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Pan K, Wang B, Xu X, Liang J, Tang Y, Ma S, Xia B, Zhu L. Hypofractionated stereotactic radiotherapy for brain metastases in lung cancer patients: dose‒response effect and toxicity. Discov Oncol 2024; 15:318. [PMID: 39078419 DOI: 10.1007/s12672-024-01191-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 07/24/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND Lung cancer is a common cause of brain metastases, approximately 40% of patients with lung cancer will develop brain metastases at some point during their disease. Hypofractionated stereotactic radiotherapy (HSRT) has been demonstrated to be effective in controlling limited brain metastases. However, there is still no conclusive on the optimal segmentation of HSRT. The aim of our study was to explore the correlation between the HSRT dosage and its treatment effect and toxicity. METHODS A retrospective analysis was conducted on patients with non-small cell lung cancer (NSCLC) brain metastasis at Hangzhou Cancer Hospital from 1 January 2019 to 1 January 2021. The number of brain metastases did not exceed 10 in all patients and the number of fractions of HSRT was 5. The prescription dose ranges from 25 to 40 Gy. The Kaplan-Meier method was used for estimation of the localised intracranial control rate (iLC). Adverse radiation effects (AREs) were evaluated according to CTCAE 5.0. This study was approved by the Institutional Ethics Review Board of the Hangzhou Cancer Hospital (#73/HZCH-2022). RESULTS Forty eligible patients with a total of 70 brain metastases were included in this study. The 1-year iLC was 76% and 89% in the prescribed dose ≤ 30 Gy and > 30 Gy group, respectively (P < 0.05). For patients treated with HSRT combined with targeted therapy, immunotherapy and chemotherapy, the 1-year iLC was 89%, 100%, and 45%, respectively. No significant associations were observed between the number, maximum diameter, location, and type of pathology of brain metastases. The rate of all-grade AREs was 33%. Two patients who received a total dose of 40 Gy developed grade 3 headache, the rest of the AREs were grade 1-2. CONCLUSIONS Increasing the prescription dose of HSRT improves treatment effect but may also exacerbate the side effects. Systemic therapy might impact the iLC rate, and individualized treatment regimens need to be developed.
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Affiliation(s)
- Kaicheng Pan
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China
| | - Bing Wang
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China
| | - Xiao Xu
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China
| | - Jiafeng Liang
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China
| | - Yi Tang
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China
| | - Shenglin Ma
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China
| | - Bing Xia
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China.
| | - Lucheng Zhu
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China.
- Department of Oncology, Affiliated Hangzhou Cancer Hospital, Zhejiang Chinese Medical University, Hangzhou, China.
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Yoshida T, Sasaki K, Hayakawa T, Kawadai T, Shibasaki T, Kawasaki Y. Recommendation for reducing the crystalline lens exposure dose by reducing imaging field width in cone-beam computed tomography for image-guided radiation therapy: an anthropomorphic phantom study. Radiol Phys Technol 2024:10.1007/s12194-024-00810-0. [PMID: 38691308 DOI: 10.1007/s12194-024-00810-0] [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: 01/23/2024] [Revised: 03/23/2024] [Accepted: 04/26/2024] [Indexed: 05/03/2024]
Abstract
In cone-beam computed tomography (CBCT) for image-guided radiation therapy (IGRT) of the head, we evaluated the exposure dose reduction effect to the crystalline lens and position-matching accuracy by narrowing one side (X2) of the X-ray aperture (blade) in the X-direction. We defined the ocular surface dose of the head phantom as the crystalline lens exposure dose and measured using a radiophotoluminescence dosimeter (RPLD, GD-352 M) in the preset field (13.6 cm) and in each of the fields when blade X2 aperture was reduced in 0.5 cm increments from 10.0 to 5.0 cm. Auto-bone matching was performed on CBCT images acquired five times with blade X2 aperture set to 13.6 cm and 5.0 cm at each position when the head phantom was moved from - 5.0 to + 5.0 mm in 1.0 mm increment. The maximum reduction rate in the crystalline lens exposure dose was - 38.7% for the right lens and - 13.2% for the left lens when blade X2 aperture was 5.0 cm. The maximum difference in the amount of position correction between blade X2 aperture of 13.6 cm and 5.0 cm was 1 mm, and the accuracy of auto-bone matching was similar. In CBCT of the head, reduced blade X2 aperture is a useful technique for reducing the crystalline lens exposure dose while ensuring the accuracy of position matching.
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Affiliation(s)
- Tatsuya Yoshida
- Department of Radiology, Koritsu Tatebayashi Kosei General Hospital, Gunma, Japan.
- Graduate School of Radiological Technology, Gunma Prefectural College of Health Sciences, Gunma, Japan.
| | - Koji Sasaki
- Graduate School of Radiological Technology, Gunma Prefectural College of Health Sciences, Gunma, Japan
| | - Tomoki Hayakawa
- Department of Radiology, Koritsu Tatebayashi Kosei General Hospital, Gunma, Japan
| | - Toshiyuki Kawadai
- Department of Radiology, Koritsu Tatebayashi Kosei General Hospital, Gunma, Japan
| | - Takako Shibasaki
- Department of Radiology, Koritsu Tatebayashi Kosei General Hospital, Gunma, Japan
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Harikar MM, Venkataram T, Palmisciano P, Scalia G, Baldoncini M, Cardali SM, Umana GE, Ferini G. Comparison of Staged Stereotactic Radiosurgery and Fractionated Stereotactic Radiotherapy in Patients with Brain Metastases > 2 cm without Prior Whole Brain Radiotherapy: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 178:213-232.e6. [PMID: 37543203 DOI: 10.1016/j.wneu.2023.07.143] [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: 07/07/2023] [Accepted: 07/30/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE To compare fractionated stereotactic radiotherapy (FSRT) with staged stereotactic radiosurgery (SSRS) in patients with brain metastases >2 cm without prior whole brain radiotherapy. METHODS In this systematic review and meta-analysis, PubMed, Scopus, Web of Science, Embase, and Cochrane were searched to include studies that evaluated FSRT and/or SSRS for brain metastases >2 cm or 4 cm3 in adult patients with a known primary malignancy and no prior history of whole brain radiotherapy. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed and an indirect random-effect meta-analyses was conducted to compare treatment outcomes between the two modalities. RESULTS A total of 10 studies were included, comprising 612 (778 metastases) and 250 patients (265 metastases) in the SSRS and FSRT groups, respectively. The SSRS group had significantly older patients (66.6 ± 17.51 years vs. 62.37 ± 37.89 years; P = 0.029) with lower rate of control of primary disease (11.59% vs. 78.7%, P < 0.00001), and more patients with Karnofsky performance status ≥70 at baseline (92.81% vs. 88.56%; P = 0.045). FSRT was associated with a statistically nonsignificant but clinically important lower 12-month overall survival (44.75% [95% confidence interval [CI]: 30.48%-59.95%] vs. 53.25% [95%CI: 45.15%-61.19%], P = 0.1615) and higher rate of salvage radiotherapy (18.18% [95%CI: 8.75%-34%] vs. 12.27% [95%CI: 5.98%-23.53%], P = 0.0841). Both groups had comparable rates of local tumor control, mortality, tumor progression, recurrence, neurological death, and 6-month overall survival. CONCLUSIONS SSRS and FSRT were found to be comparable for treating brain metastases >2 cm not previously irradiated. Given the paucity of such studies, trials directly comparing the two treatment strategies are warranted to support these findings.
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Affiliation(s)
- Mandara M Harikar
- Clinical Trials Programme, Usher Institute of Molecular, Genetic and Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Tejas Venkataram
- Department of Neurosurgery, St. John's Medical College Hospital, Bangalore, India
| | - Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Gianluca Scalia
- Department of Head and Neck Surgery, Neurosurgery Unit, Garibaldi Hospital, Catania, Italy
| | - Matias Baldoncini
- Department of Neurological Surgery, San Fernando Hospital, San Fernando, Argentina
| | - Salvatore Massimiliano Cardali
- Department of Neurosurgery, Azienda Ospedaliera Papardo, University of Messina, Messina, Italy; Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
| | - Giuseppe E Umana
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy.
| | - Gianluca Ferini
- Department of Radiation Oncology, REM Radioterapia srl, Viagrande, Italy
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Chen T, Tang M, Zhou Y, Wang Z, Li S, Wang H, Lu Y, Wang J, Shen W. Pretreatment lymphocyte-to-monocyte ratio as a prognostic factor and influence on dose-effect in fractionated stereotactic radiotherapy for oligometastatic brain metastases in non-small cell lung cancer patients. Front Oncol 2023; 13:1216852. [PMID: 37456254 PMCID: PMC10348423 DOI: 10.3389/fonc.2023.1216852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/14/2023] [Indexed: 07/18/2023] Open
Abstract
Background Studies on the prognostic factors for patients with brain oligo-metastasis treated with fractionated stereotactic radiotherapy (FSRT) usually focus on the size of metastatic tumor and radiation dose. Some inflammatory indicators have predictive value in non-small cell lung cancer (NSCLC) with brain metastasis receiving stereotactic radiotherapy. However, the prognostic value of inflammatory indicators in NSCLC patients with brain oligo-metastasis treated with FSRT, and their effect on radiotherapy dose is unknown. Methods A total of 95 advanced NSCLC patients with brain oligo-metastasis who had undergone FSRT treatment at Ningbo Medical Center Lihuili Hospital between January 2015 and April 2022 were enrolled into the study. Neutrophil to lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR), lymphocyte to monocyte ratio (LMR), tumor diameter and biologically effective dose (BED10) were analyzed using Chi-square test. Univariate and multivariate Cox regressions were used to identify predictors of survival. Results Tumor diameter (< 2 cm), BED10 (≥ 48Gy) and LMR (≥ 4) were found to be independently associated with good intracranial local control survival (i-LCS) through multivariate analysis. The median i-LCS was longer in patients with 2 independent risk factors (tumor diameter ≥ 2 and LMR < 4) administered with BED10 > 53.6Gy compared with patients administered with BED10 ≤ 53.6Gy (20.7 months vs 12.0 months, P = 0.042). LMR ≥ 4 (P = 0.019) and positivity for driver gene mutations (P = 0.011) were independently associated with better overall survival (OS). Conclusions LMR is an independent prognostic factor of i-LCS and OS in NSCLC patients with brain oligo-metastasis treated with FSRT. Patients with tumor diameter ≥ 2 and LMR < 4 should be treated with BED10 greater than 53.6Gy.
