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Lee CK, Soon YY, Jeffree RL, Joshi R, Koh ES, Lam WS, Le H, Lwin Z, Pinkham MB, Siva S, Ng E, John T. Management Paradigm of Central Nervous System Metastases in NSCLC: An Australian Perspective. JTO Clin Res Rep 2023; 4:100553. [PMID: 37663675 PMCID: PMC10472312 DOI: 10.1016/j.jtocrr.2023.100553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 07/05/2023] [Accepted: 07/21/2023] [Indexed: 09/05/2023] Open
Abstract
Life-prolonging central nervous system active systemic therapies for metastatic NSCLC have increased the complexity of managing brain metastases (BMs). Australian medical oncologists, radiation oncologists, and neurosurgeons discussed the evidence guiding the diverse clinical approaches to the management of BM in NSCLC. The Australian context is broadly applicable to other jurisdictions; therefore, we have documented these discussions as principles with broader applications. Patient management was stratified according to clinical and radiologic factors under two broad classifications of newly diagnosed BMs: symptomatic and asymptomatic. Other important considerations include the number and location of metastases, tumor histotypes, molecular subtype, and treatment purpose. Careful consideration of the pace and burden of symptoms, risk of worsening neurologic function at a short interval, and extracranial disease burden should determine whether central nervous system active systemic therapies are used alone or in combination with local therapies (surgery with or without radiation therapy). Most clinical trial evidence currently focuses on historical treatment options or a single treatment modality rather than the optimal sequencing of multiple modern therapies; therefore, an individualized approach is key in a rapidly changing therapeutic landscape.
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Affiliation(s)
- Chee Khoon Lee
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Yu Yang Soon
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore
| | - Rosalind L. Jeffree
- Kenneth G Jamieson Department of Neurosurgery, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, St. Lucia, Queensland, Australia
| | - Rohit Joshi
- Medical Oncology, Lyell McEwin Hospital, University of Adelaide, Adelaide, South Australia, Australia
- Allied Health & Human Performance, University of South Australia, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Science, Adelaide, South Australia, Australia
| | - Eng-Siew Koh
- Liverpool and Macarthur Cancer Therapy Centres, Liverpool, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Wei-Sen Lam
- Department of Medical Oncology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Hien Le
- Department of Radiation Oncology, Royal Adelaide Hospital, South Australia, Australia
| | - Zarnie Lwin
- Faculty of Medicine, University of Queensland, St. Lucia, Queensland, Australia
- Department of Medical Oncology, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - Mark B. Pinkham
- Faculty of Medicine, University of Queensland, St. Lucia, Queensland, Australia
- The Radiation Oncology Centre, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Shankar Siva
- Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Victoria, Australia
| | - Evan Ng
- Department of Radiation Oncology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Thomas John
- Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Victoria, Australia
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Nagai N, Koide Y, Shindo Y, Hashimoto S, Tachibana H, Kodaira T, Ishihara S, Naganawa S. Retrospective non-inferiority study of stereotactic radiosurgery for more than ten brain metastases. J Neurooncol 2023; 163:385-395. [PMID: 37286638 DOI: 10.1007/s11060-023-04358-8] [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: 05/04/2023] [Accepted: 05/29/2023] [Indexed: 06/09/2023]
Abstract
AIM This study aimed to investigate the clinical benefits of stereotactic radiosurgery (SRS) in patients with > 10 brain metastases (BM) compared to patients with 2-10 BM. METHODS The study included multiple BM patients who underwent SRS between 2014 and 2022, excluding patients who underwent whole brain radiotherapy, had a Karnofsky Performance Status score < 60, suspected leptomeningeal disease, or a single BM lesion. Patients were divided into two groups (2-10 and > 10 BM groups) and matched 2:1 based on propensity scores. The primary endpoint was overall survival (OS) in the matched dataset, with intracranial progression-free survival (PFS) as the secondary endpoint. Non-inferiority was established if the upper limit of the 95% confidence interval (CI) of the adjusted hazard ratio was below 1.3. RESULTS Of the 1042 patients identified, 434 met eligibility criteria. After propensity score matching, 240 patients were analyzed (160 in the BM 2-10 group and 80 in the > 10 BM group). The median OS was 18.2 months in the 2-10 BM group and 19.4 months in the > 10 BM group (P = 0.60). The adjusted hazard ratio was 0.86 (95% CI: 0.59-1.24), indicating non-inferiority. PFS was not significantly different between the groups (4.8 months vs. 4.8 months, P = 0.94). The number of BM did not significantly impact OS or PFS. CONCLUSIONS SRS for selected patients with > 10 BM was non-inferior in terms of OS compared to those with 2-10 BM in a propensity score-matched dataset.
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Affiliation(s)
- Naoya Nagai
- Department of Radiation Oncology, Aichi Cancer Center, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Postal Code: 464-0824, Japan
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yutaro Koide
- Department of Radiation Oncology, Aichi Cancer Center, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Postal Code: 464-0824, Japan.
| | - Yurika Shindo
- Department of Radiation Oncology, Aichi Cancer Center, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Postal Code: 464-0824, Japan
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shingo Hashimoto
- Department of Radiation Oncology, Aichi Cancer Center, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Postal Code: 464-0824, Japan
| | - Hiroyuki Tachibana
- Department of Radiation Oncology, Aichi Cancer Center, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Postal Code: 464-0824, Japan
| | - Takeshi Kodaira
- Department of Radiation Oncology, Aichi Cancer Center, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Postal Code: 464-0824, Japan
| | - Shunichi Ishihara
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shinji Naganawa
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Chen J, Williams M, Huang Y, Si S. Identifying Topics and Evolutionary Trends of Literature on Brain Metastases Using Latent Dirichlet Allocation. Front Mol Biosci 2022; 9:858577. [PMID: 35720132 PMCID: PMC9201447 DOI: 10.3389/fmolb.2022.858577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/01/2022] [Indexed: 11/13/2022] Open
Abstract
Research on brain metastases kept innovating. We aimed to illustrate what topics the research focused on and how it varied in different periods of all the studies on brain metastases with topic modelling. We used the latent Dirichlet allocation model to analyse the titles and abstracts of 50,176 articles on brain metastases retrieved from Web of Science, Embase and MEDLINE. We further stratified the articles to find out the topic trends of different periods. Our study identified that a rising number of studies on brain metastases were published in recent decades at a higher rate than all cancer articles. Overall, the major themes focused on treatment and histopathology. Radiotherapy took over the first and third places in the top 20 topics. Since the 2010’s, increasing attention concerned about gene mutations. Targeted therapy was a popular topic of brain metastases research after 2020.
