1601
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Valery CA, Boskos C, Boisserie G, Lamproglou I, Cornu P, Mazeron JJ, Simon JM. Minimized doses for linear accelerator radiosurgery of brainstem metastasis. Int J Radiat Oncol Biol Phys 2011; 80:362-8. [PMID: 20598449 DOI: 10.1016/j.ijrobp.2010.02.028] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2009] [Revised: 01/26/2010] [Accepted: 02/02/2010] [Indexed: 11/26/2022]
Abstract
PURPOSE Treatment of cerebral metastases located inside the brainstem remains a challenge, as the brainstem is considered to be a neurological organ at risk, whatever the treatment strategy. We report a retrospective study of 30 consecutive patients treated in our institution between 2005 and 2007 with micromultileaf linear accelerator (LINAC)-radiosurgery for brainstem metastases, with reduced doses compared to those usually reported in the literature. METHODS AND MATERIALS Mean follow-up was 311 days (range, 41-1351). Median age was 57 years (range, 37-82), Mean Karnofsky Index (KI) was 80. Primary tumor site was lung (n = 13), breast (n = 4), kidney (n = 4), skin (melanoma; n = 3), and others (n = 6). Primary tumor was controlled in 17 cases; extracranial metastases were controlled in 12 cases. Mean number of metastases was 1.46 (one to three); median volume was 2.82 cc (0.06-18). Dose was delivered by a micromultileaf collimator 6-MV LINAC . RESULTS Dose administered at the 70% isodose was 13.4 Gy (range, 8.2-15). Median survival was 10 months. Local control rates at 3, 6, and 12 months were 100%, 100%, and 79% respectively. Median neurological control duration was 5 months. Neurological control rates at 3, 6, and 12 months were 73%, 42%, and 25%, respectively. No parameter was found to significantly correlate with survival, local, or cerebral control. No patients had severe side effects (Grade III-IV), according to the Radiation Therapy Oncology Group (RTOG) scale. CONCLUSION Lower doses than previously reported can achieve the same local control and survival rates in brain metastases, with minimal side effects.
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Affiliation(s)
- Charles A Valery
- Department of Neurosurgery, Assistance Publique des Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris, France.
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1602
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Rush S, Elliott RE, Morsi A, Mehta N, Spriet J, Narayana A, Donahue B, Parker EC, Golfinos JG. Incidence, timing, and treatment of new brain metastases after Gamma Knife surgery for limited brain disease: the case for reducing the use of whole-brain radiation therapy. J Neurosurg 2011; 115:37-48. [DOI: 10.3171/2011.2.jns101724] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
In this paper, the authors' goal was to analyze the incidence, timing, and treatment of new metastases following initial treatment with 20-Gy Gamma Knife surgery (GKS) alone in patients with limited brain metastases without whole-brain radiation therapy (WBRT).
Methods
A retrospective analysis of 114 consecutive adults (75 women and 34 men; median age 61 years) with KPS scores of 60 or higher who received GKS for 1–3 brain metastases ≤ 2 cm was performed (median lesion volume 0.35 cm3). Five patients lacking follow-up data were excluded from analysis. After treatment, patients underwent MR imaging at 6 weeks and every 3 months thereafter. New metastases were preferentially treated with additional GKS. Indications for WBRT included development of numerous metastases, leptomeningeal disease, or diffuse surgical-site recurrence.
Results
The median overall survival from GKS was 13.8 months. Excluding the 3 patients who died before follow-up imaging, 12 patients (11.3%) experienced local failure at a median of 7.4 months. Fifty-three patients (50%) developed new metastases at a median of 5 months. Six (7%) of 86 instances of new lesions were symptomatic. Most patients (67%) with distant failures were successfully treated using salvage GKS alone. Whole-brain radiotherapy was indicated in 20 patients (18.3%). Thirteen patients (11.9%) died of neurological disease.
Conclusions
For patients with limited brain metastases and functional independence, 20-Gy GKS provides excellent disease control and high-functioning survival with minimal morbidity. New metastases developed in almost 50% of patients, but additional GKS was extremely effective in controlling disease. Using our algorithm, fewer than 20% of patients required WBRT, and only 12% died of progressive intracranial disease.
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Affiliation(s)
- Stephen Rush
- 1Departments of Radiation Oncology and
- 2Neurosurgery, New York University Langone Medical Center, New York; and
| | - Robert E. Elliott
- 2Neurosurgery, New York University Langone Medical Center, New York; and
| | - Amr Morsi
- 2Neurosurgery, New York University Langone Medical Center, New York; and
| | - Nisha Mehta
- 2Neurosurgery, New York University Langone Medical Center, New York; and
| | - Jeri Spriet
- 2Neurosurgery, New York University Langone Medical Center, New York; and
| | | | - Bernadine Donahue
- 3Department of Radiation Oncology, Maimonides Medical Center, Brooklyn, New York
| | - Erik C. Parker
- 2Neurosurgery, New York University Langone Medical Center, New York; and
| | - John G. Golfinos
- 2Neurosurgery, New York University Langone Medical Center, New York; and
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1603
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Abstract
The results of a randomized, controlled trial investigating the neurocognitive effects of stereotactic radiosurgery (SRS), with or without whole-brain radiation therapy (WBRT), to treat brain metastases demonstrated a significant reduction in learning and memory, associated with the addition of WBRT to SRS. the results indicate that SRS monotherapy is an effective and safe initial management strategy for brain metastases.
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1604
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Jensen CA, Chan MD, McCoy TP, Bourland JD, deGuzman AF, Ellis TL, Ekstrand KE, McMullen KP, Munley MT, Shaw EG, Urbanic JJ, Tatter SB. Cavity-directed radiosurgery as adjuvant therapy after resection of a brain metastasis. J Neurosurg 2011; 114:1585-91. [PMID: 21166567 PMCID: PMC3789371 DOI: 10.3171/2010.11.jns10939] [Citation(s) in RCA: 124] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT As a strategy to delay or avoid whole-brain radiotherapy (WBRT) after resection of a brain metastasis, the authors used high-resolution MR imaging and cavity-directed radiosurgery for the detection and treatment of further metastases. METHODS Between April 2001 and October 2009, 112 resection cavities in 106 patients with no prior WBRT were treated using radiosurgery directed to the tumor cavity and for any synchronous brain metastases detected on high-resolution MR imaging at the time of radiosurgical planning. A median dose of 17 Gy to the 50% isodose line was prescribed to the gross tumor volume, defined as the rim of enhancement around the resection cavity. Patients were followed up via serial imaging, and new brain metastases were generally treated using additional radiosurgery, with salvage WBRT typically reserved for local treatment failure at a resection cavity, numerous failures, or failures occurring at short time intervals. Local and distant treatment failures were determined based on imaging results. Kaplan-Meier curves were generated to estimate local and distant treatment failure rates, overall survival, neurological cause-specific survival, and time delay to salvage WBRT. RESULTS Radiosurgery was delivered to the resection cavity alone in 57.5% of patients, whereas 24.5% of patients also received treatment for 1 synchronous metastasis, 11.3% also received treatment for 2 synchronous metastases, and 6.6% also received treatment for 3-10 additional lesions. The median overall survival was 10.9 months. Overall survival at 1 year was 46.8%. The local tumor control rate at 1 year was 80.3%. The disease control rate in distant regions of the brain at 1 year was 35.4%, with a median time of 6.9 months to distant failure. Thirty-nine of 106 patients eventually received salvage WBRT, and the median time to salvage WBRT was 12.6 months. Kaplan-Meier estimates showed that the rate of requisite WBRT at 1 year was 45.9%. Neurological cause-specific survival at 1 year was 50.1%. Leptomeningeal failure occurred in 8 patients. One patient had treatment failure within the resection tract. Seven patients required reoperation: 2 for resection cavity recurrence, 3 for radiation necrosis, 1 for hydrocephalus, and 1 for a CSF cutaneous fistula. On multivariate analysis, a preoperative tumor diameter > 3 cm was predictive of local treatment failure. CONCLUSIONS Cavity-directed radiosurgery combined with high-resolution MR imaging detection and radiosurgical treatment of synchronous brain metastases is an effective strategy for delaying and even foregoing WBRT in most patients. This technique provides acceptable local disease control, although distant treatment failure remains significant.