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Affiliation(s)
- Tian Chen
- Department of Radiation Oncology, Ningbo Medical Center Lihuili Hospital, Ningbo University, Ningbo, China
| | - Mengqiu Tang
- Department of Radiation Oncology, Ningbo Medical Center Lihuili Hospital, Ningbo University, Ningbo, China
| | - Yang Zhou
- Department of Ningbo Institute of Innovation for Combined Medicine and Engineering, Ningbo Medical Center Lihuili Hospital, Ningbo University, Ningbo, China
| | - Zhepei Wang
- Department of Neurosurgery, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Shiwei Li
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo University, Ningbo, China
| | - Hongcai Wang
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo University, Ningbo, China
| | - Yangfang Lu
- Department of Radiation Oncology, Ningbo Medical Center Lihuili Hospital, Ningbo University, Ningbo, China
| | - Jinguo Wang
- Department of Radiation Oncology, Ningbo Medical Center Lihuili Hospital, Ningbo University, Ningbo, China
| | - Weiyu Shen
- Department of Thoracic Surgery, Ningbo Medical Center Lihuili Hospital, Ningbo University, Ningbo, China
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Piras A, Boldrini L, Menna S, Sanfratello A, D'Aviero A, Cusumano D, Di Cristina L, Messina M, Spada M, Angileri T, Daidone A. Five-Fraction Stereotactic Radiotherapy for Brain Metastases: A Single-Institution Experience on Different Dose Schedules. Oncol Res Treat 2022; 45:408-414. [PMID: 35172322 DOI: 10.1159/000522645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/11/2022] [Indexed: 11/19/2022]
Abstract
Introduction The most common intracranial neoplasm diagnosed in adults are brain metastases (BrM). The benefit in terms of clinical control and toxicity for stereotactic radiotherapy (SRT)has been investigated for patients with low load of brain metastases. Aim of this single-institution experience was to investigate the best dose schedule for five-fraction stereotactic radiotherapy (FFSRT). Methods A retrospective analysis of patients treated for BrM with different dose schedules of FFSRT was performed. Local Control and clinical outcomes were evaluated with Magnetic resonance imaging (MRI) at 3, 6 and 9 months. Toxicity data were also collected. Results A total of 41 patients treated from November 2016 to September 2020 were enrolled in the analysis. Non Small Cell Lung cancer (51,2%) and breast cancer (24,3%) represented the most frequent primitive tumors. Treatment was performed on 5 consecutive days with prescribed dose ranging from 30 to 40 Gy, prescribed to the 95% isodose line that covered at least 98% of the GTV. Statistically significant differences (p=0.025) with higher LC control rates for dose schedules > 6Gy for fractions. Toxicity rates were not found to be higher than G1. Conclusion The results of this retrospective analysis suggest that FFSRT for BrM seems to be safe and feasible. Our results also underline that a total dose lower than 30 Gy in 5 fractions should not be used due to the expected minor LC.
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Affiliation(s)
- Antonio Piras
- UO Radioterapia Oncologica, Villa Santa Teresa, Palermo, Italy
| | - Luca Boldrini
- UOC Radioterapia Oncologica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica Ed Ematologia, Roma, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sebastiano Menna
- UOC Radioterapia Oncologica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica Ed Ematologia, Roma, Italy
| | | | - Andrea D'Aviero
- Radiation Oncology, Mater Olbia Hospital, Olbia, Sassari, Italy
| | - Davide Cusumano
- UOC Radioterapia Oncologica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica Ed Ematologia, Roma, Italy
| | | | - Marco Messina
- UOC Oncologia Medica, Ospedali Riuniti Villa Sofia Cervello, Palermo, Italy
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Papp J, Simon M, Csiki E, Kovács Á. CBCT Verification of SRT for Patients With Brain Metastases. Front Oncol 2022; 11:745140. [PMID: 35127470 PMCID: PMC8807635 DOI: 10.3389/fonc.2021.745140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 12/23/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe aim of our work is to demonstrate the role of image guidance and volumetric imaging in stereotactic radiotherapy (SRT) of brain metastases.MethodsBetween 2018 and 2020, 106 patients underwent intracranial stereotactic radiotherapy. 10 patients with metastatic brain tumors treated with SRT were randomly selected and included in our study model. Patients were scanned pre- and post-treatment with cone beam CT. Total of 100 verifications of 50 stereotaxic treatments were performed and analyzed.ResultsPopulation mean X, Y, Z values were -0.13 cm, -0.04 cm, -0.03 cm, respectively, rotation values 0.81°, 0.51°, 0.46°, respectively. Systematic error components for translational displacements pre corrections were as follows: 0.14 cm for X, 0.13 cm for Y and 0.1 cm for Z. Systematic error components of the post-treatment HR 3D CBCTs were as follows: 0.01 cm for X, 0.06 cm for Y and 0.04 cm for Z.ConclusionsPopulation mean values close to 0 confirmed that there is no systematic variation in our system and the accuracy of our equipment and tools is reliable. HR 3D CBCT scans performed pre SRTs further refine patient and target volume setting, support medical decision making and eliminate the possibility of gross error.
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Affiliation(s)
- Judit Papp
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Mihály Simon
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Emese Csiki
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Árpád Kovács
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary
- *Correspondence: Árpád Kovács,
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Loo M, Clavier JB, Attal Khalifa J, Moyal E, Khalifa J. Dose-Response Effect and Dose-Toxicity in Stereotactic Radiotherapy for Brain Metastases: A Review. Cancers (Basel) 2021; 13:cancers13236086. [PMID: 34885193 PMCID: PMC8657210 DOI: 10.3390/cancers13236086] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 11/29/2022] Open
Abstract
Simple Summary Brain metastases are one of the most frequent complications for cancer patients. Stereotactic radiosurgery is considered a cornerstone treatment for patients with limited brain metastases and the ideal dose and fractionation schedule still remain unknown. The aim of this literature review is to discuss the dose-effect relation in brain metastases treated by stereotactic radiosurgery, accounting for fractionation and technical considerations. Abstract For more than two decades, stereotactic radiosurgery has been considered a cornerstone treatment for patients with limited brain metastases. Historically, radiosurgery in a single fraction has been the standard of care but recent technical advances have also enabled the delivery of hypofractionated stereotactic radiotherapy for dedicated situations. Only few studies have investigated the efficacy and toxicity profile of different hypofractionated schedules but, to date, the ideal dose and fractionation schedule still remains unknown. Moreover, the linear-quadratic model is being debated regarding high dose per fraction. Recent studies shown the radiation schedule is a critical factor in the immunomodulatory responses. The aim of this literature review was to discuss the dose–effect relation in brain metastases treated by stereotactic radiosurgery accounting for fractionation and technical considerations. Efficacy and toxicity data were analyzed in the light of recent published data. Only retrospective and heterogeneous data were available. We attempted to present the relevant data with caution. A BED10 of 40 to 50 Gy seems associated with a 12-month local control rate >70%. A BED10 of 50 to 60 Gy seems to achieve a 12-month local control rate at least of 80% at 12 months. In the brain metastases radiosurgery series, for single-fraction schedule, a V12 Gy < 5 to 10 cc was associated to 7.1–22.5% radionecrosis rate. For three-fractions schedule, V18 Gy < 26–30 cc, V21 Gy < 21 cc and V23 Gy < 5–7 cc were associated with about 0–14% radionecrosis rate. For five-fractions schedule, V30 Gy < 10–30 cc, V 28.8 Gy < 3–7 cc and V25 Gy < 16 cc were associated with about 2–14% symptomatic radionecrosis rate. There are still no prospective trials comparing radiosurgery to fractionated stereotactic irradiation.
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Affiliation(s)
- Maxime Loo
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
- Correspondence:
| | - Jean-Baptiste Clavier
- Radiotherapy Department, Strasbourg Europe Cancer Institute (ICANS), 67033 Strasbourg, France;
| | - Justine Attal Khalifa
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
| | - Elisabeth Moyal
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
| | - Jonathan Khalifa
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
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Fractionated Stereotactic Radiation Therapy Using Volumetric Modulated Arc Therapy in Patients with Solitary Brain Metastases. BIOMED RESEARCH INTERNATIONAL 2021; 2020:6342057. [PMID: 32964040 PMCID: PMC7501556 DOI: 10.1155/2020/6342057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 06/21/2020] [Accepted: 07/20/2020] [Indexed: 11/18/2022]
Abstract
Purpose To analyze retrospectively the clinical efficacy and safety for patients treated with fractionated stereotactic radiation therapy (FSRT) using volumetric modulated arc therapy. Methods Between 2016 and 2017, 46 patients with solitary brain metastasis who underwent FSRT consisting of 25-40 Gy/5 fractions were recruited in this study. All targets within the same course received different prescriptions according to size. Toxicities were graded according to the Common Terminology Criteria for Adverse Events version 4.0. Results The median follow-up was 11 months (3-53 months). The 6-month and 12-month local control rate calculated by Kaplan-Meier estimate was, respectively, 95% and 86%. Tumor diameter < 2.5 cm obtained 100% improved 12-month local control rate compared with 66% in those with ≥2.5 cm (P < 0.001). The 12-month local control calculated by Kaplan-Meier estimate was 95% in tumors with >30 Gy treatment and only 60% in tumors with ≤30 Gy treatment (P = 0.001). Multivariate analysis revealed that the prescription dose ≤ 30 Gy resulted in increased local failure (hazard ratio (HR), 0.14 (range, 0.019-0.95; P = .046)). Grade 3 or worse toxic effects were found in 5 (11%) patients, and no patient experienced surgical resection for symptomatic radioactive necrosis. Conclusions FSRT for solid brain metastasis appears to have the advantages of a high rate of local control with a minimal risk of severe toxicity and deserves application in the clinical practice.
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Cyberknife ® hypofractionated stereotactic radiosurgery (CK-hSRS) as salvage treatment for brain metastases. J Cancer Res Clin Oncol 2021; 147:2765-2773. [PMID: 33638006 PMCID: PMC8310836 DOI: 10.1007/s00432-021-03564-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 02/10/2021] [Indexed: 11/16/2022]
Abstract
Purpose The introduction of hypofractionated stereotactic radiosurgery (hSRS) extended the treatment modalities beyond the well-established single-fraction stereotactic radiosurgery and fractionated radiotherapy. Here, we report the efficacy and side effects of hSRS using Cyberknife® (CK-hSRS) for the treatment of patients with critical brain metastases (BM) and a very poor prognosis. We discuss our experience in light of current literature. Methods All patients who underwent CK-hSRS over 3 years were retrospectively included. We applied a surface dose of 27 Gy in 3 fractions. Rates of local control (LC), systemic progression-free survival (PFS), and overall survival (OS) were estimated using Kaplan–Meier method. Treatment-related complications were rated using the Common Terminology Criteria for Adverse Events (CTCAE). Results We analyzed 34 patients with 75 BM. 53% of the patients had a large tumor, tumor location was eloquent in 32%, and deep seated in 15%. 36% of tumors were recurrent after previous irradiation. The median Karnofsky Performance Status was 65%. The actuarial rates of LC at 3, 6, and 12 months were 98%, 98%, and 78.6%, respectively. Three, 6, and 12 months PFS was 38%, 32%, and 15%, and OS was 65%, 47%, and 28%, respectively. Median OS was significantly associated with higher KPS, which was the only significant factor for survival. Complications CTCAE grade 1–3 were observed in 12%. Conclusion Our radiation schedule showed a reasonable treatment effectiveness and tolerance. Representing an optimal salvage treatment for critical BM in patients with a very poor prognosis and clinical performance state, CK-hSRS may close the gap between surgery, stereotactic radiosurgery, conventional radiotherapy, and palliative care.