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Affiliation(s)
- Jiarong Chen
- Clinical Experimental Center, Jiangmen Key Laboratory of Clinical Biobanks and Translational Research, Jiangmen Central Hospital, Jiangmen, China
- Department of Oncology, Jiangmen Central Hospital, Jiangmen, China
- Computational Oncology Group, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- *Correspondence: Jiarong Chen, ; Shijing Si,
| | - Matt Williams
- Computational Oncology Group, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Department of Radiotherapy, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Yanming Huang
- Clinical Experimental Center, Jiangmen Key Laboratory of Clinical Biobanks and Translational Research, Jiangmen Central Hospital, Jiangmen, China
| | - Shijing Si
- Duke University, Durham, NC, United States
- *Correspondence: Jiarong Chen, ; Shijing Si,
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Liu J, Xu J, Ye W, Zhong W, Zhang X, Mao J, Wu D. Whole-Brain Radiotherapy Combined With Anlotinib for Multiple Brain Metastases From Non-small Cell Lung Cancer Without Targetable Driver Mutation: A Single-Arm, Phase II Study. Clin Med Insights Oncol 2022; 16:11795549221079185. [PMID: 35250325 PMCID: PMC8891900 DOI: 10.1177/11795549221079185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 01/20/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Existing evidence demonstrates that radiotherapy and antiangiogenic drugs have synergistic antitumour effects and may be a promising treatment option for patients with solid tumour. Thus, we performed a phase II trial to evaluate the efficacy and safety of whole-brain radiotherapy (WBRT) combined with anlotinib for multiple brain metastases (BMs) from non-small cell lung cancer (NSCLC) without targetable driver mutations. Methods: Patients with multiple BMs (⩾3) from NSCLC without targetable driver mutations who failed to respond to at least first-line chemotherapy were enrolled. Eligible patients received WBRT (30 Gy/10 f, 5 f/week) and anlotinib (12 mg/day, day 1-14 of 21 days per cycle, 2 cycles) until disease progression or treatment intolerance. The primary endpoint was intracranial objective response rate (iORR) and secondary endpoints included intracranial progression-free survival (iPFS), disease control rate (DCR), overall survival (OS), and safety. Results: Between April 2019 and March 2021, 21 patients were enrolled in the trial, of which 12 were aged ⩾60 years (57.1%), 13 were men (61.9%), 7 had an Eastern Cooperative Oncology Group Performance Status score of 0 to 1 (81.0%), 18 had adenocarcinoma (85.7%), and 11 had ⩾6 BMs (52.4%). Of the 21 evaluable patients, the iORR was 66.7% (1 complete response + 13 partial response [PR]), and 28.6% (7PR) had extracerebral lesions. The DCRs for intracerebral and extracerebral lesions were 90.5% and 81.0%, respectively. The iPFS and OS were 10.3 months (95% confidence interval [CI]: 0-24.8 months) and 13.4 months (95% CI: 0-27.9 months), respectively. The most frequently observed toxicities were loss of appetite (61.9%), hypertension (52.4%), fatigue (47.6%), diarrhoea (28.6%), vomiting (19.0%), dizziness (42.9%), and headache (33.3%). None of the patients developed grade 4 or higher grade adverse reactions. Conclusions: Anlotinib combined with WBRT is effective and well tolerated in patients with multiple BMs (⩾3) from NSCLC without targetable driver mutations. Therefore, further validation studies are required. Clinical trial registration number: ChiCTR 1900027769
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Affiliation(s)
- Jianjiang Liu
- Department of Radiation Oncology, Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, China
| | - Jun Xu
- Department of Radiation Oncology, Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, China
| | - Wanli Ye
- Department of Radiation Oncology, Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, China
| | - Wangyan Zhong
- Department of Radiation Oncology, Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, China
| | - Xiaoyu Zhang
- Department of Radiation Oncology, Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, China
| | - Jiwei Mao
- Department of Radiation Oncology, Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, China
| | - Dongping Wu
- Department of Radiation Oncology, Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, China
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Sas-Korczynska B, Rucinska M. WBRT for brain metastases from non-small cell lung cancer: for whom and when?-Contemporary point of view. J Thorac Dis 2021; 13:3246-3257. [PMID: 34164217 PMCID: PMC8182552 DOI: 10.21037/jtd-2019-rbmlc-06] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The incidence of brain metastases (BM) is estimated between 20% and 40% of patients with solid cancer. The most common cause of this failure is lung cancer, and in locally advanced non-small cell lung cancer (NSCLC) BM represent a common site of relapse in 30-55% cases. The basic criteria of therapeutic decision-making are based on the significant prognostic factors which are components of prognostic scores. The standard approach to treatment of BM from NSCLC include whole brain radiotherapy (WBRT) which is used as adjuvant modality after local therapy (surgery or stereotactic radiosurgery) or as primary treatment and it remains the primary modality of treatment for patients with multiple metastases. WBRT is also used in combination with systemic therapy. The aim of presented review of literature is trying to answer which patients with BM from NSCLC should receive WBRT and when it could be omitted. There were presented the aspects of application of WBRT in relation to (I) choice between WBRT or the best supportive care and (II) employment of WBRT in combination with local treatment modalities [surgical resection or stereotactic radio-surgery (SRS)] and/or with systemic therapy. According to data from literature we concluded that the most important factor that needs to be considered when assessing the suitability of a patient for WBRT is the patient's prognosis based on the Lung-molGPA score. WBRT should be applied in treatment of multiple BM from lung cancer in patients with favourable prognosis and in in patients with presence of EML4-ALK translocation before therapy with crizotinib. Whereas WBRT could be omitted in patients with poor prognosis and after primary SRS.
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Affiliation(s)
- Beata Sas-Korczynska
- Institute of Medical Sciences, Medical College of Rzeszow University, Rzeszow, Poland.,Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
| | - Monika Rucinska
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland.,Department of Oncology, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
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6
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Abraham AG, Roa W. Hippocampal avoidance in prophylactic cranial irradiation for small cell lung cancer: benefits and pitfalls. J Thorac Dis 2021; 13:3235-3245. [PMID: 34164216 PMCID: PMC8182537 DOI: 10.21037/jtd-2019-rbmlc-01] [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] [Indexed: 11/25/2022]
Abstract
Small cell lung cancers (SCLC) are a group of cancers that are clinically and pathologically different from other lung cancers. They are associated with high recurrence rates and mortality, and many patients present with metastatic disease. Approximately ten percent of SCLC patients have brain metastases at time of diagnosis, and the cumulative incidence of brain metastases increases to more than fifty percent at two years, even with optimal treatment. Hence, in patients without brain metastases at presentation, prophylactic cranial irradiation (PCI) is an important component of treatment along with systemic chemotherapy and radiotherapy. The goal of PCI is to decrease the incidence of subsequent symptomatic brain metastases in patients who show an initial response to the systemic treatment. Various clinical trials have evaluated the utility of PCI and found substantial benefit. Unfortunately, the long-term toxicity associated with PCI, namely the neuro-cognitive impairment that may develop in patients as a result of the radiation toxicity to the hippocampal areas of the brain, has raised concern both for patients and their treating physicians. Various techniques have been tried to ameliorate the neuro-cognitive impairment associated with PCI, including pharmacological agents and highly conformal hippocampal avoidance radiation. All of these have shown promise, but there is a lack of clarity about the optimal way forward. Hippocampal avoidance PCI appears to be an excellent option and a number of groups are currently evaluating this technique. Although there is clear benefit with this specialized radiation treatment, there are also concerns about the risk of disease recurrence in the undertreated hippocampal areas. This review attempts to compile the available data regarding the benefits and pitfalls associated with hippocampal avoidance PCI in the setting of SCLC.