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Affiliation(s)
- Courtney A. Jensen
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, North Carolina
| | - Michael D. Chan
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, North Carolina
| | - Thomas P. McCoy
- Department of Public Health Sciences, Wake Forest University, Winston-Salem, North Carolina
| | - J. Daniel Bourland
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, North Carolina
| | - Allan F. deGuzman
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, North Carolina
| | - Thomas L. Ellis
- Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina
| | - Kenneth E. Ekstrand
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, North Carolina
| | - Kevin P. McMullen
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, North Carolina
| | - Michael T. Munley
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, North Carolina
| | - Edward G. Shaw
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, North Carolina
| | - James J. Urbanic
- Department of Radiation Oncology, Wake Forest University, Winston-Salem, North Carolina
| | - Stephen B. Tatter
- Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina
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1605
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Chapman CH, Nagesh V, Sundgren PC, Buchtel H, Chenevert TL, Junck L, Lawrence TS, Tsien CI, Cao Y. Diffusion tensor imaging of normal-appearing white matter as biomarker for radiation-induced late delayed cognitive decline. Int J Radiat Oncol Biol Phys 2011; 82:2033-40. [PMID: 21570218 DOI: 10.1016/j.ijrobp.2011.01.068] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 01/07/2011] [Accepted: 01/31/2011] [Indexed: 11/12/2022]
Abstract
PURPOSE To determine whether early assessment of cerebral white matter degradation can predict late delayed cognitive decline after radiotherapy (RT). METHODS AND MATERIALS Ten patients undergoing conformal fractionated brain RT participated in a prospective diffusion tensor magnetic resonance imaging study. Magnetic resonance imaging studies were acquired before RT, at 3 and 6 weeks during RT, and 10, 30, and 78 weeks after starting RT. The diffusivity variables in the parahippocampal cingulum bundle and temporal lobe white matter were computed. A quality-of-life survey and neurocognitive function tests were administered before and after RT at the magnetic resonance imaging follow-up visits. RESULTS In both structures, longitudinal diffusivity (λ(‖)) decreased and perpendicular diffusivity (λ(⊥)) increased after RT, with early changes correlating to later changes (p < .05). The radiation dose correlated with an increase in cingulum λ(⊥) at 3 weeks, and patients with >50% of cingula volume receiving >12 Gy had a greater increase in λ(⊥) at 3 and 6 weeks (p < .05). The post-RT changes in verbal recall scores correlated linearly with the late changes in cingulum λ(‖) (30 weeks, p < .02). Using receiver operating characteristic curves, early cingulum λ(‖) changes predicted for post-RT changes in verbal recall scores (3 and 6 weeks, p < .05). The neurocognitive test scores correlated significantly with the quality-of-life survey results. CONCLUSIONS The correlation between early diffusivity changes in the parahippocampal cingulum and the late decline in verbal recall suggests that diffusion tensor imaging might be useful as a biomarker for predicting late delayed cognitive decline.
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Affiliation(s)
- Christopher H Chapman
- Department of Radiation Oncology, University of Michigan Medical School, Ann Arbor, MI, USA.
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1606
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Abstract
In the past therapy of advanced melanoma with distant metastases was characterized by limited success. In recent years the increased understanding of the pathogenesis of melanoma as well as tumor immunology, however, has allowed the development of new promising therapeutic options for certain subgroups of melanoma patients. In the present review these molecular-targeted and immune-modulating therapies, as well as already established therapies such as radiation or chemotherapy, will be discussed.
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1607
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Skeie BS, Skeie GO, Enger PØ, Ganz JC, Heggdal JI, Ystevik B, Hatteland S, Parr E, Pedersen PH. Gamma Knife Surgery in Brain Melanomas: Absence of Extracranial Metastases and Tumor Volume Strongest Indicators of Prolonged Survival. World Neurosurg 2011; 75:684-91; discussion 598-603. [DOI: 10.1016/j.wneu.2010.12.054] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 12/03/2010] [Accepted: 12/17/2010] [Indexed: 10/18/2022]
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1608
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Sheehan J, Xu Z. Stereotactic Radiosurgery for Brain Metastasis from Melanoma. World Neurosurg 2011. [DOI: 10.1016/j.wneu.2011.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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1609
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Chen JC. Radiosurgery for Melanoma Metastases to Brain. World Neurosurg 2011. [DOI: 10.1016/j.wneu.2011.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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1610
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Pollock BE. Is Radiosurgery Alone a Good Bet for Patients with Metastatic Brain Disease. World Neurosurg 2011. [DOI: 10.1016/j.wneu.2011.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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1611
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Abstract
The incidence of metastasis to the brain is apparently rising in cancer patients and threatens to limit the gains that have been made by new systemic treatments. The brain is considered a 'sanctuary site' as the blood-tumour barrier limits the ability of drugs to enter and kill tumour cells. Translational research examining metastasis to the brain needs to be multi-disciplinary, marrying advanced chemistry, blood-brain barrier pharmacokinetics, neurocognitive testing and radiation biology with metastasis biology, to develop and implement new clinical trial designs. Advances in the chemoprevention of brain metastases, the validation of tumour radiation sensitizers and the amelioration of cognitive deficits caused by whole-brain radiation therapy are discussed.