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Diamond BH, Jairam V, Zuberi S, Li JY, Marquis TJ, Rutter CE, Park HS. Linear accelerator-based single-fraction stereotactic radiosurgery versus hypofractionated stereotactic radiotherapy for intact and resected brain metastases up to 3 cm: A multi-institutional retrospective analysis. JOURNAL OF RADIOSURGERY AND SBRT 2021; 7:179-187. [PMID: 33898081 PMCID: PMC8055233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 11/24/2020] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Single-fraction stereotactic radiosurgery (SF-SRS) is typically used to provide local control of brain metastases. Recently, hypofractionated stereotactic radiotherapy (HF-SRT) has been utilized for large brain metastases. Data comparing these two modalities are limited for brain metastases ≤3 cm. METHODS Patients with brain metastases receiving linear accelerator-based SF-SRS or HF-SRT were identified at three institutions. Local progression-free survival (LPFS), intracranial progression-free survival (ICPFS), overall survival (OS), and radionecrosis-free survival (RNFS) were determined from time of treatment. RESULTS 108 patients (76 intact, 32 resected) with 184 brain metastases (142 intact, 42 resected) were included. There were no significant differences between SF-SRS and HF-SRT for intact metastases in 1-year LPFS (62.8% vs. 58.5%, p=0.631), ICPFS (56.9% vs. 55.3%, p=0.300), and OS (71.6% vs. 70.6%, p=0.096), or for resected metastases in 1-year LPFS (67.3% vs. 57.8%, p=0.288), ICPFS (64.8% vs. 57%, p=0.291), and OS (64.8% vs. 66.1%, p=0.603). There were also no significant differences in 1-year RNFS between SF-SRS and HF-SRT (92% vs. 92%, p=0.325). CONCLUSIONS There were no significant differences in LPFS, ICPFS, OS, and RNFS between SF-SRS and HF-SRT for brain metastases ≤3 cm suggesting SF-SRS may be preferred due to similar outcomes and reduced number of fractions.
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Affiliation(s)
- Brett H. Diamond
- Tufts University School of Medicine, Department of Radiation Oncology, Boston, MA 02111, USA
| | - Vikram Jairam
- Yale School of Medicine, Department of Therapeutic Radiology, New Haven, CT 06511, USA
| | - Shaharyar Zuberi
- University of Connecticut School of Medicine, Department of Radiation Oncology, Farmington, CT 06032, USA
| | - Jessie Y. Li
- Yale School of Medicine, Department of Therapeutic Radiology, New Haven, CT 06511, USA
| | - Timothy J. Marquis
- Yale School of Medicine, Department of Medicine, New Haven, CT 06511, USA
| | - Charles E. Rutter
- University of Connecticut School of Medicine, Department of Radiation Oncology, Farmington, CT 06032, USA
- Hartford HealthCare, Department of Radiation Oncology, Hartford, CT 06106, USA
| | - Henry S. Park
- Tufts University School of Medicine, Department of Radiation Oncology, Boston, MA 02111, USA
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Significant correlation between gross tumor volume (GTV) D98% and local control in multifraction stereotactic radiotherapy (MF-SRT) for unresected brain metastases. Radiother Oncol 2020; 154:260-268. [PMID: 33245944 DOI: 10.1016/j.radonc.2020.11.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/10/2020] [Accepted: 11/16/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Stereotactic radiotherapy (SRT) should be applied with a biologically effective dose with an α/β of 12 (BED12) ≥ 40 Gy to reach a 1-year local control (LC) ≥ 70%. The aims of this retrospective study were to report a series of 81 unresected large brain metastases treated with Linac-based multifraction SRT according to the ICRU 91 and to identify predictive factors associated with LC. METHODS Included in this study were the first 81 brain metastases (BM) consecutively treated with Linac-based volumetric modulated arc therapy (VMAT) multifraction SRT from 2017 to 2019. The prescribed dose was 33 Gy for the GTV and 23.1 Gy (70% isodose line) for the PTV in 3 fractions (3f). Mean BM largest diameter and GTV were 25.1 mm and 7.2 cc respectively. Mean follow-up was 10.2 months. RESULTS LC was 79.7% and 69.7% at 1 and 2 years respectively. Significant predictive factors of LC were GTV D98% (HR = 0.84, CI 95% = 0.75-0.95, p = 0.004) and adenocarcinoma as the histological type (HR = 0.29, CI 95% = 0.09-0.96, p = 0.042) in univariate and multivariate analysis. A threshold of 29 Gy for GTV D98% was significantly correlated to LC (1-year LC = 91.9% for GTV D98% ≥ 29 Gy vs 69.6% for GTV D98% < 29 Gy (p = 0.030)), corresponding to a BED12 = 52.4 Gy. No tumor progression was observed for a BED12 ≥ 53.4 Gy, corresponding to a GTV D98% ≥ 20 Gy /1f and GTV D98% ≥ 29.4 Gy 3f. Median OS was 15 months. Symptomatic radionecrosis occurred in 4.9% of cases. CONCLUSION The GTV D98% is a strong reproducible significant predictive factor of LC for brain SRT. Dose prescription should lead to a GTV BED12 98% ≥ 52.4-53.4 Gy to significantly improve LC, corresponding to respectively a GTV D98% ≥ 19.7-20 Gy/1f and 29-29.4 Gy/3f.
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12
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Brun L, Dupic G, Chassin V, Chautard E, Moreau J, Dedieu V, Khalil T, Verrelle P, Lapeyre M, Biau J. Hypofractionated stereotactic radiotherapy for large brain metastases: Optimizing the dosimetric parameters. Cancer Radiother 2020; 25:1-7. [PMID: 33257109 DOI: 10.1016/j.canrad.2020.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/14/2020] [Accepted: 04/27/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE Stereotactic radiotherapy plays a major role in the treatment of brain metastases (BM). We aimed to compare the dosimetric results of four plans for hypofractionated stereotactic radiotherapy (HFSRT) for large brain metastases. MATERIAL AND METHODS Ten patients treated with upfront NovalisTx® non-coplanar multiple dynamic conformal arcs (DCA) HFSRT for≥25mm diameter single BM were included. Three other volumetric modulated arc therapy (VMAT) treatment plans were evaluated: with coplanar arcs (Eclipse®, Varian, VMATcEclipse®), with coplanar and non-coplanar arcs (VMATncEclipse®), and with non-coplanar arcs (Elements Cranial SRS®, Brainlab, VMATncElements®). The marginal dose prescribed for the PTV was 23.1Gy (isodose 70%) in three fractions. The mean GTV was 27mm3. RESULTS Better conformity indices were found with all VMAT techniques compared to DCA (1.05 vs 1.28, P<0.05). Better gradient indices were found with VMATncElements® and DCA (2.43 vs 3.02, P<0.001). High-dose delivery in healthy brain was lower with all VMAT techniques compared to DCA (5.6 to 6.3 cc vs 9.4 cc, P<0.001). Low-dose delivery (V5Gy) was lower with VMATncEclipse® or VMATncElements® than with DCA (81 or 94 cc vs 110 cc, P=0.02). CONCLUSIONS NovalisTx® VMAT HFSRT for≥25mm diameter brain metastases provides the best dosimetric compromise in terms of target coverage, sparing of healthy brain tissue and low-dose delivery compared to DCA.
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Affiliation(s)
- L Brun
- Department of radiation oncology, Jean-Perrin center, 63011 Clermont-Ferrand, France
| | - G Dupic
- Department of radiation oncology, Jean-Perrin center, 63011 Clermont-Ferrand, France.
| | - V Chassin
- Department of medical physics, Jean-Perrin center, Clermont-Ferrand, France
| | - E Chautard
- Clermont Auvergne university, INSERM, U1240 IMoST, 63000 Clermont-Ferrand, France; Department of pathology, Clermont Auvergne university, Jean-Perrin center, 63011 Clermont-Ferrand, France
| | - J Moreau
- Department of radiation oncology, Jean-Perrin center, 63011 Clermont-Ferrand, France
| | - V Dedieu
- Department of medical physics, Jean-Perrin center, Clermont-Ferrand, France
| | - T Khalil
- Department of neurosurgery, Clermont-Ferrand hospital, 63003 Clermont-Ferrand, France
| | - P Verrelle
- Department of radiation oncology, Jean-Perrin center, 63011 Clermont-Ferrand, France
| | - M Lapeyre
- Department of radiation oncology, Jean-Perrin center, 63011 Clermont-Ferrand, France
| | - J Biau
- Department of radiation oncology, Jean-Perrin center, 63011 Clermont-Ferrand, France; Clermont Auvergne university, INSERM, U1240 IMoST, 63000 Clermont-Ferrand, France
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13
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Wijetunga A, Jayamanne D, Cook R, Parkinson J, Little N, Curtis J, Brown C, Back M. Hypofractionated adjuvant surgical cavity radiotherapy following resection of limited brain metastasis. J Clin Neurosci 2020; 82:155-161. [PMID: 33317725 DOI: 10.1016/j.jocn.2020.10.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/09/2020] [Accepted: 10/18/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Following surgical resection of oligometastatic disease to the brain there is a high rate of local relapse which is reduced by the addition of focal radiation therapy, often delivered as single fraction stereotactic radiosurgery (SRS) to the surgical cavity. This study audited the outcomes of an alternative approach using hypofractionated radiation therapy (HFRT) to the surgical resection cavity. METHODS AND MATERIALS Seventy-nine patients who received surgical resection and focal radiation therapy to the surgical cavity using HFRT with intensity modulated radiation therapy with or without stereotactic radiotherapy were identified. Doses were delivered in five fractions every second day for 10 days. Follow-up involved MRI surveillance with three-monthly MRI scans post resection. The major endpoints were local control at the surgical cavity site, and presence of radiation necrosis at the treated site. RESULTS Seventy-nine patients were included for the analysis with a median follow-up of 10.8 months. Of the cohort, 56% experienced intracranial progression, with all patients progressing distant to the resection cavity, and 7% progressing locally in addition. The one-year local control rate was 89.8%. The median progression-free survival was 10.0 months and median overall survival was 14.3 months. There was one CTCAE grade 3 toxicity of symptomatic radiation necrosis with no grade 4-5 toxicities seen. CONCLUSIONS The rate of local relapse following HFRT to the surgical cavity is low with minimal risk of radiation necrosis. HFRT can be considered as an alternative to SRS for focal radiotherapy after brain metastasis resection.