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Affiliation(s)
| | - Wilson Roa
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, Canada
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7
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Balasubramanian SK, Sharma M, Venur VA, Schmitt P, Kotecha R, Chao ST, Suh JH, Angelov L, Mohammadi AM, Vogelbaum MA, Barnett GH, Jia X, Pennell NA, Ahluwalia MS. Impact of EGFR mutation and ALK rearrangement on the outcomes of non-small cell lung cancer patients with brain metastasis. Neuro Oncol 2021; 22:267-277. [PMID: 31648302 DOI: 10.1093/neuonc/noz155] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The impact of activating alterations in non-small cell lung cancer (NSCLC) (epidermal growth factor receptor [EGFR] mutation/anaplastic lymphoma kinase [ALK] translocation) in prognosticating patients with brain metastasis (BM) is not well defined. This study was sought to identify this impact in NSCLC patients with BM accounting for the known validated variables. METHODS Among 1078 NSCLC-BM patients diagnosed/treated between January 1, 2000 and December 31, 2015, three hundred and forty-eight with known EGFR/ALK status were analyzed. Overall survival (OS) and intracranial progression-free survival (PFS) were measured from the time of BM. RESULTS Ninety-one patients had either ALK (n = 23) alterations or EGFR (n = 68) mutation and 257 were wild type (WT; negative actionable mutations/alterations). Median age of EGFR/ALK+ NSCLC BM patients was 60 years (range 29.8-82.6 y) and ~50% (n = 44) had Karnofsky performance status (KPS) score >80. Median number of BM was 2 (1 to ≥99). The median OS for the ALK/EGFR+ NSCLC BM was 19.9 versus 10.1 months for the WT (P = 0.028). The number of BM in the EGFR/ALK+ group did not impact OS (BM = 1 with 21.1 months vs 2-3 with 19.1 months and >3 with 23.7 months, P = 0.74), whereas fewer BM in the WT cohort had significantly better OS (BM = 1 with 13.8 mo, 2-3 with 11.0 mo and >3 with 8.1 mo; P = 0.006) with the adjustment of age, KPS, symptoms from BM and synchronicity. CONCLUSIONS Number of BM does not impact outcomes in the EGFR/ALK+ NSCLC patients, implying that targeted therapy along with surgery and/or radiation may improve OS irrespective of the number of BM. Number of BM, extracranial metastasis (ECM), and KPS independently affected OS/PFS in WT NSCLC BM, which was consistent with the known literature.
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Affiliation(s)
| | - Mayur Sharma
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | | | - Philipp Schmitt
- Research Volunteer, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Rupesh Kotecha
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samuel T Chao
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - John H Suh
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - Lilyana Angelov
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alireza M Mohammadi
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Vogelbaum
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gene H Barnett
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Xuefei Jia
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Nathan A Pennell
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manmeet S Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
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Rybarczyk-Kasiuchnicz A, Ramlau R, Stencel K. Treatment of Brain Metastases of Non-Small Cell Lung Carcinoma. Int J Mol Sci 2021; 22:ijms22020593. [PMID: 33435596 PMCID: PMC7826874 DOI: 10.3390/ijms22020593] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 12/28/2020] [Accepted: 12/30/2020] [Indexed: 02/07/2023] Open
Abstract
Lung cancer is one of the most common malignant neoplasms. As a result of the disease's progression, patients may develop metastases to the central nervous system. The prognosis in this location is unfavorable; untreated metastatic lesions may lead to death within one to two months. Existing therapies-neurosurgery and radiation therapy-do not improve the prognosis for every patient. The discovery of Epidermal Growth Factor Receptor (EGFR)-activating mutations and Anaplastic Lymphoma Kinase (ALK) rearrangements in patients with non-small cell lung adenocarcinoma has allowed for the introduction of small-molecule tyrosine kinase inhibitors to the treatment of advanced-stage patients. The Epidermal Growth Factor Receptor (EGFR) is a transmembrane protein with tyrosine kinase-dependent activity. EGFR is present in membranes of all epithelial cells. In physiological conditions, it plays an important role in the process of cell growth and proliferation. Binding the ligand to the EGFR causes its dimerization and the activation of the intracellular signaling cascade. Signal transduction involves the activation of MAPK, AKT, and JNK, resulting in DNA synthesis and cell proliferation. In cancer cells, binding the ligand to the EGFR also leads to its dimerization and transduction of the signal to the cell interior. It has been demonstrated that activating mutations in the gene for EGFR-exon19 (deletion), L858R point mutation in exon 21, and mutation in exon 20 results in cancer cell proliferation. Continuous stimulation of the receptor inhibits apoptosis, stimulates invasion, intensifies angiogenesis, and facilitates the formation of distant metastases. As a consequence, the cancer progresses. These activating gene mutations for the EGFR are present in 10-20% of lung adenocarcinomas. Approximately 3-7% of patients with lung adenocarcinoma have the echinoderm microtubule-associated protein-like 4 (EML4)/ALK fusion gene. The fusion of the two genes EML4 and ALK results in a fusion gene that activates the intracellular signaling pathway, stimulates the proliferation of tumor cells, and inhibits apoptosis. A new group of drugs-small-molecule tyrosine kinase inhibitors-has been developed; the first generation includes gefitinib and erlotinib and the ALK inhibitor crizotinib. These drugs reversibly block the EGFR by stopping the signal transmission to the cell. The second-generation tyrosine kinase inhibitor (TKI) afatinib or ALK inhibitor alectinib block the receptor irreversibly. Clinical trials with TKI in patients with non-small cell lung adenocarcinoma with central nervous system (CNS) metastases have shown prolonged, progression-free survival, a high percentage of objective responses, and improved quality of life. Resistance to treatment with this group of drugs emerging during TKI therapy is the basis for the detection of resistance mutations. The T790M mutation, present in exon 20 of the EGFR gene, is detected in patients treated with first- and second-generation TKI and is overcome by Osimertinib, a third-generation TKI. The I117N resistance mutation in patients with the ALK mutation treated with alectinib is overcome by ceritinib. In this way, sequential therapy ensures the continuity of treatment. In patients with CNS metastases, attempts are made to simultaneously administer radiation therapy and tyrosine kinase inhibitors. Patients with lung adenocarcinoma with CNS metastases, without activating EGFR mutation and without ALK rearrangement, benefit from immunotherapy. This therapeutic option blocks the PD-1 receptor on the surface of T or B lymphocytes or PD-L1 located on cancer cells with an applicable antibody. Based on clinical trials, pembrolizumab and all antibodies are included in the treatment of non-small cell lung carcinoma with CNS metastases.
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Prabhash K. Treatment of advanced nonsmall cell lung cancer: First line, maintenance and second line - Indian consensus statement update. South Asian J Cancer 2020; 8:1-17. [PMID: 30766843 PMCID: PMC6348782 DOI: 10.4103/sajc.sajc_227_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The management of advanced nonsmall cell lung cancer (NSCLC) patients is becoming increasingly complex with the identification of driver mutations/rearrangements and development/availability of appropriate targeted therapies. In 2017, an expert group of medical oncologists with expertise in treating lung cancer used data from published literature and experience to arrive at practical consensus recommendations on treatment of advanced NSCLC for use by the community oncologists. This was published subsequently in the Indian Journal of Cancer with a plan to be updated annually. The present document is an update to the 2017 document.