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1612
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McHaffie DR, Chabot P, Dagnault A, Suh JH, Fortin MA, Chang E, Timmerman R, Souhami L, Grecula J, Nabid A, Schultz C, Werner-Wasik M, Gaspar LE, Brachman D, Mody T, Mehta MP. Safety and feasibility of motexafin gadolinium administration with whole brain radiation therapy and stereotactic radiosurgery boost in the treatment of ≤ 6 brain metastases: a multi-institutional phase II trial. J Neurooncol 2011; 105:301-8. [PMID: 21523486 DOI: 10.1007/s11060-011-0590-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 04/18/2011] [Indexed: 01/03/2023]
Abstract
To determine the safety, tolerability, and report on secondary efficacy endpoints of motexafin gadolinium (MGd) in combination with whole-brain radiotherapy (WBRT) and stereotactic radiosurgery (SRS) for patients with ≤ 6 brain metastases. We conducted an international study of WBRT (37.5 Gy in 15 fractions) and SRS (15-21 Gy) with the addition of MGd (5 mg/kg preceding each fraction beginning week 2). The primary endpoint was to evaluate the rate of irreversible grade 3 or any grade ≥ 4 neurotoxicity and establish feasibility in preparation for a phase III trial. Sixty-five patients were enrolled from 14 institutions, of which 45 (69%) received SRS with MGd as intended and were available for evaluation. Grade ≥ 3 neurotoxicity attributable to radiation therapy within 3 months of SRS was seen in 2 patients (4.4%), including generalized weakness and radionecrosis requiring surgical management. Immediately following the course of MGd plus WBRT, new brain metastases were detected in 11 patients (24.4%) at the time of the SRS treatment planning MRI. The actuarial incidence of neurologic progression at 6 months and 1 year was 17 and 20%, respectively. The median investigator-determined neurologic progression free survival and overall survival times were 8 (95% CI: 5-14) and 9 months (95% CI: 6-not reached), respectively. We observed a low rate of neurotoxicity, demonstrating that the addition of MGd does not increase the incidence or severity of neurologic complications from WBRT with SRS boost.
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Affiliation(s)
- Derek R McHaffie
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, K4/B100, Madison, WI 53792, USA.
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1613
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Fogarty G, Morton RL, Vardy J, Nowak AK, Mandel C, Forder PM, Hong A, Hruby G, Burmeister B, Shivalingam B, Dhillon H, Thompson JF. Whole brain radiotherapy after local treatment of brain metastases in melanoma patients--a randomised phase III trial. BMC Cancer 2011; 11:142. [PMID: 21496312 PMCID: PMC3107806 DOI: 10.1186/1471-2407-11-142] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Accepted: 04/17/2011] [Indexed: 11/12/2022] Open
Abstract
Background Cerebral metastases are a common cause of death in patients with melanoma. Systemic drug treatment of these metastases is rarely effective, and where possible surgical resection and/or stereotactic radiosurgery (SRS) are the preferred treatment options. Treatment with adjuvant whole brain radiotherapy (WBRT) following neurosurgery and/or SRS is controversial. Proponents of WBRT report prolongation of intracranial control with reduced neurological events and better palliation. Opponents state melanoma is radioresistant; that WBRT yields no survival benefit and may impair neurocognitive function. These opinions are based largely on studies in other tumour types in which assessment of neurocognitive function has been incomplete. Methods/Design This trial is an international, prospective multi-centre, open-label, phase III randomised controlled trial comparing WBRT to observation following local treatment of intracranial melanoma metastases with surgery and/or SRS. Patients aged 18 years or older with 1-3 brain metastases excised and/or stereotactically irradiated and an ECOG status of 0-2 are eligible. Patients with leptomeningeal disease, or who have had previous WBRT or localised treatment for brain metastases are ineligible. WBRT prescription is at least 30 Gy in 10 fractions commenced within 8 weeks of surgery and/or SRS. Randomisation is stratified by the number of cerebral metastases, presence or absence of extracranial disease, treatment centre, sex, radiotherapy dose and patient age. The primary endpoint is the proportion of patients with distant intracranial failure as determined by MRI assessment at 12 months. Secondary end points include: survival, quality of life, performance status and neurocognitive function. Discussion Accrual to previous trials for patients with brain metastases has been difficult, mainly due to referral bias for or against WBRT. This trial should provide the evidence that is currently lacking in treatment decision-making for patients with melanoma brain metastases. The trial is conducted by the Australia and New Zealand Melanoma Trials Group (ANZMTG-study 01-07), and the Trans Tasman Radiation Oncology Group (TROG) but international participation is encouraged. Twelve sites are open to date with 43 patients randomised as of the 31st March 2011. The target accrual is 200 patients. Trial registration Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12607000512426
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Affiliation(s)
- Gerald Fogarty
- St Vincent's and Mater Hospitals, Radiation Oncology, University of New South Wales, Randwick, Australia.
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1614
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Kirova YM, Chargari C, Mazeron JJ. Métastases cérébrales multiples d’un cancer du sein et leur prise en charge en radiothérapie : quelle est l’attitude thérapeutique la mieux adaptée ? Bull Cancer 2011; 98:409-415. [DOI: 10.1684/bdc.2011.1335] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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1615
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Sheehan J, Benedict S, Schlesinger D. Brain dose with stereotactic radiosurgery. J Neurosurg 2011; 114:1578-9; discussion 1579. [PMID: 21375375 DOI: 10.3171/2010.12.jns102024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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1616
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Kondziolka D, Kano H, Harrison GL, Yang HC, Liew DN, Niranjan A, Brufsky AM, Flickinger JC, Lunsford LD. Stereotactic radiosurgery as primary and salvage treatment for brain metastases from breast cancer. J Neurosurg 2011; 114:792-800. [DOI: 10.3171/2010.8.jns10461] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
To evaluate the role of stereotactic radiosurgery (SRS) in the management of brain metastases from breast cancer, the authors assessed clinical outcomes and prognostic factors for survival.
Methods
The records from 350 consecutive female patients who underwent SRS for 1535 brain metastases from breast cancer were reviewed. The median patient age was 54 years (range 19–84 years), and the median number of tumors per patient was 2 (range 1–18 lesions). One hundred seventeen patients (33%) had a single metastasis to the brain, and 233 patients (67%) had multiple brain metastases. The median tumor volume was 0.7 cm3 (range 0.01–48.9 cm3), and the median total tumor volume for each patient was 4.9 cm3 (range 0.09–74.1 cm3).
Results
Overall survival after SRS was 69%, 49%, and 26% at 6, 12, and 24 months, respectively, with a median survival of 11.2 months. Factors associated with a longer survival included controlled extracranial disease, a lower recursive partitioning analysis (RPA) class, a higher Karnofsky Performance Scale score, a smaller number of brain metastases, a smaller total tumor volume per patient, the presence of deep cerebral or brainstem metastases, and HER2/neu overexpression. Sustained local tumor control was achieved in 90% of the patients. Factors associated with longer progression-free survival included a better RPA class, fewer brain metastases, a smaller total tumor volume per patient, and a higher tumor margin dose. Symptomatic adverse radiation effects occurred in 6% of patients. Overall, the condition of 82% of patients improved or remained neurologically stable.
Conclusions
Stereotactic radiosurgery was safe and effective in patients with brain metastases from breast cancer and should be considered for initial treatment.