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Affiliation(s)
- A Wijetunga
- Sydney Medical School, Northern Clinical School, Reserve Road, St Leonards 2065, Australia.
| | - D Jayamanne
- Sydney Medical School, Northern Clinical School, Reserve Road, St Leonards 2065, Australia; Department of Radiation Oncology, Royal North Shore Hospital, Reserve Road, St Leonards 2065, Australia
| | - R Cook
- Department of Neurosurgery, Royal North Shore Hospital, Reserve Road, St Leonards 2065, Australia; The Brain Cancer Group, North Shore Private Hospital, Westbourne Street, St Leonards 2065, Australia
| | - J Parkinson
- Sydney Medical School, Northern Clinical School, Reserve Road, St Leonards 2065, Australia; Department of Neurosurgery, Royal North Shore Hospital, Reserve Road, St Leonards 2065, Australia; The Brain Cancer Group, North Shore Private Hospital, Westbourne Street, St Leonards 2065, Australia
| | - N Little
- Department of Neurosurgery, Royal North Shore Hospital, Reserve Road, St Leonards 2065, Australia
| | - J Curtis
- Department of Neurosurgery, Royal North Shore Hospital, Reserve Road, St Leonards 2065, Australia
| | - C Brown
- NHMRC Clinical Trials Centre, University of Sydney, 92-94 Parramatta Rd, Camperdown 2050, Australia
| | - M Back
- Sydney Medical School, Northern Clinical School, Reserve Road, St Leonards 2065, Australia; Department of Radiation Oncology, Royal North Shore Hospital, Reserve Road, St Leonards 2065, Australia; The Brain Cancer Group, North Shore Private Hospital, Westbourne Street, St Leonards 2065, Australia; Central Coast Cancer Centre, Gosford Hospital, Holden Street, Gosford 2250, Australia
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14
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Navarria P, Minniti G, Clerici E, Comito T, Cozzi S, Pinzi V, Fariselli L, Ciammella P, Scoccianti S, Borzillo V, Anselmo P, Maranzano E, Dell'acqua V, Jereczek-Fossa B, Giaj Levra N, Podlesko AM, Giudice E, Buglione di Monale E Bastia M, Pedretti S, Bruni A, Bossi Zanetti I, Borghesi S, Busato F, Pasqualetti F, Paiar F, Scorsetti M. Brain metastases from primary colorectal cancer: is radiosurgery an effective treatment approach? Results of a multicenter study of the radiation and clinical oncology Italian association (AIRO). Br J Radiol 2020; 93:20200951. [PMID: 33035077 DOI: 10.1259/bjr.20200951] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES The prognosis of brain metastatic colorectal cancer patients (BMCRC) is poor. Several local treatments have been used, but the optimal treatment choice remains an unresolved issue. We evaluated the clinical outcomes of a large series of BMCRC patients treated in several Italian centers using stereotactic radiosurgery (SRS). METHODS 185 BMCRC patients for a total of 262 lesions treated were evaluated. Treatments included surgery followed by post-operative SRS to the resection cavity, and SRS, either single-fraction, then hypofractionated SRS (HSRS). Outcomes was measured in terms of local control (LC), toxicities, brain distant failure (BDF), and overall survival (OS). Prognostic factors influencing survival were assed too. RESULTS The median follow-up time was 33 months (range 3-183 months). Surgery plus SRS have been performed in 28 (10.7%) cases, SRS in 141 (53.8%), and HSRS in 93 (35.5%). 77 (41.6%) patients received systemic therapy. The main total dose and fractionation used were 24 Gy in single fraction or 24 Gy in three daily fractions. Local recurrence occurred in 32 (17.3%) patients. Median, 6 months,1-year-LC were 86 months (95%CI 36-86), 87.2% ± 2.8, 77.8% ± 4.1. Median,6 months,1-year-BDF were 23 months (95%CI 9-44), 66.4% ± 3.9, 55.3% ± 4.5. Median,6 months,1-year-OS were 7 months (95% CI 6-9), 52.7% ± 3.6, 33% ± 3.5. No severe neurological toxicity occurred. Stage at diagnosis, Karnofsky Performance Status (KPS), presence and number of extracranial metastases, and disease-specific-graded-prognostic-assessment (DS-GPA) score were observed as conditioning survival. CONCLUSION SRS/HSRS have proven to be an effective local treatment for BMCRC. A careful evaluation of prognostic factors as well as a multidisciplinary evaluation is a valid aid to manage the optimal therapeutic strategy for CTC patients with BMs. ADVANCES IN KNOWLEDGE The prognosis of BMCRC is poor. Several local treatments was used, but optimal treatment choice remains undefined. Radiosurgery has proven to be an effective local treatment for BMCRC. A careful evaluation of prognostic factors and a multidisciplinary evaluation needed.
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Affiliation(s)
- Pierina Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Hospital-IRCCS, Rozzano (MI), Italy
| | | | - Elena Clerici
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Hospital-IRCCS, Rozzano (MI), Italy
| | - Tiziana Comito
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Hospital-IRCCS, Rozzano (MI), Italy
| | - Salvatore Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Hospital-IRCCS, Rozzano (MI), Italy
| | - Valentina Pinzi
- Radiotherapy Unit, Istituto Neurologico Fondazione "Carlo Besta", Milan, Italy
| | - Laura Fariselli
- Radiotherapy Unit, Istituto Neurologico Fondazione "Carlo Besta", Milan, Italy
| | - Patrizia Ciammella
- Radiation Therapy Unit, Department of Oncology and Advanced Technology, Azienda Ospedaliera Arcispedale S Maria Nuova, Reggio Emilia, Italy
| | - Silvia Scoccianti
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Valentina Borzillo
- UOC Radiation Oncology, Istituto Nazionale per lo Studio e la Cura dei Tumori - Fondazione "Giovanni Pascale", Milan, Italy
| | - Paola Anselmo
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | | | - Veronica Dell'acqua
- Department of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Barbara Jereczek-Fossa
- Department of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Niccolò Giaj Levra
- Radiation Oncology, Sacro Cuore Don Calabria Hospital, Negrar-Verona, Italy
| | | | - Emilia Giudice
- Radiation Therapy unit, Policlinico Universitario Tor Vergata, Roma, Italy
| | | | - Sara Pedretti
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
| | | | | | | | | | - Francesco Pasqualetti
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Fabiola Paiar
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Hospital-IRCCS, Rozzano (MI), Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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15
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Li PJ, Luo J, Liu GE, Liu DH, Shen SS, Li XJ, Ma H. Radiation therapy for patients with brain metastases from non-small cell lung cancer without driven gene mutation. Chin Med J (Engl) 2020; 133:2359-2361. [PMID: 32858591 PMCID: PMC7546886 DOI: 10.1097/cm9.0000000000001044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Pei-Jie Li
- Department of Oncology, The Second Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou 563000, China
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16
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Remick JS, Kowalski E, Khairnar R, Sun K, Morse E, Cherng HRR, Poirier Y, Lamichhane N, Becker SJ, Chen S, Patel AN, Kwok Y, Nichols E, Mohindra P, Woodworth GF, Regine WF, Mishra MV. A multi-center analysis of single-fraction versus hypofractionated stereotactic radiosurgery for the treatment of brain metastasis. Radiat Oncol 2020; 15:128. [PMID: 32466775 PMCID: PMC7257186 DOI: 10.1186/s13014-020-01522-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/24/2020] [Indexed: 12/22/2022] Open
Abstract
Background Hypofractionated-SRS (HF-SRS) may allow for improved local control and a reduced risk of radiation necrosis compared to single-fraction-SRS (SF-SRS). However, data comparing these two treatment approaches are limited. The purpose of this study was to compare clinical outcomes between SF-SRS versus HF-SRS across our multi-center academic network. Methods Patients treated with SF-SRS or HF-SRS for brain metastasis from 2013 to 2018 across 5 radiation oncology centers were retrospectively reviewed. SF-SRS dosing was standardized, whereas HF-SRS dosing regimens were variable. The co-primary endpoints of local control and radiation necrosis were estimated using the Kaplan Meier method. Multivariate analysis using Cox proportional hazards modeling was performed to evaluate the impact of select independent variables on the outcomes of interest. Propensity score adjustments were used to reduce the effects confounding variables. To assess dose response for HF-SRS, Biologic Effective Dose (BED) assuming an α/β of 10 (BED10) was used as a surrogate for total dose. Results One-hundred and fifty six patients with 335 brain metastasis treated with SF-SRS (n = 222 lesions) or HF-SRS (n = 113 lesions) were included. Prior whole brain radiation was given in 33% (n = 74) and 34% (n = 38) of lesions treated with SF-SRS and HF-SRS, respectively (p = 0.30). After a median follow up time of 12 months in each cohort, the adjusted 1-year rate of local control and incidence of radiation necrosis was 91% (95% CI 86–96%) and 85% (95% CI 75–95%) (p = 0.26) and 10% (95% CI 5–15%) and 7% (95% CI 0.1–14%) (p = 0.73) for SF-SRS and HF-SRS, respectively. For lesions > 2 cm, the adjusted 1 year local control was 97% (95% CI 84–100%) for SF-SRS and 64% (95% CI 43–85%) for HF-SRS (p = 0.06). On multivariate analysis, SRS fractionation was not associated with local control and only size ≤2 cm was associated with a decreased risk of developing radiation necrosis (HR 0.21; 95% CI 0.07–0.58, p < 0.01). For HF-SRS, 1 year local control was 100% for lesions treated with a BED10 ≥ 50 compared to 77% (95% CI 65–88%) for lesions that received a BED10 < 50 (p = 0.09). Conclusions In this comparison study of dose fractionation for the treatment of brain metastases, there was no difference in local control or radiation necrosis between HF-SRS and SF-SRS. For HF-SRS, a BED10 ≥ 50 may improve local control.
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Affiliation(s)
- Jill S Remick
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Emily Kowalski
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Rahul Khairnar
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Kai Sun
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emily Morse
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hua-Ren R Cherng
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Yannick Poirier
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Narottam Lamichhane
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Stewart J Becker
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shifeng Chen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Akshar N Patel
- Chesapeake Oncology Hematology Associates, Glen Bernie, MD, USA
| | - Young Kwok
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Elizabeth Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Graeme F Woodworth
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA.