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Affiliation(s)
- Kumar Prabhash
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
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10
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Iorio-Morin C, Mercure-Cyr R, Figueiredo G, Touchette CJ, Masson-Côté L, Mathieu D. Repeat stereotactic radiosurgery for the management of locally recurrent brain metastases. J Neurooncol 2019; 145:551-559. [DOI: 10.1007/s11060-019-03323-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 10/25/2019] [Indexed: 01/23/2023]
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11
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Impact of adjuvant fractionated stereotactic radiotherapy dose on local control of brain metastases. J Neurooncol 2019; 145:385-390. [PMID: 31606876 DOI: 10.1007/s11060-019-03308-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/07/2019] [Accepted: 10/09/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The aim of this study was to determine whether a higher biological effective dose (BED) would result in improved local control in patients treated with fractionated stereotactic radiotherapy (FSRT) for their resected brain metastases. METHODS Patients with newly diagnosed brain metastases without previous brain radiotherapy were retrospectively reviewed. Patients underwent surgical resection of at least one brain metastasis and were treated with adjuvant FSRT, delivering 25-36 Gy in 5-6 fractions. Outcomes were computed using Kaplan-Meier survival analysis and univariate analysis. RESULTS Fifty-four patients with 63 post-operative cavities were included. Median follow-up was 16 months (3-60). Median metastasis size at diagnosis was 2.9 cm (0.6-8.1) and median planning target volume was 19.7 cm3 (6.3-68.1). Two-year local control (LC) was 83%. When stratified by dose, 2 years LC rate was 95.1% in those treated with 30-36 Gy in 5-6 fractions (BED10 of 48-57.6 Gy10) versus 59.1% lesions treated with 25 Gy in 5 fractions (BED10 of 37.5 Gy10) (p < 0.001). LC was not associated with resection cavity size. One year overall survival was 68.7%, and was independent of BED10. Symptomatic radiation necrosis occurred in 7.9% of patients and was not associated with dose. CONCLUSION In the post-operative setting, high-dose FSRT (BED10 > 37.5 Gy10) were associated with a significantly higher rate of LC compared to lower BED regimens. Overall, 25 Gy in 5 fractions is not an adequate dose to control microscopic disease. If selecting a 5-fraction regimen, 30 Gy in five fractions appears to provide excellent tumor bed control.
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Tripathy D, Tolaney SM, Seidman AD, Anders CK, Ibrahim N, Rugo HS, Twelves C, Dieras V, Müller V, Tagliaferri M, Hannah AL, Cortés J. ATTAIN: Phase III study of etirinotecan pegol versus treatment of physician's choice in patients with metastatic breast cancer and brain metastases. Future Oncol 2019; 15:2211-2225. [PMID: 31074641 DOI: 10.2217/fon-2019-0180] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The increasing incidence of breast cancer brain metastases is a major clinical problem with its associated poor prognosis and limited treatment options. The long-acting topoisomerase-1 inhibitor, etirinotecan pegol, was designed to preferentially accumulate in tumor tissue including brain metastases, providing sustained cytotoxic SN38 levels. Motivated by improved survival findings from subgroup analyses from the Phase III BEACON trial, this ongoing randomized, Phase III trial compares etirinotecan pegol to drugs commonly used for advanced breast cancer in patients with stable, treated breast cancer brain metastases who have been previously treated with an anthracycline, taxane and capecitabine. The primary end point is overall survival. Secondary end points include objective response rate, progression-free survival and time to CNS disease progression or recurrence in patients with/without CNS lesions present at study entry. Trial registration number: NCT02915744.
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Affiliation(s)
- Debu Tripathy
- The University of Texas MD Anderson Cancer Center, Department of Breast Medical Oncology, Houston, TX 77030, USA
| | - Sara M Tolaney
- Dana-Farber Cancer Institute, Center for Women's Cancers, Boston, MA 02215, USA
| | - Andrew D Seidman
- Memorial Sloan-Kettering Cancer Center, Bobst International Center, New York, NY 10065, USA
| | - Carey K Anders
- University of North Carolina School of Medicine, Duke Cancer Center, Chapel Hill, NC 27710, USA
| | - Nuhad Ibrahim
- The University of Texas MD Anderson Cancer Center, Department of Breast Medical Oncology, Houston, TX 77030, USA
| | - Hope S Rugo
- University of California San Francisco, Department of Medicine (Hematology/Oncology), San Francisco, CA 94115, USA
| | - Chris Twelves
- University of Leeds, Leeds Institute of Cancer and Pathology (LICAP), Leeds, LS2 9JT, UK.,St James' University Hospital, Institute of Oncology, Leeds, LS9 7BE, UK
| | - Veronique Dieras
- Institut Curie, Oncological Medicine Department, 75248, Paris, France
| | - Volkmar Müller
- University Medical Center Hamburg-Eppendorf, Department of Obstetrics and Gynecology, 20246 Hamburg, Germany
| | | | | | - Javier Cortés
- IOB Institute of Oncology, Quironsalud Group, 28034 Madrid & 08023 Barcelona, Spain.,Vall d'Hebron Institute of Oncology (VHIO), Breast Cancer and Melanoma Group, 08035 Barcelona, Spain
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13
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Fernández-Méndez R, Rastall RJ, Sage WA, Oberg I, Bullen G, Charge AL, Crofton A, Santarius T, Watts C, Price SJ, Brodbelt A, Joannides AJ. Quality improvement of neuro-oncology services: integrating the routine collection of patient-reported, health-related quality-of-life measures. Neurooncol Pract 2019; 6:226-236. [PMID: 31385996 PMCID: PMC6656295 DOI: 10.1093/nop/npy040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Brain cancer has a strong impact on health-related quality of life (HRQoL), and its evaluation in clinical practice can improve the quality of care provided. The aim of this project was to integrate routine collection of HRQoL information from patients with brain tumor or metastasis in 2 specialized United Kingdom tertiary centers, and to evaluate the implementation process. METHODS Since October 2016, routine collection of electronic self-reported HRQoL information has been progressively embedded in the participating centers using standard questionnaires. During the first year, the project was implemented, and the process evaluated, through regular cycles of process evaluation followed by an action plan, monitoring of questionnaire completion rates, and assessment of patient views. RESULTS Main challenges encountered included reluctance to change usual practice and limited resources. Key measures for success included strong leadership of senior staff, involvement of stakeholders in project design and evaluation, and continuous strategic support to professionals. Final project workflow included 6 process steps, 1 decision step, and 4 outputs. Questionnaires were mostly self-completed (75.1%), and completion took 6-9 minutes. Most patients agreed that the questionnaire items were easy to understand (97.0%), important for them (93.0%), and helped them think what they wanted to discuss in their clinical consultation (75.4%). CONCLUSIONS Integrating HRQoL information as a routine part of clinical assessments has the potential to enhance individually tailored patient care in our institutions. Challenges involved in innovations of this nature can be overcome through a systematic approach involving strong leadership, wide stakeholder engagement, and strategic planning.