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Affiliation(s)
- Douglas Kondziolka
- 1Departments of Neurological Surgery,
- 2Radiation Oncology, and
- 4Center for Image-Guided Neurosurgery
- 5University of Pittsburgh Cancer Institute
| | - Hideyuki Kano
- 1Departments of Neurological Surgery,
- 4Center for Image-Guided Neurosurgery
| | | | - Huai-che Yang
- 1Departments of Neurological Surgery,
- 4Center for Image-Guided Neurosurgery
- 7Department of Neurological Surgery, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Donald N. Liew
- 1Departments of Neurological Surgery,
- 4Center for Image-Guided Neurosurgery
| | - Ajay Niranjan
- 1Departments of Neurological Surgery,
- 4Center for Image-Guided Neurosurgery
| | - Adam M. Brufsky
- 3Hematology/Oncology
- 5University of Pittsburgh Cancer Institute
| | - John C. Flickinger
- 2Radiation Oncology, and
- 4Center for Image-Guided Neurosurgery
- 6University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - L. Dade Lunsford
- 1Departments of Neurological Surgery,
- 2Radiation Oncology, and
- 4Center for Image-Guided Neurosurgery
- 5University of Pittsburgh Cancer Institute
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1617
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Kienast Y, Winkler F. Therapy and prophylaxis of brain metastases. Expert Rev Anticancer Ther 2011; 10:1763-77. [PMID: 21080803 DOI: 10.1586/era.10.165] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Metastases of various tumors to the brain account for the majority of brain cancers, and are associated with a poor prognosis. The most common primary sites are lung, breast, skin, kidney and colon; 10-40% of cancer patients develop brain metastases during the course of the disease. The incidence of brain metastasis appears to be rising; reasons may include better therapies for the systemic disease with longer survival of cancer patients but lower efficiency against brain metastases. In this article, we will discuss the conventional treatment with surgery, radiosurgery, radiotherapy and chemotherapy, but also new directions in the management of solid brain metastases. While general therapeutic nihilism should be avoided, it is important to recognize that the number of brain metastases, the extent of the systemic disease and also the tumor type have to be taken into account when choosing individual treatment regimens. Finally, special emphasis will be put on established and future approaches to prevent the disease. We thus aim to provide a framework for treating patients with different presentations of brain metastases, and to highlight important avenues for research.
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Affiliation(s)
- Yvonne Kienast
- Roche Diagnostics GmbH, Pharma Research Penzberg, Nonnenwald 2, 82377 Penzberg, Germany
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1618
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1619
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Sheehan JP, Yen CP, Nguyen J, Rainey JA, Dassoulas K, Schlesinger DJ. Timing and risk factors for new brain metastasis formation in patients initially treated only with Gamma Knife surgery. J Neurosurg 2011; 114:763-8. [DOI: 10.3171/2010.2.jns091539] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Stereotactic radiosurgery has been shown to afford a reasonable chance of local tumor control. However, new brain metastasis can arise following successful local tumor control from radiosurgery. This study evaluates the timing, number, and risk factors for development of subsequent new brain metastasis in a group of patients treated with stereotactic radiosurgery alone.
Methods
One hundred seventeen patients with histologically confirmed metastatic cancer underwent Gamma Knife surgery (GKS) to treat all brain metastases demonstrable on MR imaging. Patients were followed clinically and radiologically at approximately 3-month intervals for a median of 14.4 months (range 0.37–51.8 months). Follow-up MR images were evaluated for evidence of new brain metastasis formation. Statistical analyses were performed to determine the timing, number, and risk factors for development of new brain metastases.
Results
The median time to development of a new brain metastasis was 8.8 months. Patients with 3 or more metastases at the time of initial radiosurgery or those with cancer histologies other than non–small cell lung carcinoma were found to be at increased risk for early formation of new brain metastasis (p < 0.05). The mean number of new metastases per patient was 1.6 (range 0–11). Those with a higher Karnofsky Performance Scale score at the time of initial GKS were significantly more likely to develop a greater number of brain metastases by the last follow-up evaluation.
Conclusions
The timing and number of new brain metastases developing in patients treated with GKS alone is not inconsequential. Those with 3 or more metastases at the time of radiosurgery and those with cancer histology other than non–small cell lung carcinoma were at greater risk of early formation of new brain metastasis. Frequent follow-up evaluations, such as at 3-month intervals, appears appropriate in this patient population, particularly in high-risk patients. When detected early, salvage treatments including repeat radiosurgery can be used to treat new brain metastasis.
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1620
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Jenkinson MD, Haylock B, Shenoy A, Husband D, Javadpour M. Management of cerebral metastasis: Evidence-based approach for surgery, stereotactic radiosurgery and radiotherapy. Eur J Cancer 2011; 47:649-55. [DOI: 10.1016/j.ejca.2010.11.033] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Accepted: 11/30/2010] [Indexed: 10/18/2022]
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1621
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Roos D. What is the randomised evidence for surgery and stereotactic radiosurgery for patients with solitary (or few) brain metastases? INT J EVID-BASED HEA 2011; 9:61-6. [DOI: 10.1111/j.1744-1609.2010.00201.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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1622
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Wiggenraad R, Kanter AVD, Kal HB, Taphoorn M, Vissers T, Struikmans H. Dose–effect relation in stereotactic radiotherapy for brain metastases. A systematic review. Radiother Oncol 2011; 98:292-7. [PMID: 21316787 DOI: 10.1016/j.radonc.2011.01.011] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Revised: 01/16/2011] [Accepted: 01/16/2011] [Indexed: 11/25/2022]
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1623
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Roberge D, Souhami L. Tumor bed radiosurgery following resection of brain metastases: a review. Technol Cancer Res Treat 2011; 9:597-602. [PMID: 21070082 DOI: 10.1177/153303461000900608] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
There is a growing interest in adjuvant radiosurgery following resection of hematogenous brain metastases. We have identified 12 series reporting on a total of 480 patients treated to a tumor bed following microsurgery. These cases fall into 3 paradigms: adjuvant radiosurgery as an alternative to whole-brain radiotherapy (WBRT), radiosurgery as an intensification of adjuvant WBRT and adjuvant radiosurgery for patients having failed prior WBRT. For these paradigms the reported crude local control rates are 79%, 92% and 95%, respectively. The procedure appears well tolerate with approximately a 5% risk of late radiation necrosis. Prospective data is lagging behind clinical practice and plans for prospective trials are discussed.
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Affiliation(s)
- David Roberge
- Department of Oncology, Division of Radiation Oncology, McGill University, 1650 Cedar Avenue, Montreal, QC H3G 1A4, Canada.