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17
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Loo M, Pin Y, Thierry A, Clavier JB. Single-fraction radiosurgery versus fractionated stereotactic radiotherapy in patients with brain metastases: a comparative study. Clin Exp Metastasis 2020; 37:425-434. [PMID: 32185576 DOI: 10.1007/s10585-020-10031-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/10/2020] [Indexed: 12/11/2022]
Abstract
To compare the local control and brain radionecrosis in patients with brain metastasis primarily treated by single-fraction radiosurgery (SRS) or hypofractionated stereotactic radiotherapy (HFSRT). Between January 2012 and December 2017, 179 patients with only 1-3 brain metastases (total: 287) primarily treated by SRS (14 Gy) or HFSRT (23.1 Gy in 3 fractions of 7.7 Gy, every other day) were retrospectively analyzed in a single center. Follow-up imaging data were available in 152 patients with 246 lesions. The corresponding Biological Effective Dose (BED) were 33.6 Gy and 40.9 Gy respectively for SRS and HFSRT group, assuming an α/β of 10 Gy. Local control (LC) and risk of radionecrosis (RN) were calculated by the Kaplan-Meier method. The actuarial local control rates at 6 and 12 months were 94% and 88.1% in SRS group, and 87.6% and 78.4%, in HFSRT group (p = 0.06), respectively. Only the total volume of edema was associated with worse LC (p = 0.01, HR 1.02, 95% CI [1.004-1.03]) in multivariate analysis. Brain radionecrosis occurred in 1 lesion in SRS group and 9 in HFSRT group. Median time to necrosis was 5.5 months (range 1-9). Only the volume of GTV was associated with RN (p = 0.02, HR 1.09, 95% CI [1.01-1.18]) in multivariate analysis. Multi-fraction SRT dose of 23.31 Gy in 3 fractions has similar efficacy to single-fraction SRT dose of 14 Gy in patients with brain metastases. A slightly higher occurrence of radionecrosis appeared in HFSRT group.
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Affiliation(s)
- Maxime Loo
- Radiotherapy Department, Centre Paul Strauss, Strasbourg Cedex, 67065, France.
| | - Yvan Pin
- Radiotherapy Department, Centre Paul Strauss, Strasbourg Cedex, 67065, France
| | - Alicia Thierry
- Public Health and Statistics Department, Centre Paul Strauss, Strasbourg Cedex, 67065, France
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18
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Zhang S, Yang R, Shi C, Li J, Zhuang H, Tian S, Wang J. Noncoplanar VMAT for Brain Metastases: A Plan Quality and Delivery Efficiency Comparison With Coplanar VMAT, IMRT, and CyberKnife. Technol Cancer Res Treat 2020; 18:1533033819871621. [PMID: 31451059 PMCID: PMC6710677 DOI: 10.1177/1533033819871621] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose: To compare plan quality and delivery efficiency of noncoplanar volumetric modulated arc therapy with coplanar volumetric modulated arc therapy, intensity-modulated radiation therapy, and CyberKnife for multiple brain metastases. Methods: For 15 patients with multiple brain metastases, noncoplanar volumetric modulated arc therapy, coplanar volumetric modulated arc therapy, intensity-modulated radiation therapy, and CyberKnife plans with a prescription dose of 30 Gy in 3 fractions were generated. Noncoplanar volumetric modulated arc therapy and coplanar volumetric modulated arc therapy plans consisted of 4 noncoplanar arcs and 2 full coplanar arcs, respectively. Intensity-modulated radiation therapy plans consisted of 7 coplanar fields. CyberKnife plans used skull tracking to ensure accurate position. All plans were generated to cover 95% target volume with prescription dose. Gradient index, conformity index, normal brain tissue volume (V3Gy − V24Gy), monitor units, and beam on time were evaluated. Results: Gradient index was the lowest for CyberKnife (3.49 ± 0.65), followed by noncoplanar volumetric modulated arc therapy (4.21 ± 1.38), coplanar volumetric modulated arc therapy (4.87 ± 1.35), and intensity-modulated radiation therapy (5.36 ± 1.98). Conformity index was the largest for noncoplanar volumetric modulated arc therapy (0.87 ± 0.03), followed by coplanar volumetric modulated arc therapy (0.86 ± 0.04), CyberKnife (0.86 ± 0.07), and intensity-modulated radiation therapy (0.85 ± 0.05). Normal brain tissue volume at high-to-moderate dose spreads (V24Gy − V9Gy) was significantly reduced in noncoplanar volumetric modulated arc therapy over that of intensity-modulated radiation therapy and coplanar volumetric modulated arc therapy. Normal brain tissue volume for noncoplanar volumetric modulated arc therapy was comparable with noncoplanar volumetric modulated arc therapy at high-dose level (V24Gy − V15Gy) and larger than CyberKnife at moderate-to-low dose level (V12Gy − V3Gy). Monitor units was highest for CyberKnife (28 733.59 ± 7197.85), followed by intensity-modulated radiation therapy (4128.40 ± 1185.38), noncoplanar volumetric modulated arc therapy (3105.20 ± 371.23), and coplanar volumetric modulated arc therapy (2997.27 ± 446.84). Beam on time was longest for CyberKnife (30.25 ± 7.32 minutes), followed by intensity-modulated radiation therapy (2.95 ± 0.85 minutes), noncoplanar volumetric modulated arc therapy (2.61 ± 0.07 minutes), and coplanar volumetric modulated arc therapy (2.30 ± 0.23 minutes). Conclusion: For brain metastases far away from organs-at-risk, noncoplanar volumetric modulated arc therapy generated more rapid dose falloff and higher conformity compared to intensity-modulated radiation therapy and coplanar volumetric modulated arc therapy. Noncoplanar volumetric modulated arc therapy provided a comparable dose falloff with CyberKnife at high-dose level and a slower dose falloff than CyberKnife at moderate-to-low dose level. Noncoplanar volumetric modulated arc therapy plans had less monitor units and shorter beam on time than CyberKnife plans.
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Affiliation(s)
- Shuming Zhang
- 1 Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Ruijie Yang
- 1 Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Chengyu Shi
- 2 Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, NY, USA
| | - Jiaqi Li
- 1 Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Hongqing Zhuang
- 1 Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Suqing Tian
- 1 Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Junjie Wang
- 1 Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
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19
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Vallard A, Vial N, Jmour O, Rehailia-Blanchard A, Trone JC, Sotton S, Daguenet E, Guy JB, Magné N. [Stereotactic body radiotherapy: Passing fad or revolution?]. Bull Cancer 2019; 107:244-253. [PMID: 31864665 DOI: 10.1016/j.bulcan.2019.09.011] [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: 02/20/2019] [Revised: 09/25/2019] [Accepted: 09/26/2019] [Indexed: 12/25/2022]
Abstract
Stereotactic body radiotherapy (SBRT) is a young technology that can deliver a high dose of radiation to the target, utilizing either a single dose or a small number of fractions with a high degree of precision within the body. Various technical solutions co-exist nowadays, with particular features, possibilities and limitations. Health care authorities have currently validated SBRT in a very limited number of locations, but many indications are still under investigation. It is therefore challenging to accurately appreciate the SBRT therapeutic index, its place and its role within the anticancer therapeutic arsenal. The aim of the present review is to provide SBRT definitions, current indications, and summarize the future ways of research. There are three validated indications for SBRT: un-resecable T1-T2 non small cell lung cancer, <3 slow-growing pulmonary metastases secondary to a stabilized primary, and the tumours located close to the medulla. In other situations, the benefit of SBRT is still to be demonstrated. One of the most promising way of research is the ablative treatment of oligo metastatic cancers, with recent studies suggesting a survival benefit. Furthermore, the most recent data suggest that SBRT is safe. Finally, the SBRT combined with immune therapies is promising, since it could theoretically trigger the adaptative anticancer response.
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Affiliation(s)
- Alexis Vallard
- Institut de cancérologie Lucien-Neuwirth, département de radiothérapie, 108, bis avenue Albert-Raimond, BP60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - Nicolas Vial
- Institut de cancérologie Lucien-Neuwirth, département de radiothérapie, 108, bis avenue Albert-Raimond, BP60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - Omar Jmour
- Institut de cancérologie Lucien-Neuwirth, département de radiothérapie, 108, bis avenue Albert-Raimond, BP60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - Amel Rehailia-Blanchard
- Institut de cancérologie Lucien-Neuwirth, département de radiothérapie, 108, bis avenue Albert-Raimond, BP60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - Jane-Chloé Trone
- Institut de cancérologie Lucien-Neuwirth, département de radiothérapie, 108, bis avenue Albert-Raimond, BP60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - Sandrine Sotton
- Institut de cancérologie Lucien-Neuwirth, département de radiothérapie, 108, bis avenue Albert-Raimond, BP60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - Elisabeth Daguenet
- Institut de cancérologie Lucien-Neuwirth, département de radiothérapie, 108, bis avenue Albert-Raimond, BP60008, 42271 Saint-Priest-en-Jarez cedex, France; Institut de cancérologie Lucien-Neuwirth, département universitaire de la recherche et de l'enseignement, 108, bis avenue Albert-Raimond, BP60008, 42271 Saint Priest en Jarez cedex, France
| | - Jean-Baptiste Guy
- Institut de cancérologie Lucien-Neuwirth, département de radiothérapie, 108, bis avenue Albert-Raimond, BP60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - Nicolas Magné
- Institut de cancérologie Lucien-Neuwirth, département de radiothérapie, 108, bis avenue Albert-Raimond, BP60008, 42271 Saint-Priest-en-Jarez cedex, France; Institut de cancérologie Lucien-Neuwirth, département universitaire de la recherche et de l'enseignement, 108, bis avenue Albert-Raimond, BP60008, 42271 Saint Priest en Jarez cedex, France.