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Affiliation(s)
| | | | - William A Sage
- Department of Clinical Neurosciences, University of Cambridge, UK
| | - Ingela Oberg
- Neurosurgery Department, Cambridge University Hospitals NHS Trust, Addenbrookes Hospital, UK
| | - Gemma Bullen
- Neurosurgery Department, Cambridge University Hospitals NHS Trust, Addenbrookes Hospital, UK
| | - Amy Louise Charge
- Neurosurgery Department, Cambridge University Hospitals NHS Trust, Addenbrookes Hospital, UK
| | - Anna Crofton
- Neurosurgery Department, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Thomas Santarius
- Department of Clinical Neurosciences, University of Cambridge, UK
- Neurosurgery Department, Cambridge University Hospitals NHS Trust, Addenbrookes Hospital, UK
| | - Colin Watts
- Department of Clinical Neurosciences, University of Cambridge, UK
- Neurosurgery Department, Cambridge University Hospitals NHS Trust, Addenbrookes Hospital, UK
| | - Stephen J Price
- Department of Clinical Neurosciences, University of Cambridge, UK
- Neurosurgery Department, Cambridge University Hospitals NHS Trust, Addenbrookes Hospital, UK
| | - Andrew Brodbelt
- Neurosurgery Department, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Alexis J Joannides
- Department of Clinical Neurosciences, University of Cambridge, UK
- Neurosurgery Department, Cambridge University Hospitals NHS Trust, Addenbrookes Hospital, UK
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14
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Oertel M, Baehr A, Habibeh O, Haverkamp U, Stummer W, Eich HT, Trog D. Effect of Postoperative Radiotherapy for Brain Metastases: An Analysis. Oncol Res Treat 2019; 42:256-262. [PMID: 30995671 DOI: 10.1159/000499323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 02/27/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Brain metastases (BM) have a very poor prognosis, creating a demand for effective local therapies, such as radiotherapy (RT) and neurosurgery, the combination of which is debatable. The aim of the present study was to investigate prognostic factors and to develop treatment recommendations for patients with BM. MATERIAL AND METHODS A total of 84 patients treated between May 2011 and July 2016 were analyzed in a single-institution retrospective study. RESULTS Overall survival (OS) was 10.3 months. Poor OS was defined by a Karnofsky performance index of ≤70% (2.9 vs. 15.8 months; p = 0.009), male gender (6.5 vs. 18.3 months; p = 0.044), and incomplete neurosurgical resection (2.5 vs. 15.8 months; p = 0.017). These factors were also shown to be significant in univariate analysis, while only radical resection remained significant in multivariate testing (p = 0.023). A direct comparison between whole-brain RT (with or without boost) and local RT illustrated a superior OS for local therapy (22.7 vs. 9.5 months; p = 0.022), especially in case of up to 3 metastases (p = 0.041). Intracranial control was 81% with a median duration of 31.6 months. CONCLUSION Combined modality treatment of RT and neurosurgery is effective and feasible. A complete removal of all metastases is the cardinal prognostic factor.
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Affiliation(s)
- Michael Oertel
- Department of Radiation Oncology, University Hospital Münster, Münster, Germany,
| | - Andrea Baehr
- Department of Radiation Oncology, University Hospital Münster, Münster, Germany
| | - Omar Habibeh
- Department of Radiation Oncology, University Hospital Münster, Münster, Germany
| | - Uwe Haverkamp
- Department of Radiation Oncology, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Hans Theodor Eich
- Department of Radiation Oncology, University Hospital Münster, Münster, Germany
| | - Daniela Trog
- Department of Radiation Oncology, University Hospital Münster, Münster, Germany
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15
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Sittenfeld SMC, Suh JH, Murphy ES, Yu JS, Chao ST. Contemporary Management of 1-4 Brain Metastases. Front Oncol 2018; 8:385. [PMID: 30319962 PMCID: PMC6165904 DOI: 10.3389/fonc.2018.00385] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 08/28/2018] [Indexed: 11/13/2022] Open
Abstract
Brain metastases remain the most common neurologic complication of cancer. With improvement in surveillance and systemic therapy, patients with limited CNS disease are living longer after diagnosis, thus influencing the importance of optimal radiation treatment in order to maximize local control and minimize morbidity. In patients with a limited number of brain metastases, stereotactic radiosurgery is more recently seen as an appropriate sole modality for management with excellent local control. As newer systemic therapies emerge and with the advent of immunotherapies and targeted therapies for metastatic CNS disease, further research is needed in the optimal timing and sequencing of these modalities.
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Affiliation(s)
- Sarah M C Sittenfeld
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, United States
| | - John H Suh
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, United States
| | - Erin S Murphy
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, United States
| | - Jennifer S Yu
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, United States
| | - Samuel T Chao
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, United States
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16
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Park ES, Lee EJ, Yun JH, Cho YH, Kim JH, Kwon DH. Gamma Knife Radiosurgery for Metastatic Brain Tumors with Exophytic Hemorrhage. J Korean Neurosurg Soc 2018; 61:592-599. [PMID: 30196656 PMCID: PMC6129753 DOI: 10.3340/jkns.2017.0303.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 10/23/2017] [Indexed: 01/10/2023] Open
Abstract
Objective Metastatic brain tumors (MBTs) often present with intracerebral hemorrhage. Although Gamma Knife surgery (GKS) is a valid treatment option for hemorrhagic MBTs, its efficacy is unclear. To achieve oncologic control and reduce radiation toxicity, we used a radiosurgical targeting technique that confines the tumor core within the hematoma when performing GKS in patients with such tumors. We reviewed our experience in this endeavor, focusing on local tumor control and treatment-associated morbidities.
Methods From 2007 to 2014, 13 patients with hemorrhagic MBTs were treated via GKS using our targeting technique. The median marginal dose prescribed was 23 Gy (range, 20–25). GKS was performed approximately 2 weeks after tumor bleeding to allow the patient’s condition to stabilize.
Results The primary sites of the MBTs included the liver (n=7), lung (n=2), kidney (n=1), and stomach (n=1); in two cases, the primary tumor was a melanoma. The mean tumor volume was 4.00 cm3 (range, 0.74–11.0). The mean overall survival duration after GKS was 12.5 months (range, 3–29), and three patients are still alive at the time of the review. The local tumor control rate was 92% (tumor disappearance 23%, tumor regression 46%, and stable disease 23%). There was one (8%) instance of local recurrence, which occurred 11 months after GKS in the solid portion of the tumor. No GKS-related complications were observed.
Conclusion Our experience shows that GKS performed in conjunction with our targeting technique safely and effectively treats hemorrhagic MBTs. The success of this technique may reflect the presence of scattered metastatic tumor cells in the hematoma that do not proliferate owing to the inadequate microenvironment of the hematoma. We suggest that GKS can be a useful treatment option for patients with hemorrhagic MBTs that are not amenable to surgery.