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1624
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Barlesi F, Gervais R, Lena H, Hureaux J, Berard H, Paillotin D, Bota S, Monnet I, Chajara A, Robinet G. Pemetrexed and cisplatin as first-line chemotherapy for advanced non-small-cell lung cancer (NSCLC) with asymptomatic inoperable brain metastases: a multicenter phase II trial (GFPC 07-01). Ann Oncol 2011; 22:2466-2470. [PMID: 21321089 DOI: 10.1093/annonc/mdr003] [Citation(s) in RCA: 165] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Brain metastases (BM) occur in up to 40% of non-small-cell lung cancer (NSCLC) patients. This trial assessed the safety and efficacy of pemetrexed-cisplatin in this population. PATIENTS AND METHODS Chemonaive NSCLC patients with BM ineligible for (radio)surgery, performance status (PS) of 0 to 2, were eligible for up to six cycles of cisplatin 75 mg/m(2) and pemetrexed 500 mg/m(2) every 3 weeks. Whole -brain radiotherapy was given in case of disease progression or at chemotherapy completion. Primary end point was objective response rate (RR) on BM. Secondary end points included extracerebral and overall RR, safety profile and survival. RESULTS Forty-three patients were enrolled. Initial characteristics were mean age 60.4 years; males 29; PS: 0 in 37.2%, 1 in 60.5% and 2 in 22.3% of patients; adenocarcinoma in 36 patients, large cell in 4 patients (nonsquamous, 93%) and squamous carcinoma in 3 patients. Functional classification of neurological status was stage I/II 86.0%, III 2.3% and IV 11.6%. Grade 3-4 hematological toxic effects were neutropenia, 11 patients (febrile neutropenia, 1 patient), and anemia, 6 patients. Non-hematological toxic effects were grade 2 urinary infection, one patient; grade 3 pneumonia, two patients; and grade 3 hypoacousia, one patient. Cerebral, extracerebral and overall RR by intent to treat analysis were 41.9%, 34.9% and 34.9%, respectively. Median survival time and time to progression were 7.4 and 4.0 months, respectively. CONCLUSION Pemetrexed-cisplatin is an effective and well-tolerated regimen as first-line therapy for NSCLC patients with BM who always suffer a poor prognosis.
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Affiliation(s)
- F Barlesi
- Multidisciplinary Oncology and Therapeutic Innovations Department & Centre Investigation Clinique, University of Méditerranée-Assistance Publique Hôpitaux de Marseille, Marseille.
| | - R Gervais
- Department of Oncology, François Baclesse Center, Caen
| | - H Lena
- Department of Pneumology, Rennes University Hospital, Rennes
| | - J Hureaux
- Department of Pneumology, Thorax and Vessel Center Academic Hospital, Angers
| | - H Berard
- Department of Pneumology, Hopital d'Instruction des Armées Sainte-Anne, Toulon
| | - D Paillotin
- Department of Pulmonary and Respiratory Intensive Care, Rouen University Hospital
| | - S Bota
- Department of Pneumology, Rouen University Hospital, Charles Nicolle Hospital, Rouen
| | - I Monnet
- Department of Pneumology, Créteil Intercommunal Hospital Center, Créteil
| | - A Chajara
- Department of Pneumology, Institute of Cancerology and Hematology, Centre Hospitalier Regional Universitaire, Morvan, Brest, France
| | - G Robinet
- Department of Pneumology, Institute of Cancerology and Hematology, Centre Hospitalier Regional Universitaire, Morvan, Brest, France
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1625
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Abstract
Palliative radiotherapy has been prescribed since shortly after the discovery of the x-ray in the late 1800s, and it provides symptom relief that is successful, time-efficient, and cost-effective. Although palliative radiotherapy is worthwhile in a wide variety of clinical circumstances, there are situations where it is less worthwhile. We contrast the effective use of palliative radiotherapy with its ineffective use because of issues related to the patient, treatment, or health care system.
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1626
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Craighead PS, Chan A. Defining treatment for brain metastases patients: nihilism versus optimism. Support Care Cancer 2011; 20:279-85. [PMID: 21212987 DOI: 10.1007/s00520-010-1068-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Accepted: 12/13/2010] [Indexed: 10/18/2022]
Abstract
AIMS Treatment of brain metastases patients has included whole brain radiotherapy (WBRT) for over 50 years, and there is much data showing this to be associated with short-term gains. The integration of resection and radiosurgery to these patients allows some better prognostic groups to experience long-term local control and improvement in quality of life. The recursive partitioning analysis of the Radiation Therapy Oncology Group (RTOG) has been used as a predictive model for over a decade to identify three classes of patients. Number of lesions has been used to define treatment for a good prognostic subgroup that is eligible for surgery or radiosurgery, but there are few prospective studies of poorer prognosis brain metastases patients to evaluate the influence of number of lesions on the prediction of outcome. We examined patient, treatment and outcome parameters of all brain metastases patients in a 5-year period so that we could measure outcome and evaluate various factors on survival. METHODS AND RESULTS This was a population-based study of all brain metastases patients in Southern Alberta between 2000 and 2005. It used an Excel spreadsheet database and STATA 8 software to analyze outcomes. The study included 568 patients representing 4.4% of our radiotherapy population. Median age, performance status and distribution of primary disease sites were comparable with other large series. Overall survival for the whole group was 3.05 months. Independent factors predicting for improved overall survival included younger age, KPS <70, less than four lesions and the use of stereotactic radiosurgery. Presence of extracranial disease or persistence of primary disease did not adversely impact survival outcome. CONCLUSIONS This series shows that the number of lesions is a strong predictor of outcome. Integration of this factor into a decision-making model allows for identification of not only good prognosis patients who will benefit from aggressive treatment but it also facilitates decision making for poorer prognosis patients who are less likely to benefit from WBRT. Recursive partitioning RTOG class 2 and 3 patients with more than three lesions did particularly poor and had an overall survival of 3 months with WBRT. We question the value of WBRT in this subgroup and wonder if best supportive care would be more justifiable given the low survival figures achieved.
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Affiliation(s)
- Peter S Craighead
- Department of Oncology, University of Calgary and Alberta Radiosurgery Centre, Calgary, AB, Canada.