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20
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Zhang S, Yang R, Wang X. Dosimetric quality and delivery efficiency of robotic radiosurgery for brain metastases: Comparison with C-arm linear accelerator based plans. J Appl Clin Med Phys 2019; 20:104-110. [PMID: 31580532 PMCID: PMC6839388 DOI: 10.1002/acm2.12746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 08/25/2019] [Accepted: 09/10/2019] [Indexed: 12/31/2022] Open
Abstract
The incidence of brain metastases is increasing and various treatment modalities exist for brain metastases. The aim of this study was to investigate the dosimetric quality and delivery efficiency of robotic radiosurgery (CyberKnife) for multiple brain metastases compared with C‐arm linear accelerator (linac) based plans. C‐arm linac based plans included intensity‐modulated radiation therapy (IMRT), volumetric modulated arc therapy (VMAT) and non‐coplanar VMAT with 1, 3 and 5 non‐coplanar arcs, respectively (NC1, NC3 and NC5). For 20 patients, six plans with a prescription dose of 30 Gy in three fractions were generated. The gradient index (GI), conformity index (CI), maximum dose (Dmax) of organs at risk (OARs), normal brain tissue volume (V3 Gy–V24 Gy), monitor units (MUs) and beam on time (BT) were evaluated. The GI of CyberKnife plans (3.60 ± 0.70) was lower than IMRT (6.21 ± 2.26, P < 0.05), VMAT (6.04 ± 1.93, P < 0.05), NC1 (5.16 ± 1.71, P < 0.05), NC3 (5.02 ± 1.59, P < 0.05) and NC5 (5.03 ± 1.72, P < 0.05). The CI of the VMAT plans (both coplanar and non‐coplanar) was larger than IMRT and CK plans. The Dmax for most OARs of the CyberKnife plan was lower than the C‐arm linac based plans, although some differences were not statistically significant. The normal brain tissue volume of CyberKnife plan was lower than the C‐arm linac based plans, and the normal brain tissue volume of non‐coplanar VMAT plans was lower than IMRT and VMAT plans at high‐moderate dose level. However, the MUs and BT of CyberKnife plans was more than C‐arm linac based plans. CyberKnife plan was better than C‐arm linac based plans in protecting normal brain tissue and OARs for patients with multiple brain metastases. C‐arm linac based plan with non‐coplanar arc provided better protection of normal brain tissue than coplanar plan. However, the BT of CyberKnife plan was longer than C‐arm linac based plans.
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Affiliation(s)
- Shuming Zhang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Ruijie Yang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Xin Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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21
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Zhong J, Press RH, Olson JJ, Oyesiku NM, Shu HKG, Eaton BR. The use of Hypofractionated Radiosurgery for the Treatment of Intracranial Lesions Unsuitable for Single-Fraction Radiosurgery. Neurosurgery 2019; 83:850-857. [PMID: 29718388 DOI: 10.1093/neuros/nyy145] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 03/22/2018] [Indexed: 11/15/2022] Open
Abstract
Stereotactic radiosurgery (SRS) is commonly used in the treatment of brain metastases, benign tumors, and arteriovenous malformations (AVM). Single-fraction radiosurgery, though ubiquitous, is limited by lesion size and location. In these cases, hypofractionated radiosurgery (hfSRS) offers comparable efficacy and toxicity. We review the recent literature concerning hfSRS in the treatment of brain metastases, benign tumors, and AVMs that are poorly suited for single-fraction SRS. Published retrospective analyses suggest that local control rates for brain metastases and benign tumors, as well as the rates of AVM obliteration, following hfSRS treatment are comparable to those reported for single-fraction SRS. Additionally, the toxicities from hypofractionated treatment appear comparable to those seen with single-fractioned SRS to small lesions.
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Affiliation(s)
- Jim Zhong
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Robert H Press
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | | | - Hui-Kuo G Shu
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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22
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Yamamoto M, Higuchi Y, Serizawa T, Kawabe T, Nagano O, Sato Y, Koiso T, Watanabe S, Aiyama H, Kasuya H. Three-stage Gamma Knife treatment for metastatic brain tumors larger than 10 cm3: a 2-institute study including re-analyses of earlier results using competing risk analysis. J Neurosurg 2019; 129:77-85. [PMID: 30544297 DOI: 10.3171/2018.7.gks181392] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 07/11/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe results of 3-stage Gamma Knife treatment (3-st-GK-Tx) for relatively large brain metastases have previously been reported for a series of patients in Chiba, Japan (referred to in this study as the C-series). In the current study, the authors reappraised, using a competing risk analysis, the efficacy and safety of 3-st-GK-Tx by comparing their experience with that of the C-series.METHODSThis was a retrospective cohort study. Among 1767 patients undergoing GK radiosurgery for brain metastases at Mito Gamma House during the 2005-2015 period, 78 (34 female, 44 male; mean age 65 years, range 35-86 years) whose largest tumor was > 10 cm3, treated with 3-st-GK-Tx, were studied (referred to in this study as the M-series). The target volumes were covered with a 50% isodose gradient and irradiated with a peripheral dose of 10 Gy at each procedure. The interval between procedures was 2 weeks. Because competing risk analysis had not been employed in the published C-series, the authors reanalyzed the previously published data using this method.RESULTSThe overall median survival time after 3-st-GK-Tx was 8.3 months (95% CI 5.6-12.0 months) in the M-series and 8.6 months (95% CI 5.5-10.6 months) in the C-series (p = 0.41). Actuarial survival rates at the 6th and 12th post-3-st-GK-Tx months were, respectively, 55.1% and 35.2% in the M-series and 62.5% and 26.4% in the C-series (HR 1.175, 95% CI 0.790-1.728, p = 0.42). Cumulative incidences at the 12th post-3-st-GK-Tx, determined by competing risk analyses, of neurological deterioration (14.2% in C-series vs 12.8% in M-series), neurological death (7.2% vs 7.7%), local recurrence (4.8% vs 6.2%), repeat SRS (25.9% vs 18.0%), and SRS-related complications (2.3% vs 5.1%) did not differ significantly between the 2 series.CONCLUSIONSThere were no significant differences in post-3-st-GK-Tx results between the 2 series in terms of overall survival times, neurological death, maintained neurological status, local control, repeat SRS, and SRS-related complications. The previously published results (C-series) are considered to be validated by the M-series results.
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Affiliation(s)
- Masaaki Yamamoto
- 1Katsuta Hospital Mito Gamma House, Hitachi-naka, Ibaraki.,2Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, Tokyo
| | - Yoshinori Higuchi
- 3Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba
| | - Toru Serizawa
- 3Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba.,4Tokyo Gamma Unit Center, Tsukiji Neurological Clinic, Tokyo
| | - Takuya Kawabe
- 5Department of Neurosurgery, Rakusai Shimizu Hospital, Kyoto
| | - Osamu Nagano
- 6Gamma Knife House, Chiba Cerebral and Cardiovascular Center, Ichihara
| | - Yasunori Sato
- 7Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo; and
| | - Takao Koiso
- 1Katsuta Hospital Mito Gamma House, Hitachi-naka, Ibaraki.,8Department of Neurosurgery, Faculty of Medicine, and
| | - Shinya Watanabe
- 1Katsuta Hospital Mito Gamma House, Hitachi-naka, Ibaraki.,9Tsukuba Clinical Research and Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Hitoshi Aiyama
- 1Katsuta Hospital Mito Gamma House, Hitachi-naka, Ibaraki.,8Department of Neurosurgery, Faculty of Medicine, and
| | - Hidetoshi Kasuya
- 2Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, Tokyo
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23
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Kim KH, Kong DS, Cho KR, Lee MH, Choi JW, Seol HJ, Kim ST, Nam DH, Lee JI. Outcome evaluation of patients treated with fractionated Gamma Knife radiosurgery for large (> 3 cm) brain metastases: a dose-escalation study. J Neurosurg 2019; 133:675-684. [PMID: 31419791 DOI: 10.3171/2019.5.jns19222] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 05/21/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Fractionated Gamma Knife radiosurgery (GKS) represents a feasible option for patients with large brain metastases (BM). However, the dose-fractionation scheme balanced between local control and radiation-induced toxicity remains unclear. Therefore, the authors conducted a dose-escalation study using fractionated GKS as the primary treatment for large (> 3 cm) BM. METHODS The exclusion criteria were more than 3 lesions, evidence of leptomeningeal disease, metastatic melanoma, poor general condition, and previously treated lesions. Patients were randomized to receive 24, 27, or 30 Gy in 3 fractions (8, 9, or 10 Gy per fraction, respectively). The primary endpoint was the development of radiation necrosis assessed by a neuroradiologist blinded to the study. The secondary endpoints included the local progression-free survival (PFS) rate, change in tumor volume, development of distant intracranial progression, and overall survival. RESULTS Between September 2016 and April 2018, 60 patients were eligible for the study, with 46 patients (15, 17, and 14 patients in the 8-, 9-, and 10-Gy groups, respectively) available for analysis. The median follow-up duration was 9.6 months (range 2.5-25.1 months). The 6-month estimated cumulative incidence of radiation necrosis was 0% in the 8-Gy group, 13% (95% confidence interval [CI] 0%-29%) in the 9-Gy group, and 37% (95% CI 1%-58%) in the 10-Gy group. Being in the 10-Gy group was a significant risk factor for the development of radiation necrosis (p = 0.047; hazard ratio [HR] 7.2, 95% CI 1.1-51.4). The 12-month local PFS rates were 65%, 80%, and 75% in the 8-, 9-, and 10-Gy groups, respectively. Being in the 8-Gy group was a risk factor for local treatment failure (p = 0.037; HR 2.5, 95% CI 1.1-29.6). The mean volume change from baseline was a 47.5% decrease in this cohort. Distant intracranial progression and overall survival did not differ among the 3 groups. CONCLUSIONS In this dose-escalation study, 27 Gy in 3 fractions appeared to be a relevant regimen of fractionated GKS for large BM because 30 Gy in 3 fractions resulted in unacceptable toxicities and 24 Gy in 3 fractions was associated with local treatment failure.
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Affiliation(s)
- Kyung Hwan Kim
- 1Department of Neurosurgery, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon; and
| | | | | | | | | | | | - Sung Tae Kim
- 3Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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24
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Traylor JI, Habib A, Patel R, Muir M, Gadot R, Briere T, Yeboa DN, Li J, Rao G. Fractionated stereotactic radiotherapy for local control of resected brain metastases. J Neurooncol 2019; 144:343-350. [PMID: 31313060 DOI: 10.1007/s11060-019-03233-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 06/26/2019] [Indexed: 01/03/2023]
Abstract
PURPOSE Postoperative stereotactic radiosurgery (SRS) has been shown to establish local control in patients with resected brain metastases, yet its efficacy may be limited, particularly for resected lesions with large post-operative resection cavities. We describe the efficacy of postoperative fractionated stereotactic radiotherapy (FSRT) for local control in patients who have undergone resection for brain metastases. METHODS In this retrospective cohort study, we analyzed patients who received FSRT for resected brain metastases in 3 or 5 fractions. Time to local recurrence was the primary endpoint in this study. RESULTS Sixty-seven patients (n = 29 female, n = 38 male) met study criteria for review. The median age of the cohort was 62 years (range 18-79 years). Median preoperative tumor volume was 11.1 cm3 (range 0.4-77.0 cm3). The rate of local control was 91.0% at 6 months, 85.1% at 12 months, and 85.1% at 18 months. Estimates of freedom from local recurrence at 6 and 12 months were 90.9% and 84.3%, respectively. Higher biologically equivalent doses (BED10) were found to be predictive of longer freedom from local recurrence on univariate and multivariable analysis. Larger cavity volumes were found to correspond to longer time to local recurrence on univariate and multivariable analysis. CONCLUSION Our results suggest that postoperative FSRT may be an effective method for providing local control to the surgical bed in patients with resected brain metastases, particularly for larger tumors not amenable to conventional, single-fraction SRS. Additional prospective studies are needed to confirm these findings.
