metastases and should be considered especially for patients with good performance status.
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Affiliation(s)
- Edward W Jung
- Department of Radiation Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, USA
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48
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A review of the clinical outcomes for patients diagnosed with brainstem metastasis and treated with stereotactic radiosurgery. ISRN SURGERY 2013; 2013:652895. [PMID: 23691365 PMCID: PMC3649612 DOI: 10.1155/2013/652895] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 03/19/2013] [Indexed: 11/17/2022]
Abstract
Only 3%-5% of all brain metastases are located in the brainstem. We present a comprehensive review of the clinical outcomes from modern studies that treated patients with brainstem metastasis using either a Gamma Knife or a linear accelerator-based stereotactic radiosurgery. The median survival time of patients was compared to better understand what clinical or treatment factors are predictive of improved survival. This information can then be utilized to optimize patient care. The data suggests that higher prescribed marginal dose and the associated greater local control of brainstem lesions are associated with longer patient survival. Further research is necessary to better describe the most effective dose for individual brainstem lesions and to tailor optimum therapy to specific patient subgroups.
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49
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Treatment of brainstem metastases with gamma-knife radiosurgery. J Neurooncol 2013; 113:33-8. [PMID: 23443514 DOI: 10.1007/s11060-013-1086-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 02/17/2013] [Indexed: 12/25/2022]
Abstract
The aim was to investigate the efficacy and safety of gamma-knife stereotactic radiosurgery (SRS) for treating brainstem metastases. The cases of 44 patients who underwent SRS as treatment for 46 brainstem metastases were retrospectively evaluated. The median age was 57 years (range 42-82 years) and the median Karnofsky performance score (KPS) was 80 (range 60-90). The primary tumor was lung carcinoma in 28 cases, breast carcinoma in 7 cases, colon carcinoma in 3 cases, renal cell carcinoma in 3 cases, malignant melanoma in 1 case, and unknown origin in 2 cases. Of the 46 metastases, 30 were in the pons, 14 were in the mesencephalon, and 2 were in the medulla oblongata. The median volume of the 46 metastases was 0.6 cc (range 0.34-7.3 cc). The median marginal dose of radiation was 16 Gy (range 10-20 Gy). Twenty-three patients (52 %) received whole brain radiotherapy prior to SRS, and 6 (14 %) received this therapy after SRS. In the remaining 15 cases (34 %), SRS was applied as the only treatment. Recursive partitioning analysis, graded prognostic assessment, and basic score for brain metastases were used to predict survival time. Local control was achieved for all but two of the 46 metastases (96 %). The overall survival time after SRS was 8 months. Female gender, KPS >70, mesencephalon tumor location, and response to treatment were associated with longer survival. Basic score for brain metastases class I and recursive partitioning analysis classification were associated with better prognosis. Peri-tumoral changes were detected radiologically at 2 (4 %) of the metastatic lesion sites but neither of these patients exhibited symptoms. Gamma-knife radiosurgery is effective for treating brainstem metastases without a higher risk for radiation necrosis.
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50
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Metastatic Melanoma from Unknown Primary Presenting as Dorsal Midbrain Syndrome. Optom Vis Sci 2012; 89:e112-7. [DOI: 10.1097/opx.0b013e3182771698] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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