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1627
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1628
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Mariya Y, Sekizawa G, Matsuoka Y, Seki H, Sugawara T, Sasaki Y. Repeat Stereotactic Radiosurgery in the Management of Brain Metastases from Non-Small Cell Lung Cancer. TOHOKU J EXP MED 2011; 223:125-31. [PMID: 21301184 DOI: 10.1620/tjem.223.125] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yasushi Mariya
- Department of Radiation Oncology, Iwate Prefectural Central Hospital
| | | | | | - Hirobumi Seki
- Department of Neurosurgery, Iwate Prefectural Central Hospital
| | | | - Yuka Sasaki
- Department of Psychiatry, Iwate Prefectural Central Hospital
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1629
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Witgert ME, Meyers CA. Neurocognitive and Quality of Life Measures in Patients with Metastatic Brain Disease. Neurosurg Clin N Am 2011; 22:79-85, vii. [DOI: 10.1016/j.nec.2010.08.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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1630
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1631
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Higginson DS, Morris DE, Jones EL, Clarke-Pearson D, Varia MA. Stereotactic body radiotherapy (SBRT): Technological innovation and application in gynecologic oncology. Gynecol Oncol 2010; 120:404-12. [PMID: 21194733 DOI: 10.1016/j.ygyno.2010.11.042] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 11/28/2010] [Accepted: 11/30/2010] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Stereotactic body radiotherapy (SBRT) is a novel form of noninvasive, highly conformal radiation treatment that delivers a high dose to tumor. The advantage of the technique resides in its ability to provide a high dose to tumor but spare normal tissues to an extent not previously possible. In this paper we will provide an introduction and review of this technology with regard to its use in gynecologic malignancies. Preliminary results from our experience are presented for the purpose of illustrating the range of SBRT applications in gynecologic oncology. METHODS A comprehensive literature review was conducted and our experience from the past three years was reviewed. RESULTS Six case series are published that report results of SBRT for gynecologic malignancies. Sixteen gynecologic patients have been treated with SBRT at our institution. Treatment sites include pelvic and periaortic nodes (9 patients), oligometastatic disease (2), and cervical or endometrial primary tumors when other conventional external radiation or brachytherapy techniques were unsuitable (5). Preliminary follow-up at a median of 11 months (range, 0.3-33 months) demonstrates 79% locoregional control, 43% distant failure, and 50% overall survival. CONCLUSIONS SBRT boosts to macroscopic periaortic node recurrences and other sites seem to provide local control and a possibility of long-term disease-free survival in carefully selected patients. Previously this had been difficult to achieve with conventional radiotherapy because of the proximity of periaortic nodes to small bowel. SBRT also offers a novel approach for minimally invasive treatment in the management of gynecological cancer where current surgical and radiotherapy techniques are unsuitable.
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Affiliation(s)
- Daniel S Higginson
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC 27514, USA.
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1632
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Abstract
Neurological complications of systemic cancer-those arising outside the nervous system-can be distressing, disabling, and sometimes fatal. Diagnosis is often difficult because different neurological disorders may present with similar signs and symptoms. Furthermore, comorbid neurological illnesses, common in elderly patients with cancer, can complicate diagnosis. Early diagnosis and aggressive treatment can improve neurological symptoms and can substantially enhance a patient's quality of life. We approach the problem of neurological complications of systemic cancer as would a neurologist: first by identifying the anatomical area or areas that are affected (ie, brain, spinal cord, peripheral nerve), then by evaluating the diagnostic approach, considering the symptoms and signs and including appropriate laboratory tests, and finally, by recommending treatment. We focus on disorders that are difficult to diagnose, need neurological consultation, and for which effective treatments exist.
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Affiliation(s)
- Mustafa Khasraw
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, USA.
| | - Jerome B Posner
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, USA
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1633
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Chi A, Komaki R. Treatment of brain metastasis from lung cancer. Cancers (Basel) 2010; 2:2100-37. [PMID: 24281220 PMCID: PMC3840463 DOI: 10.3390/cancers2042100] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2010] [Revised: 11/11/2010] [Accepted: 12/02/2010] [Indexed: 12/25/2022] Open
Abstract
Brain metastases are not only the most common intracranial neoplasm in adults but also very prevalent in patients with lung cancer. Patients have been grouped into different classes based on the presence of prognostic factors such as control of the primary tumor, functional performance status, age, and number of brain metastases. Patients with good prognosis may benefit from more aggressive treatment because of the potential for prolonged survival for some of them. In this review, we will comprehensively discuss the therapeutic options for treating brain metastases, which arise mostly from a lung cancer primary. In particular, we will focus on the patient selection for combined modality treatment of brain metastases, such as surgical resection or stereotactic radiosurgery (SRS) combined with whole brain irradiation; the use of radiosensitizers; and the neurocognitive deficits after whole brain irradiation with or without SRS. The benefit of prophylactic cranial irradiation (PCI) and its potentially associated neuro-toxicity for both small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) are also discussed, along with the combined treatment of intrathoracic primary disease and solitary brain metastasis. The roles of SRS to the surgical bed, fractionated stereotactic radiotherapy, WBRT with an integrated boost to the gross brain metastases, as well as combining WBRT with epidermal growth factor receptor (EGFR) inhibitors, are explored as well.
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Affiliation(s)
- Alexander Chi
- Department of Radiation Oncology, University of Arizona, 1501 N Campbell Ave., Tucson, AZ 85724, USA; E-Mail:
| | - Ritsuko Komaki
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
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1634
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Sun A, Bae K, Gore EM, Movsas B, Wong SJ, Meyers CA, Bonner JA, Schild SE, Gaspar LE, Bogart JA, Werner-Wasik M, Choy H. Phase III trial of prophylactic cranial irradiation compared with observation in patients with locally advanced non-small-cell lung cancer: neurocognitive and quality-of-life analysis. J Clin Oncol 2010; 29:279-86. [PMID: 21135267 DOI: 10.1200/jco.2010.29.6053] [Citation(s) in RCA: 265] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE There are scant data regarding the effects of prophylactic cranial irradiation (PCI) on neurocognitive function (NCF) and quality of life (QOL). Radiation Therapy Oncology Group trial 0214 showed no overall survival (OS) benefit for PCI in stage III non-small-cell lung cancer (NSCLC) at 1 year. However, there was a significant decrease in brain metastases (BM). This analysis focuses on the impact of PCI on NCF and QOL. PATIENTS AND METHODS Patients with stage III NSCLC who completed definitive therapy without progression were randomly assigned to PCI or observation. NCF was assessed with Mini-Mental Status Examination (MMSE), Activities of Daily Living Scale (ADLS), and Hopkins Verbal Learning Test (HVLT). QOL was assessed with the European Organisation for Research and Treatment of Cancer (EORTC) core tool (QOL Questionnaire-QLQC30) and brain module (QLQBN20). RESULTS There were no statistically significant differences at 1 year between the two arms in any component of the EORTC-QLQC30 or QLQBN20 (P > .05), although a trend for greater decline in patient-reported cognitive functioning with PCI was noted. There were no significant differences in MMSE (P = .60) or ADLS (P = .88). However, for HVLT, there was greater decline in immediate recall (P = .03) and delayed recall (P = .008) in the PCI arm at 1 year. CONCLUSION PCI in stage III NSCLC significantly decreases the risk of BM without improving 1-year OS. There were no significant differences in global cognitive function (MMSE) or QOL after PCI, but there was a significant decline in memory (HVLT) at 1 year. This study provides prospective data regarding the relative risks and benefits of PCI in this setting and the need to use sensitive cognitive assessments.
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Affiliation(s)
- Alexander Sun
- Princess Margaret Hospital-University Health Network, University of Toronto, 610 University Ave, Toronto, Ontario, Canada, M5G 2M9.