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Affiliation(s)
- Jeffrey I Traylor
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ahmed Habib
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rajan Patel
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew Muir
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ron Gadot
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tina Briere
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Debra N Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ganesh Rao
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. .,Department of of Neurosurgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Room FC7.2000, Unit 853, Houston, TX, 77030-4009, USA.
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25
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Jhaveri J, Chowdhary M, Zhang X, Press RH, Switchenko JM, Ferris MJ, Morgan TM, Roper J, Dhabaan A, Elder E, Eaton BR, Olson JJ, Curran WJ, Shu HKG, Crocker IR, Patel KR. Does size matter? Investigating the optimal planning target volume margin for postoperative stereotactic radiosurgery to resected brain metastases. J Neurosurg 2019; 130:797-803. [PMID: 29676690 PMCID: PMC6195865 DOI: 10.3171/2017.9.jns171735] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 09/08/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The optimal margin size in postoperative stereotactic radiosurgery (SRS) for brain metastases is unknown. Herein, the authors investigated the effect of SRS planning target volume (PTV) margin on local recurrence and symptomatic radiation necrosis postoperatively. METHODS Records of patients who received postoperative LINAC-based SRS for brain metastases between 2006 and 2016 were reviewed and stratified based on PTV margin size (1.0 or > 1.0 mm). Patients were treated using frameless and framed SRS techniques, and both single-fraction and hypofractionated dosing were used based on lesion size. Kaplan-Meier and cumulative incidence models were used to estimate survival and intracranial outcomes, respectively. Multivariate analyses were also performed. RESULTS A total of 133 patients with 139 cavities were identified; 36 patients (27.1%) and 35 lesions (25.2%) were in the 1.0-mm group, and 97 patients (72.9%) and 104 lesions (74.8%) were in the > 1.0-mm group. Patient characteristics were balanced, except the 1.0-mm cohort had a better Eastern Cooperative Group Performance Status (grade 0: 36.1% vs 19.6%), higher mean number of brain metastases (1.75 vs 1.31), lower prescription isodose line (80% vs 95%), and lower median single fraction-equivalent dose (15.0 vs 17.5 Gy) (all p < 0.05). The median survival and follow-up for all patients were 15.6 months and 17.7 months, respectively. No significant difference in local recurrence was noted between the cohorts. An increased 1-year rate of symptomatic radionecrosis was seen in the larger margin group (20.9% vs 6.0%, p = 0.028). On multivariate analyses, margin size > 1.0 mm was associated with an increased risk for symptomatic radionecrosis (HR 3.07, 95% CI 1.13-8.34; p = 0.028), while multifraction SRS emerged as a protective factor for symptomatic radionecrosis (HR 0.13, 95% CI 0.02-0.76; p = 0.023). CONCLUSIONS Expanding the PTV margin beyond 1.0 mm is not associated with improved local recurrence but appears to increase the risk of symptomatic radionecrosis after postoperative SRS.
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Affiliation(s)
- Jaymin Jhaveri
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
- Department of Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mudit Chowdhary
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
- Department of Winship Cancer Institute, Emory University, Atlanta, Georgia
- Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois
| | - Xinyan Zhang
- Department of Biostatistics and Bioinformatics Shared Resource, Emory University, Atlanta, Georgia
| | - Robert H. Press
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
- Department of Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey M. Switchenko
- Department of Biostatistics and Bioinformatics Shared Resource, Emory University, Atlanta, Georgia
| | - Matthew J. Ferris
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
- Department of Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Tiffany M. Morgan
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
- Department of Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Justin Roper
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
- Department of Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Anees Dhabaan
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
- Department of Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Eric Elder
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
- Department of Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bree R. Eaton
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
- Department of Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey J. Olson
- Department of Winship Cancer Institute, Emory University, Atlanta, Georgia
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Walter J. Curran
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
- Department of Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Hui-Kuo G. Shu
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
- Department of Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Ian R. Crocker
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
- Department of Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kirtesh R. Patel
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
- Department of Winship Cancer Institute, Emory University, Atlanta, Georgia
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
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Yoon KJ, Cho B, Kwak JW, Lee D, Kwon DH, Ahn SD, Lee SW, Kim CJ, Roh SW, Cho YH. Cyberknife Dosimetric Planning Using a Dose-Limiting Shell Method for Brain Metastases. J Korean Neurosurg Soc 2018; 61:753-760. [PMID: 30396248 PMCID: PMC6280060 DOI: 10.3340/jkns.2018.0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 08/04/2018] [Indexed: 11/30/2022] Open
Abstract
Objective We investigated the effect of optimization in dose-limiting shell method on the dosimetric quality of CyberKnife (CK) plans in treating brain metastases (BMs).
Methods We selected 19 BMs previously treated using CK between 2014 and 2015. The original CK plans (CKoriginal) had been produced using 1 to 3 dose-limiting shells : one at the prescription isodose level (PIDL) for dose conformity and the others at lowisodose levels (10–30% of prescription dose) for dose spillage. In each case, a modified CK plan (CKmodified) was generated using 5 dose-limiting shells : one at the PIDL, another at intermediate isodose level (50% of prescription dose) for steeper dose fall-off, and the others at low-isodose levels, with an optimized shell-dilation size based on our experience. A Gamma Knife (GK) plan was also produced using the original contour set. Thus, three data sets of dosimetric parameters were generated and compared.
Results There were no differences in the conformity indices among the CKoriginal, CKmodified, and GK plans (mean 1.22, 1.18, and 1.24, respectively; p=0.079) and tumor coverage (mean 99.5%, 99.5%, and 99.4%, respectively; p=0.177), whereas the CKmodified plans produced significantly smaller normal tissue volumes receiving 50% of prescription dose than those produced by the CKoriginal plans (p<0.001), with no statistical differences in those volumes compared with GK plans (p=0.345).
Conclusion These results indicate that significantly steeper dose fall-off is able to be achieved in the CK system by optimizing the shell function while maintaining high conformity of dose to tumor.
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Affiliation(s)
- Kyoung Jun Yoon
- Radiosurgery Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byungchul Cho
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Won Kwak
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Doheui Lee
- Radiosurgery Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kwon
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Do Ahn
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Wook Lee
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Jin Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Woo Roh
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Hyun Cho
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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O'Beirn M, Benghiat H, Meade S, Heyes G, Sawlani V, Kong A, Hartley A, Sanghera P. The Expanding Role of Radiosurgery for Brain Metastases. MEDICINES (BASEL, SWITZERLAND) 2018; 5:medicines5030090. [PMID: 30110927 PMCID: PMC6165316 DOI: 10.3390/medicines5030090] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/03/2018] [Accepted: 08/07/2018] [Indexed: 06/08/2023]
Abstract
Stereotactic radiosurgery (SRS) has become increasingly important in the management of brain metastases due to improving systemic disease control and rising incidence. Initial trials demonstrated SRS with whole-brain radiotherapy (WBRT) improved local control rates compared with WBRT alone. Concerns with WBRT associated neurocognitive toxicity have contributed to a greater use of SRS alone, including for patients with multiple metastases and following surgical resection. Molecular information, targeted agents, and immunotherapy have also altered the landscape for the management of brain metastases. This review summarises current and emerging data on the role of SRS in the management of brain metastases.
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Affiliation(s)
- Mark O'Beirn
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK.
| | - Helen Benghiat
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK.
| | - Sara Meade
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK.
| | - Geoff Heyes
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK.
| | - Vijay Sawlani
- Neuroradiology, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK.
| | - Anthony Kong
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK.
| | - Andrew Hartley
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK.
| | - Paul Sanghera
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham B15 2TH, UK.
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Postoperative hypofractionated stereotactic brain radiation (HSRT) for resected brain metastases: improved local control with higher BED 10. J Neurooncol 2018; 139:449-454. [PMID: 29749569 DOI: 10.1007/s11060-018-2885-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/26/2018] [Indexed: 11/27/2022]
Abstract
INTRODUCTION HSRT directed to large surgical beds in patients with resected brain metastases improves local control while sparing patients the toxicity associated with whole brain radiation. We review our institutional series to determine factors predictive of local failure. METHODS In a total of 39 consecutive patients with brain metastases treated from August 2011 to August 2016, 43 surgical beds were treated with HSRT in three or five fractions. All treatments were completed on a robotic radiosurgery platform using the 6D Skull tracking system. Volumetric MRIs from before and after surgery were used for radiation planning. A 2-mm PTV margin was used around the contoured surgical bed and resection margins; these were reviewed by the radiation oncologist and neurosurgeon. Lower total doses were prescribed based on proximity to critical structures or if prior radiation treatments were given. Local control in this study is defined as no volumetric MRI evidence of recurrence of tumor within the high dose radiation volume. Statistics were calculated using JMP Pro v13. RESULTS Of the 43 surgical beds analyzed, 23 were from NSCLC, 5 were from breast, 4 from melanoma, 5 from esophagus, and 1 each from SCLC, sarcoma, colon, renal, rectal, and unknown primary. Ten were treated with three fractions with median dose 24 Gy and 33 were treated with five fractions with median dose 27.5 Gy using an every other day fractionation. There were no reported grade 3 or higher toxicities. Median follow up was 212 days after completion of radiation. 10 (23%) surgical beds developed local failure with a median time to failure of 148 days. All but three patients developed new brain metastases outside of the treated field and were treated with stereotactic radiosurgery, whole brain radiation and/or chemotherapy. Five patients (13%) developed leptomeningeal disease. With a median follow up of 226 days, 30 Gy/5 fx was associated with the best local control (93%) with only 1 local failure. A lower total dose in five fractions (ie 27.5 or 25 Gy) had a local control rate of 70%. For three fraction SBRT, local control was 100% using a dose of 27 Gy in three fractions (follow up was > 600 days) and 71% if 24 Gy in three fractions was used. A higher total biologically equivalent dose (BED10) was statistically significant for improved local control (p = 0.04) with a threshold BED10 ≥ 48 associated with better local control. CONCLUSIONS HSRT after surgical resection for brain metastasis is well tolerated and has improved local control with BED10 ≥ 48 (30 Gy/5 fx and 27 Gy/3 fx). Additional study is warranted.