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Affiliation(s)
- Eun Suk Park
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Eun Jung Lee
- Department of Neurosurgery, Dongtan Sacred Heart Hospital, College of Medicine, Hallym University, Hwaseong, Korea
| | - Jung-Ho Yun
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
| | - Young Hyun Cho
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Kim
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kwon
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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17
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Combs SE, Bilger A, Diehl C, Bretzinger E, Lorenz H, Oehlke O, Specht HM, Kirstein A, Grosu A. Multicenter analysis of stereotactic radiotherapy of the resection cavity in patients with brain metastases. Cancer Med 2018; 7:2319-2327. [PMID: 29696815 PMCID: PMC6010760 DOI: 10.1002/cam4.1477] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/03/2018] [Accepted: 01/03/2018] [Indexed: 11/06/2022] Open
Abstract
Brain metastases show a recurrence rate of about 50% after surgical resection. Adjuvant radiotherapy can prevent progression; however, whole-brain radiotherapy (WBRT) can be associated with significant side effects. Local hypofractionated stereotactic radiotherapy (HFSRT) is a good alternative to provide local control with minimal toxicity. In this multicenter analysis, we evaluated the treatment outcome of local HFSRT after resection brain metastases in 181 patients. Patient's characteristics, treatment data as well as follow-up data were collected and analyzed with special focus on local control, locoregional control and survival. After a median follow-up of 12.6 months (range 0.3-80.2 months), the crude rate for local control was 80.5%; 1- and 2-year local recurrence-free survival rates were 75% and 70% (median not reached). Resection cavity size was a significant predictor for local recurrence (P = 0.033). The median overall survival was 16.0 months. Both graded prognostic assessment score and recursive partitioning analysis were accurate predictors of survival. HFSRT leads to excellent local control and has a high potential to consolidate results after surgery; acute and late toxicity is low. Distant intracerebral metastases occur frequently during follow-up, and therefore, a close patient monitoring needs to be warranted if whole-brain radiotherapy is omitted.
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Affiliation(s)
- Stephanie E. Combs
- Department of Radiation OncologyTechnische Universität MünchenKlinikum rechts der IsarMünchenGermany
- Deutsches Konsortium für Translationale Krebsforschungs (dktk), Partner Site MunichMunichGermany
- Department of Radiation Sciences (DRS)Institute of Innovative Radiotherapy (iRT)Helmholtz Zentrum MünchenNeuherbergGermany
| | - Angelika Bilger
- Department of Radiation OncologyUniversitätsklinikum FreiburgFreiburgGermany
- Deutsches Konsortium für Translationale Krebsforschungs (dktk), Partner SiteFreiburgGermany
| | - Christian Diehl
- Department of Radiation OncologyTechnische Universität MünchenKlinikum rechts der IsarMünchenGermany
- Deutsches Konsortium für Translationale Krebsforschungs (dktk), Partner Site MunichMunichGermany
- Department of Radiation Sciences (DRS)Institute of Innovative Radiotherapy (iRT)Helmholtz Zentrum MünchenNeuherbergGermany
| | - Eva Bretzinger
- Department of Radiation OncologyUniversitätsklinikum FreiburgFreiburgGermany
- Deutsches Konsortium für Translationale Krebsforschungs (dktk), Partner SiteFreiburgGermany
| | - Hannah Lorenz
- Department of Radiation OncologyUniversitätsklinikum FreiburgFreiburgGermany
- Deutsches Konsortium für Translationale Krebsforschungs (dktk), Partner SiteFreiburgGermany
| | - Oliver Oehlke
- Department of Radiation OncologyUniversitätsklinikum FreiburgFreiburgGermany
- Deutsches Konsortium für Translationale Krebsforschungs (dktk), Partner SiteFreiburgGermany
| | - Hanno M. Specht
- Department of Radiation OncologyTechnische Universität MünchenKlinikum rechts der IsarMünchenGermany
- Deutsches Konsortium für Translationale Krebsforschungs (dktk), Partner Site MunichMunichGermany
- Department of Radiation Sciences (DRS)Institute of Innovative Radiotherapy (iRT)Helmholtz Zentrum MünchenNeuherbergGermany
| | - Anna Kirstein
- Department of Radiation OncologyTechnische Universität MünchenKlinikum rechts der IsarMünchenGermany
- Deutsches Konsortium für Translationale Krebsforschungs (dktk), Partner Site MunichMunichGermany
- Department of Radiation Sciences (DRS)Institute of Innovative Radiotherapy (iRT)Helmholtz Zentrum MünchenNeuherbergGermany
| | - Anca‐Ligia Grosu
- Department of Radiation OncologyUniversitätsklinikum FreiburgFreiburgGermany
- Deutsches Konsortium für Translationale Krebsforschungs (dktk), Partner SiteFreiburgGermany
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18
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Mahmood F, Johannesen HH, Geertsen P, Hansen RH. Ultra-early apparent diffusion coefficient change indicates irradiation and predicts radiotherapy outcome in brain metastases. Acta Oncol 2017; 56:1651-1653. [PMID: 28849704 DOI: 10.1080/0284186x.2017.1348627] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Faisal Mahmood
- Radiotherapy Research Unit (RRU), Department of Oncology, University of Copenhagen, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Helle H. Johannesen
- Department of Radiology, University of Copenhagen, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Poul Geertsen
- Radiotherapy Research Unit (RRU), Department of Oncology, University of Copenhagen, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Rasmus H. Hansen
- Department of Radiology, University of Copenhagen, Herlev and Gentofte Hospital, Herlev, Denmark
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19
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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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20
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Lamba N, Muskens IS, DiRisio AC, Meijer L, Briceno V, Edrees H, Aslam B, Minhas S, Verhoeff JJC, Kleynen CE, Smith TR, Mekary RA, Broekman ML. Stereotactic radiosurgery versus whole-brain radiotherapy after intracranial metastasis resection: a systematic review and meta-analysis. Radiat Oncol 2017. [PMID: 28646895 PMCID: PMC5483276 DOI: 10.1186/s13014-017-0840-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background In patients with one to three brain metastases who undergo resection, options for post-operative treatments include whole-brain radiotherapy (WBRT) or stereotactic radiosurgery (SRS) of the resection cavity. In this meta-analysis, we sought to compare the efficacy of each post-operative radiation modality with respect to tumor recurrence and survival. Methods Pubmed, Embase and Cochrane databases were searched through June 2016 for cohort studies reporting outcomes of SRS or WBRT after metastasis resection. Pooled effect estimates were calculated using fixed-effect and random-effect models for local recurrence, distant recurrence, and overall survival. Results Eight retrospective cohort studies with 646 patients (238 with SRS versus 408 with WBRT) were included in the analysis. Comparing SRS to WBRT, the overall crude risk ratio using the fixed-effect model was 0.59 for local recurrence (95%-CI: 0.32–1.09, I2: 3.35%, P-heterogeneity = 0.36, 3 studies), 1.09 for distant recurrence (95%-CI: 0.74–1.60, I2: 50.5%, P-heterogeneity = 0.13; 3 studies), and 2.99 for leptomeningeal disease (95% CI 1.55–5.76; I2: 14.4% p-heterogeneity: 0.28; 2 studies). For the same comparison, the risk ratio for median overall survival was 0.47 (95% CI: 0.41–0.54; I2: 79.1%, P-heterogeneity < 0.01; 4 studies) in a fixed-effect model, but was no longer significant (0.63; 95%-CI: 0.40–1.00) in a random-effect model. SRS was associated with a lower risk of leukoencephalopathy (RR: 0.15, 95% CI: 0.07–0.33, 1 study), yet with a higher risk of radiation-necrosis (RR: 19.4, 95% CI: 1.21–310, 1 study). Conclusion Based on retrospective cohort studies, the results of this study suggest that SRS of the resection cavity may offer comparable survival and similar local and distant control as adjuvant WBRT, yet may be associated with a higher risk for developing leptomeningeal disease. Future research on SRS should focus on achieving a better understanding of the various factors that may favor SRS over WBRT.