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1635
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1636
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Gondi V, Tomé WA, Mehta MP. Why avoid the hippocampus? A comprehensive review. Radiother Oncol 2010; 97:370-6. [PMID: 20970214 PMCID: PMC2997490 DOI: 10.1016/j.radonc.2010.09.013] [Citation(s) in RCA: 263] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2010] [Revised: 09/04/2010] [Accepted: 09/14/2010] [Indexed: 11/22/2022]
Abstract
In this review article, we provide a detailed and comprehensive discussion of the rationale for using modern IMRT techniques to spare the subgranular zone of the hippocampus during cranial irradiation. We review the literature on neurocognitive effects of cranial irradiation; discuss clinical and preclinical data associating damage to neural progrenitor cells located in subgranular zone of the hippocampus with radiation-induced neurocognitive decline, specifically in terms of short-term memory formation and recall; and present a review of our pilot investigations into the feasibility and risks of sparing the subgranular zone of the hippocampus during whole-brain radiotherapy for brain metastases. We also introduce our phase II cooperative group clinical trial (RTOG 0933) designed to prospectively evaluate the postulated neurocognitive benefit of hippocampal subgranular zone sparing and scheduled to open in 2010.
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Affiliation(s)
- Vinai Gondi
- Department of Human Oncology, University of Wisconsin Comprehensive Cancer Center, Madison, WI 53792, USA.
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1637
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Abd-El-Barr MM, Rahman M, Rao G. Investigational therapies for brain metastases. Neurosurg Clin N Am 2010; 22:87-96, vii. [PMID: 21109153 DOI: 10.1016/j.nec.2010.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Contrary to the incidence of primary cancers, the incidence of brain metastasis has been increasing. This increase is likely because of the effects of an aging population, improved neuroimaging surveillance, and better control of systemic cancer, allowing time for brain metastasis to occur. Unlike systemic cancers, for which chemotherapy is the mainstay of treatment, the therapeutic strategies available to treat brain metastasis have traditionally been limited to surgical resection, whole brain radiation therapy, or stereotactic radiosurgery, either individually or in combination. It is important to put the treatment in the context of the prognosis for patients with brain metastases.
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Affiliation(s)
- Muhammad M Abd-El-Barr
- Department of Neurosurgery, University of Florida, Box 100265, Gainesville, FL 32610, USA
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1638
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Kocher M, Soffietti R, Abacioglu U, Villà S, Fauchon F, Baumert BG, Fariselli L, Tzuk-Shina T, Kortmann RD, Carrie C, Ben Hassel M, Kouri M, Valeinis E, van den Berge D, Collette S, Collette L, Mueller RP. Adjuvant whole-brain radiotherapy versus observation after radiosurgery or surgical resection of one to three cerebral metastases: results of the EORTC 22952-26001 study. J Clin Oncol 2010; 29:134-41. [PMID: 21041710 DOI: 10.1200/jco.2010.30.1655] [Citation(s) in RCA: 1333] [Impact Index Per Article: 95.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE This European Organisation for Research and Treatment of Cancer phase III trial assesses whether adjuvant whole-brain radiotherapy (WBRT) increases the duration of functional independence after surgery or radiosurgery of brain metastases. PATIENTS AND METHODS Patients with one to three brain metastases of solid tumors (small-cell lung cancer excluded) with stable systemic disease or asymptomatic primary tumors and WHO performance status (PS) of 0 to 2 were treated with complete surgery or radiosurgery and randomly assigned to adjuvant WBRT (30 Gy in 10 fractions) or observation (OBS). The primary end point was time to WHO PS deterioration to more than 2. RESULTS Of 359 patients, 199 underwent radiosurgery, and 160 underwent surgery. In the radiosurgery group, 100 patients were allocated to OBS, and 99 were allocated to WBRT. After surgery, 79 patients were allocated to OBS, and 81 were allocated to adjuvant WBRT. The median time to WHO PS more than 2 was 10.0 months (95% CI, 8.1 to 11.7 months) after OBS and 9.5 months (95% CI, 7.8 to 11.9 months) after WBRT (P = .71). Overall survival was similar in the WBRT and OBS arms (median, 10.9 v 10.7 months, respectively; P = .89). WBRT reduced the 2-year relapse rate both at initial sites (surgery: 59% to 27%, P < .001; radiosurgery: 31% to 19%, P = .040) and at new sites (surgery: 42% to 23%, P = .008; radiosurgery: 48% to 33%, P = .023). Salvage therapies were used more frequently after OBS than after WBRT. Intracranial progression caused death in 78 (44%) of 179 patients in the OBS arm and in 50 (28%) of 180 patients in the WBRT arm. CONCLUSION After radiosurgery or surgery of a limited number of brain metastases, adjuvant WBRT reduces intracranial relapses and neurologic deaths but fails to improve the duration of functional independence and overall survival.
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1639
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Sheehan J. Radiosurgery for breast cancer. J Neurosurg 2010; 114:790-1; discussion 791. [PMID: 20887092 DOI: 10.3171/2010.8.jns101285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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1640
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Suh JH, Videtic GMM, Aref AM, Germano I, Goldsmith BJ, Imperato JP, Marcus KJ, McDermott MW, McDonald MW, Patchell RA, Robins HI, Rogers CL, Wolfson AH, Wippold FJ, Gaspar LE. ACR Appropriateness Criteria: single brain metastasis. Curr Probl Cancer 2010; 34:162-74. [PMID: 20541055 DOI: 10.1016/j.currproblcancer.2010.04.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Single brain metastasis represents a common neurologic complication of cancer. Given the number of treatment options that are available for patients with brain metastasis and the strong opinions that are associated with each option, appropriate treatment for these patients has become controversial. Prognostic factors such as recursive partitioning analysis and graded prognostic assessment can help guide treatment decisions. Surgery, whole brain radiation therapy (WBRT), stereotactic radiosurgery or combination of these treatments can be considered based on a number of factors. Despite Class I evidence suggestive of best therapy, the treatment recommendation is quite varied among physicians as demonstrated by the American College of Radiology's Appropriateness Panel on single brain metastasis. Given the potential concerns of the neurocognitive effects of WBRT, the use of SRS alone or SRS to a resection cavity has gained support. Since aggressive local therapy is beneficial for survival, local control and quality of life, the use of these various treatment modalities needs to be carefully investigated given the growing number of long-term survivors. Enrollment of patients onto clinical trials is important to advance our understanding of brain metastasis.