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Affiliation(s)
- Nayan Lamba
- Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Ivo S Muskens
- Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, HP G03.124, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Aislyn C DiRisio
- Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Louise Meijer
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, HP G03.124, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | | | - Heba Edrees
- School of Pharmacy, MCPHS University, Boston, MA, USA
| | - Bilal Aslam
- School of Pharmacy, MCPHS University, Boston, MA, USA
| | - Sadia Minhas
- School of Pharmacy, MCPHS University, Boston, MA, USA
| | - Joost J C Verhoeff
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Catharina E Kleynen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Timothy R Smith
- Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rania A Mekary
- Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,School of Pharmacy, MCPHS University, Boston, MA, USA
| | - Marike L Broekman
- Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. .,Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, HP G03.124, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
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21
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Rava P, Rosenberg J, Jamorabo D, Sioshansi S, DiPetrillo T, Wazer DE, Hepel J. Feasibility and safety of cavity-directed stereotactic radiosurgery for brain metastases at a high-volume medical center. Adv Radiat Oncol 2016; 1:141-147. [PMID: 28740883 PMCID: PMC5514013 DOI: 10.1016/j.adro.2016.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 06/13/2016] [Accepted: 06/15/2016] [Indexed: 11/20/2022] Open
Abstract
Objective Our objective was to report safety and efficacy of stereotactic radiosurgery (SRS) to the surgical bed following resection of brain metastases. Methods Eighty-seven consecutive patients who underwent cavity-directed SRS to the operative bed for the treatment of brain metastases between 2002 and 2010 were evaluated. SRS required a gadolinium-enhanced, high-resolution, T1-weighted magnetic resonance imaging for tumor targeting and delivered a median dose of 18 Gy (14-22 Gy) prescribed to encompass the entire resection cavity. Whole brain irradiation was reserved for salvage. Patients were followed every 3 months with clinical examination and magnetic resonance imaging. Overall survival, local and regional recurrence, and factors affecting these outcomes were evaluated using Kaplan-Meier and log-rank analyses. Results The median imaging follow-up was 7.1 months, with >40% of patients having imaging for ≥1 year. Local control at 1 and 2 years was 82% and 75%, respectively. Cavity recurrence was more common with a tumor diameter >3 cm (P < .020) or resection cavity volume >14 mL (P < .050). One-year local control for tumors <2 cm, 2 cm to 3 cm, and >3 cm were 100%, 86%, and 72%, respectively. Neither subtotal resection nor target margins >2 mm to 3 mm affected local control. The median overall survival was 14.3 months with actuarial 5-year survival of 20%. Actuarial regional central nervous system recurrence was 44% at 1 year. On univariate analysis, only the presence of extracranial disease was associated with survival (P < .001) and central nervous system failure (P < .030). Conclusions Excellent local control is achievable with cavity-directed SRS in well-selected patients, particularly for lesions with diameter <3 cm and resection cavity volumes <14 mL. Long-term survival is possible for select patients.
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Affiliation(s)
- Paul Rava
- Department of Radiation Oncology, University of Massachusetts, Worcester, Massachusetts
- Corresponding author. Radiation Oncology, University of Massachusetts, 55 Lake Avenue North, Worcester, MA 01655Radiation OncologyUniversity of Massachusetts55 Lake Avenue NorthWorcesterMA01655
| | - Jennifer Rosenberg
- Department of Radiation Oncology, Pennsylvania State University, Hershey, Pennsylvania
| | - Daniel Jamorabo
- Department of Radiation Oncology, University of Massachusetts, Worcester, Massachusetts
| | - Shirin Sioshansi
- Department of Radiation Oncology, University of Massachusetts, Worcester, Massachusetts
| | - Thomas DiPetrillo
- Department of Radiation Oncology, Rhode Island Hospital, Providence, Rhode Island
| | - David E. Wazer
- Department of Radiation Oncology, Rhode Island Hospital, Providence, Rhode Island
| | - Jaroslaw Hepel
- Department of Radiation Oncology, Rhode Island Hospital, Providence, Rhode Island
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VRÁNA DAVID, ŠTUDENTOVÁ HANA, MATZENAUER MARCEL, VLACHOVÁ ZUZANA, CWIERTKA KAREL, GREMLICA DAVID, KALITA ONDŘEJ. Treatment of brain metastases of renal cell cancer with combined hypofractionated stereotactic radiotherapy and whole brain radiotherapy with hippocampal sparing. Oncol Lett 2016; 11:3777-3781. [PMID: 27313693 PMCID: PMC4888132 DOI: 10.3892/ol.2016.4440] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 03/01/2016] [Indexed: 11/05/2022] Open
Abstract
Renal cell cancer patients with brain metastatic disease generally have poor prognosis. Treatment options include surgery, radiotherapy, targeted therapy or best supportive care with respect to disease burden, patient preference and performance status. In the present case report the radiotherapy technique combining whole brain radiotherapy with hippocampal sparing (hippocampal avoidance whole brain radiotherapy HA-WBRT) and hypofractionated stereotactic radiotherapy (SRT) of the brain metastases is performed in a patient with metastatic renal cell carcinoma. HA-WBRT was administered to 30 Gy in 10 fractions with sparing of the hippocampal structures and SRT of 21 Gy in 3 fractions to brain metastases which has preceded the HA-WBRT. Two single arc volumetric modulated arc radiotherapy (VMAT) plans were prepared using Monaco planning software. The HA-WBRT treatment plan achieved the following results: D2=33.91 Gy, D98=25.20 Gy, D100=14.18 Gy, D50=31.26 Gy. The homogeneity index was calculated as a deduction of the minimum dose in 2% and 98% of the planning target volume (PTV), divided by the minimum dose in 50% of the PTV. The maximum dose to the hippocampus was 17.50 Gy and mean dose was 11.59 Gy. The following doses to organs at risk (OAR) were achieved: Right opticus Dmax, 31.96 Gy; left opticus Dmax, 30.96 Gy; chiasma D max, 32,76 Gy. The volume of PTV for stereotactic radiotherapy was 3,736 cm3, with coverage D100=20.95 Gy and with only 0.11% of the PTV being irradiated to dose below the prescribed dose. HA-WBRT with SRT represents a feasible technique for radiotherapy of brain metastatic disease, however this technique is considerably demanding on departmental equipment and staff time/experience.
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Affiliation(s)
- DAVID VRÁNA
- Department of Oncology, Faculty of Medicine and Dentistry, Palacky University, Olomouc 77900, Czech Republic
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacky University, University Hospital in Olomouc, Olomouc 77900, Czech Republic
- Toxicogenomics Unit, National Institute of Public Health, Prague 10042, Czech Republic
| | - HANA ŠTUDENTOVÁ
- Department of Oncology, Faculty of Medicine and Dentistry, Palacky University, Olomouc 77900, Czech Republic
| | - MARCEL MATZENAUER
- Department of Oncology, Faculty of Medicine and Dentistry, Palacky University, Olomouc 77900, Czech Republic
| | - ZUZANA VLACHOVÁ
- Department of Oncology, Faculty of Medicine and Dentistry, Palacky University, Olomouc 77900, Czech Republic
| | - KAREL CWIERTKA
- Department of Oncology, Faculty of Medicine and Dentistry, Palacky University, Olomouc 77900, Czech Republic
| | - DAVID GREMLICA
- Department of Oncology, Faculty of Medicine and Dentistry, Palacky University, Olomouc 77900, Czech Republic
| | - ONDŘEJ KALITA
- Department of Neurosurgery, Faculty of Medicine and Dentistry, Palacky University, Olomouc 77900, Czech Republic
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Bates JE, Youn P, Usuki KY, Dhakal S, Milano MT. Repeat courses of SRS in patients initially treated with SRS alone for brain-metastatic melanoma. Melanoma Manag 2016; 3:97-104. [PMID: 30190878 DOI: 10.2217/mmt-2016-0005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 02/08/2016] [Indexed: 11/21/2022] Open
Abstract
Aim Stereotactic radiosurgery (SRS) is often used in the treatment of brain metastatic melanoma. Little data exist regarding outcomes of repeat course of SRS in this population. We aimed to identify treatment outcomes and toxicities in melanoma patients treated with repeat SRS after upfront SRS. Patients & methods We reviewed ten consecutive patients treated with repeat SRS following upfront SRS alone for brain metastatic melanoma. Results The median overall survival from initial treatment was 17.5 months. The median overall survival from repeat SRS was 6.7 months with a 6-month local control rate of 80%. The majority of patients progressed systemically before death. Four patients reported six adverse events, all grade 1. Conclusion Prospective study regarding the safety and efficacy of repeat courses of SRS in patients with brain-metastatic melanoma, especially in combination with novel immunotherapies, is warranted.
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Affiliation(s)
- James E Bates
- Department of Radiation Oncology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 647, Rochester, NY 14642, USA
| | - Paul Youn
- Department of Radiation Oncology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 647, Rochester, NY 14642, USA
| | - Kenneth Y Usuki
- Department of Radiation Oncology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 647, Rochester, NY 14642, USA
| | - Sughosh Dhakal
- Department of Radiation Oncology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 647, Rochester, NY 14642, USA
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 647, Rochester, NY 14642, USA
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Redjal N, Agarwalla PK, Dietrich J, Dinevski N, Stemmer-Rachamimov A, Nahed BV, Loeffler JS. Remote acute demyelination after focal proton radiation therapy for optic nerve meningioma. J Clin Neurosci 2015; 22:1367-9. [PMID: 25937571 DOI: 10.1016/j.jocn.2015.02.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 02/14/2015] [Indexed: 11/17/2022]
Abstract
We present a unique patient with delayed onset, acute demyelination that occurred distant to the effective field of radiation after proton beam radiotherapy for an optic nerve sheath meningioma. The use of stereotactic radiotherapy as an effective treatment modality for some brain tumors is increasing, given technological advances which allow for improved targeting precision. Proton beam radiotherapy improves the precision further by reducing unnecessary radiation to surrounding tissues. A 42-year-old woman was diagnosed with an optic nerve sheath meningioma after initially presenting with vision loss. After biopsy of the lesion to establish diagnosis, the patient underwent stereotactic proton beam radiotherapy to a small area localized to the tumor. Subsequently, the patient developed a large enhancing mass-like lesion with edema in a region outside of the effective radiation field in the ipsilateral frontal lobe. Given imaging features suggestive of possible primary malignant brain tumor, biopsy of this new lesion was performed and revealed an acute demyelinating process. This patient illustrates the importance of considering delayed onset acute demyelination in the differential diagnosis of enhancing lesions in patients previously treated with radiation.
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Affiliation(s)
- Navid Redjal
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
| | - Pankaj K Agarwalla
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Jorg Dietrich
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nikolaj Dinevski
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anat Stemmer-Rachamimov
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Jay S Loeffler
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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25
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Faria SL. Role of radiotherapy in metastatic non-small cell lung cancer. Front Oncol 2014; 4:229. [PMID: 25353005 PMCID: PMC4195278 DOI: 10.3389/fonc.2014.00229] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 08/08/2014] [Indexed: 11/13/2022] Open
Abstract
Radiotherapy has had important role in the palliation of NSCLC. Randomized trials tend to suggest that, in general, short regimens give similar palliation and toxicity compared to longer regimens. The benefit of combining chemotherapy to radiosensitize the palliative radiation treatment is an open question, but so far it has not been proved to be very useful in NSCLC. The addition of molecular targeted drugs to radiotherapy outside of approved regimens or clinical trials warrants careful consideration for every single case and probably should not be used as a routine management. Stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) are modern techniques being used each time more frequently in the treatment of single or oligometastases. In general, they offer good tumor control with little toxicity (with a more expensive cost) compared to the traditionally fractionated radiotherapy regimens.
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Affiliation(s)
- Sergio L Faria
- Department of Radiation Oncology, McGill University Health Centre, Montreal General Hospital , Montreal, QC , Canada
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Nieder C, Grosu AL, Gaspar LE. Stereotactic radiosurgery (SRS) for brain metastases: a systematic review. Radiat Oncol 2014; 9:155. [PMID: 25016309 PMCID: PMC4107473 DOI: 10.1186/1748-717x-9-155] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 07/09/2014] [Indexed: 01/10/2023] Open
Abstract
In many patients with brain metastases, the primary therapeutic aim is symptom palliation and maintenance of neurologic function, but in a subgroup, long-term survival is possible. Local control in the brain, and absent or controlled extracranial sites of disease are prerequisites for favorable survival. Stereotactic radiosurgery (SRS) is a focal, highly precise treatment option with a long track record. Its clinical development and implementation by several pioneering institutions eventually rendered possible cooperative group randomized trials. A systematic review of those studies and other landmark studies was undertaken. Most clinicians are aware of the potential benefits of SRS such as a short treatment time, a high probability of treated-lesion control and, when adhering to typical dose/volume recommendations, a low normal tissue complication probability. However, SRS as sole first-line treatment carries a risk of failure in non-treated brain regions, which has resulted in controversy around when to add whole-brain radiotherapy (WBRT). SRS might also be prescribed as salvage treatment in patients relapsing despite previous SRS and/or WBRT. An optimal balance between intracranial control and side effects requires continued research efforts.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092 Bodø, Norway.
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