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1641
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Saconn PA, Shaw EG, Chan MD, Squire SE, Johnson AJ, McMullen KP, Tatter SB, Ellis TL, Lovato J, Bourland JD, Ekstrand KE, DeGuzman AF, Munley MT. Use of 3.0-T MRI for stereotactic radiosurgery planning for treatment of brain metastases: a single-institution retrospective review. Int J Radiat Oncol Biol Phys 2010; 78:1142-6. [PMID: 20832185 DOI: 10.1016/j.ijrobp.2010.05.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2009] [Revised: 05/04/2010] [Accepted: 05/04/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE To investigate the efficacy of 3.0-T magnetic resonance imaging (MRI) for detecting brain metastases for stereotactic radiosurgery (SRS) planning. METHODS AND MATERIALS All adult patients scheduled for SRS treatment for brain metastases at our institution between October 2005 and January 2008 were eligible for analysis. All patients underwent radiosurgery treatment planning 3.0-T MRI on the day of scheduled radiosurgery and a diagnostic 1.5-T MRI in the days or weeks prior to radiosurgery for comparison. Both scans were interpreted by neuroradiologists who reported their findings in the radiology reports. We performed a retrospective review of the radiology reports to determine the number of brain metastases identified using each MRI system. RESULTS Of 254 patients scheduled for treatment from October 2005 to January 2008, 138 patients had radiology reports that explicitly described the number of metastases identified on both scans. With a median interval of 17 days (range, 1-82) between scans, the number of metastases detected using 1.5-T MRI system ranged from 1 to 5 and from 1 to 8 using the 3.0 T-MRI system. Twenty-two percent of patients were found to have a greater number of metastases with the 3.0 T-MRI system. The difference in number of metastases detected between the two scans for the entire cohort ranged from 0 to 6. Neither histology (p = 0.52 by chi-sq test) nor time between scans (p = 0.62 by linear regression) were significantly associated with the difference in number of metastases between scans. CONCLUSIONS The 3.0-T MRI system appears to be superior to a 1.5-T MRI system for detecting brain metastases, which may have significant implications in determining the appropriate treatment modality. Our findings suggest the need for a prospectively designed study to further evaluate the use of a 3.0 T-MRI system for stereotactic radiosurgery planning in the treatment of brain metastases.
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Affiliation(s)
- Paul A Saconn
- Department of Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
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1642
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Lo SS, Clarke JW, Grecula JC, McGregor JM, Mayr NA, Cavaliere R, Kendra KL, Gupta N, Wang JZ, Sarkar A, Olencki TE. Stereotactic radiosurgery alone for patients with 1–4 radioresistant brain metastases. Med Oncol 2010; 28 Suppl 1:S439-44. [DOI: 10.1007/s12032-010-9670-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Accepted: 08/19/2010] [Indexed: 11/27/2022]
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1643
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Muacevic A, Kreth FW. Stereotactic radiosurgery for the management of brain metastases. N Engl J Med 2010; 363:592; author reply 592-3. [PMID: 20818895 DOI: 10.1056/nejmc1005003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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1644
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Abstract
The central nervous system (CNS) and peripheral nervous system (PNS) are very susceptible to cancer and its treatment. The most direct involvement of the nervous system manifests in the development of primary brain and spinal cord tumors. Many cancers exhibit a propensity toward spread to the CNS, and brain metastases are common problems seen in malignancies such as lung, breast, and melanoma. Such spread may involve the brain or spine parenchyma or the subarachnoid space. In the PNS, spread is usually through direct infiltration of nerve roots, plexi, or muscle by neighboring malignancies. In some cases, cancer has sudden, devastating effects on the nervous system: epidural spinal cord compression or cord transection from pathologic fractures of vertebra involved by cancer; increased intracranial pressure from intracranial mass lesion growth and edema; and uncontrolled seizure activity as a result of intracranial tumors (status epilepticus), which are neuro-oncologic emergencies. The best known indirect or remote effects of cancer on the nervous system are the neurologic paraneoplastic syndromes. Cancer can also result in a hypercoagulable state causing cerebrovascular complications. Treatment of cancer can have neurologic complications. The commonest of these complications are radiation-induced injury to the brain, spine, and peripheral nerves and chemotherapy-induced peripheral neuropathy. The suppressant effect of cancer and its treatment on the body's immune system can result in infectious complications within the nervous system.
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1645
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Rades D, Dziggel L, Haatanen T, Veninga T, Lohynska R, Dunst J, Schild SE. Scoring systems to estimate intracerebral control and survival rates of patients irradiated for brain metastases. Int J Radiat Oncol Biol Phys 2010; 80:1122-7. [PMID: 20638188 DOI: 10.1016/j.ijrobp.2010.03.031] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Revised: 03/01/2010] [Accepted: 03/19/2010] [Indexed: 11/30/2022]
Abstract
PURPOSE To create and validate scoring systems for intracerebral control (IC) and overall survival (OS) of patients irradiated for brain metastases. METHODS AND MATERIALS In this study, 1,797 patients were randomly assigned to the test (n = 1,198) or the validation group (n = 599). Two scoring systems were developed, one for IC and another for OS. The scores included prognostic factors found significant on multivariate analyses. Age, performance status, extracerebral metastases, interval tumor diagnosis to RT, and number of brain metastases were associated with OS. Tumor type, performance status, interval, and number of brain metastases were associated with IC. The score for each factor was determined by dividing the 6-month IC or OS rate (given in percent) by 10. The total score represented the sum of the scores for each factor. The score groups of the test group were compared with the corresponding score groups of the validation group. RESULTS In the test group, 6-month IC rates were 17% for 14-18 points, 49% for 19-23 points, and 77% for 24-27 points (p < 0.0001). IC rates in the validation group were 19%, 52%, and 77%, respectively (p < 0.0001). In the test group, 6-month OS rates were 9% for 15-19 points, 41% for 20-25 points, and 78% for 26-30 points (p < 0.0001). OS rates in the validation group were 7%, 39%, and 79%, respectively (p < 0.0001). CONCLUSIONS Patients irradiated for brain metastases can be given scores to estimate OS and IC. IC and OS rates of the validation group were similar to the test group demonstrating the validity and reproducibility of both scores.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany.
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Chargari C, Campana F, Pierga JY, Védrine L, Ricard D, Le Moulec S, Fourquet A, Kirova YM. Whole-brain radiation therapy in breast cancer patients with brain metastases. Nat Rev Clin Oncol 2010; 7:632-40. [DOI: 10.1038/nrclinonc.2010.119] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Haberer S, Assouline A, Mazeron JJ. Dose de tolérance à l’irradiation des tissus sains : encéphale et hypophyse. Cancer Radiother 2010; 14:263-8. [DOI: 10.1016/j.canrad.2010.02.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 02/02/2010] [Indexed: 10/19/2022]
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Cognitive Sparing during the Administration of Whole Brain Radiotherapy and Prophylactic Cranial Irradiation: Current Concepts and Approaches. JOURNAL OF ONCOLOGY 2010; 2010:198208. [PMID: 20671962 PMCID: PMC2910483 DOI: 10.1155/2010/198208] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Accepted: 04/07/2010] [Indexed: 12/25/2022]
Abstract
Whole brain radiotherapy (WBRT) for the palliation of metastases, or as prophylaxis to prevent intracranial metastases, can be associated with subacute and late decline in memory and other cognitive functions. Moreover, these changes are often increased in both frequency and severity when cranial irradiation is combined with the use of systemic or intrathecal chemotherapy. Approaches to preventing or reducing this toxicity include the use of stereotactic radiosurgery (SRS) instead of WBRT; dose reduction for PCI; exclusion of the limbic circuit, hippocampal formation, and/or neural stem cell regions of the brain during radiotherapy; avoidance of intrathecal and/or systemic chemotherapy during radiotherapy; the use of high-dose, systemic chemotherapy in lieu of WBRT. This review discusses these concepts in detail as well as providing both neuroanatomic and radiobiologic background relevant to these issues.
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