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Marcrom SR, McDonald AM, Thompson JW, Popple RA, Riley KO, Markert JM, Willey CD, Bredel M, Fiveash JB. Fractionated stereotactic radiation therapy for intact brain metastases. Adv Radiat Oncol 2017; 2:564-571. [PMID: 29204523 PMCID: PMC5707424 DOI: 10.1016/j.adro.2017.07.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 06/12/2017] [Accepted: 07/14/2017] [Indexed: 11/06/2022] Open
Abstract
Purpose Limited data exist on fractionated stereotactic radiation therapy (FSRT) for brain metastases. We sought to evaluate the safety and efficacy of FSRT and further define its role in brain metastasis management. Methods and materials A total of 72 patients were treated with linear accelerator–based FSRT to 182 previously untreated, intact brain metastases. Targets received 25 or 30 Gy in 5 fractions. All targets within the same course received the same prescription regardless of size. Toxicity was recorded per Radiation Therapy Oncology Group central nervous system toxicity criteria. Results The median follow-up was 5 months (range, 1-71 months). The Kaplan-Meier estimate of 12-month local control was 86%. Tumors <3 cm in diameter demonstrated improved 12-month local control of 95% compared with 61% in tumors ≥3 cm (P < .001). The Kaplan-Meier estimate of 12-month local control was 91% in tumors treated with 30 Gy and only 75% in tumors treated with 25 Gy (P = .015). Tumor diameter ≥3 cm resulted in increased local failure, and a 30 Gy prescription resulted in decreased local failure on multivariate analysis (hazard ratio [HR], 8.11 [range, 2.09-31.50; P = .003] and HR, 0.26 [range, 0.07-0.93; P = .038]). Grade 4 central nervous system toxicity occurred in 4 patients (6%) requiring surgery, and no patient experienced irreversible grade 3 or 5 toxicity. Increasing tumor diameter was associated with increased toxicity risk (HR, 2.45 [range, 1.04-5.742; P = .04]). Conclusions FSRT for brain metastases appears to demonstrate a high rate of local control with minimal risk of severe toxicity. Local control appears to be associated with smaller tumor sizeand a higher prescription dose. FSRT is a viable option for those who are poor single-fraction candidates.
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Affiliation(s)
- Samuel R Marcrom
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Andrew M McDonald
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jonathan W Thompson
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Richard A Popple
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kristen O Riley
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - James M Markert
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Christopher D Willey
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Markus Bredel
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - John B Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
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Outcomes Following Hypofractionated Stereotactic Radiotherapy in the Management of Brain Metastases. Am J Clin Oncol 2017; 39:379-83. [PMID: 24755663 DOI: 10.1097/coc.0000000000000076] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To evaluate the outcomes of patients treated with hypofractionated stereotactic radiotherapy (HSRT) for radiosensitive and radioresistant brain metastases. METHODS Between August 2006 and July 2013, a total of 56 lesions in 44 patients with brain metastases were treated with HSRT. Twenty-three (41.1%) lesions were radioresistant. Patients were treated to a total dose of 24 to 30 Gy in 3 to 5 fractions. Median planning target volume was 6.18 cm. The primary endpoint for this study was local control with secondary endpoints of overall survival, distant failure, performance status, and treatment toxicity. RESULTS The median follow-up for all patients was 5 months (range, 0.4 to 58.3 mo). Six- and 12-month Kaplan-Meier estimates of local control for all lesions were 85.6% and 79.4%, respectively. Radioresistant tumors had a 6- and 12-month local control rate of 87.0%, whereas radiosensitive tumors had a 6- and 12-month local control rate of 82.5% and 72.2%, respectively (P=0.41). Six- and 12-month distant brain control rates were 56.8% and 46.9%, respectively. Overall survival was significantly associated with recursive partitioning analysis classes I, II, and III (P=0.0003) and graded prognostic assessment classes 2 to 3 and 1 to 1.5 (P=0.041). CONCLUSIONS HSRT is a safe and feasible alternative to single-session stereotactic radiosurgery for brain metastases. No difference was observed in local control rates between radioresistant and radiosensitive tumors.
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Royer P, Salleron J, Vogin G, Taillandier L, Clément-Duchêne C, Klein O, Faivre JC, Peiffert D, Bernier V. [Hypofractionated stereotactic radiotherapy for brain metastasis: Benefit of additional whole brain radiotherapy?]. Cancer Radiother 2017; 21:731-740. [PMID: 28711413 DOI: 10.1016/j.canrad.2017.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 02/01/2017] [Accepted: 02/28/2017] [Indexed: 02/03/2023]
Abstract
PURPOSE To study overall survival, risk of neurological death, local recurrence and development of new brain metastasis in patients treated for brain oligometastases with hypofractionated stereotactic radiotherapy with CyberKnife®, according to the association or not with an additional whole brain irradiation. PATIENTS AND METHODS Institutional retrospective study of 102 patients treated for one to three brain metastasis: 76 with exclusive hypofractionated stereotactic radiotherapy and 26 with hypofractionated stereotactic radiotherapy and whole brain irradiation. Objectives were assessed and compared between these two groups according to the Kaplan-Meier method and Cox model. RESULTS Median follow-up was 18.8 months. There were no difference between exclusive hypofractionated stereotactic radiotherapy and hypofractionated stereotactic radiotherapy with whole brain irradiation for overall survival (respective median 21.5 and 20.1 months), risk of neurological death (respectively 9.2% and 15.4% at one year). At one year: the risk of cerebral progressive disease was greater in the group receiving exclusive hypofractionated stereotactic radiotherapy (respectively 43.4% vs. 26.2%, P=0.043), the risk of local recurrence was 25% versus 17.6% (P=0.28) and the development of new brain metastasis was 23.7% versus 11.5% (P=0.27). After salvage treatments, crude local control was similar in the two groups, respectively 78.6% and 73.5%. Whole brain irradiation has been avoided for 72.4% of patients in the group receving exclusive hypofractionated stereotactic radiotherapy. CONCLUSION Whole brain irradiation improves local control of brain metastatic disease in addition to hypofractionated stereotactic radiotherapy. Sparing whole brain irradiation for salvage treatments only does not affect overall survival or risk of neurological death in selected patients with favourable prognosis.
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Affiliation(s)
- P Royer
- Département universitaire de radiothérapie-curiethérapie, institut de cancérologie de Lorraine Alexis-Vautrin, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France.
| | - J Salleron
- Cellule datamanagement et biostatistiques, institut de cancérologie de Lorraine Alexis-Vautrin, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
| | - G Vogin
- Département universitaire de radiothérapie-curiethérapie, institut de cancérologie de Lorraine Alexis-Vautrin, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
| | - L Taillandier
- Service de neurologie, université de Lorraine, CHRU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, CO 60034, 54035 Nancy, France
| | - C Clément-Duchêne
- Département universitaire d'oncologie médicale, institut de cancérologie de Lorraine Alexis-Vautrin, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
| | - O Klein
- Service de neurochirurgie pédiatrique, hôpital d'enfants, université de Lorraine, CHRU de Nancy, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France
| | - J-C Faivre
- Département universitaire de radiothérapie-curiethérapie, institut de cancérologie de Lorraine Alexis-Vautrin, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
| | - D Peiffert
- Département universitaire de radiothérapie-curiethérapie, institut de cancérologie de Lorraine Alexis-Vautrin, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
| | - V Bernier
- Département universitaire de radiothérapie-curiethérapie, institut de cancérologie de Lorraine Alexis-Vautrin, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
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Kirkpatrick JP, Soltys SG, Lo SS, Beal K, Shrieve DC, Brown PD. The radiosurgery fractionation quandary: single fraction or hypofractionation? Neuro Oncol 2017; 19:ii38-ii49. [PMID: 28380634 DOI: 10.1093/neuonc/now301] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Stereotactic radiosurgery (SRS), typically administered in a single session, is widely employed to safely, efficiently, and effectively treat small intracranial lesions. However, for large lesions or those in close proximity to critical structures, it can be difficult to obtain an acceptable balance of tumor control while avoiding damage to normal tissue when single-fraction SRS is utilized. Treating a lesion in 2 to 5 fractions of SRS (termed "hypofractionated SRS" [HF-SRS]) potentially provides the ability to treat a lesion with a total dose of radiation that provides both adequate tumor control and acceptable toxicity. Indeed, studies of HF-SRS in large brain metastases, vestibular schwannomas, meningiomas, and gliomas suggest that a superior balance of tumor control and toxicity is observed compared with single-fraction SRS. Nonetheless, a great deal of effort remains to understand radiobiologic mechanisms for HF-SRS driving the dose-volume response relationship for tumors and normal tissues and to utilize this fundamental knowledge and the results of clinic studies to optimize HF-SRS. In particular, the application of HF-SRS in the setting of immunomodulatory cancer therapies offers special challenges and opportunities.
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Affiliation(s)
| | | | - Simon S Lo
- University of Washington, Seattle, Washington, USA
| | - Kathryn Beal
- Memorial Sloan Kettering Cancer Center, New York, USA
| | - Dennis C Shrieve
- University of Utah School of Medicine, Salt Lake City, Utah, UT, USA
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The impact of different stereotactic radiation therapy regimens for brain metastases on local control and toxicity. Adv Radiat Oncol 2017; 2:391-397. [PMID: 29114607 PMCID: PMC5605319 DOI: 10.1016/j.adro.2017.05.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 03/04/2017] [Accepted: 05/30/2017] [Indexed: 11/24/2022] Open
Abstract
Purpose Stereotactic radiation therapy (SRT) enables focused, short course, high dose per fraction radiation delivery to brain tumors that are less ideal for single fraction treatment because of size, shape, or close proximity to sensitive structures. We sought to identify optimal SRT treatment regimens for maximizing local control while minimizing morbidity. Methods and materials We performed a retrospective review of patients treated with SRT for solid brain metastases using variable dose schedules between 2001 and 2011 at 3 academic hospitals. Endpoints included (1) local control, (2) acute toxicity (Common Toxicity Criteria for Adverse Events v3.0), and (3) symptomatic radionecrosis. Kaplan-Meier and a competing risks methodology were used to estimate the actuarial rate of local failure and assess the association of clinical and treatment covariates with time to local failure. Results A total of 156 patients was identified. Common tumor histologies included breast (21%), non-small cell lung (32%), melanoma (22%), small cell lung (9%), and renal cell carcinoma (6%). The majority of lesions were supratentorial (57%). Median target volume was 3.99 mL (range, 0.04-58.42). Median total SRT dose was 25 Gy (range, 12-36), median fractional dose was 5 Gy (range, 2.5-11), and median number of fractions was 5 (range, 2-10). Cumulative incidence of local progression at 3, 6, 12, 18, and 24 months was 11%, 22%, 29%, 34%, and 36%. Total prescription dose was the only factor significantly associated with time to local progression on univariate (P = .02) and multivariable analysis (P = .01, adjusted hazards ratio, 0.87). Five patients experienced seizures within 10 days of SRT and 5 patients developed radionecrosis. All patients with documented radionecrosis received prior radiation to the index lesion. Conclusions Our series of SRT for brain metastases found total prescription dose to be the only factor associated with local control. Both acute and long-term toxicity events from SRT were modest.
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Clinical outcomes of patients with limited brain metastases treated with hypofractionated (5×6Gy) conformal radiotherapy. Radiother Oncol 2017; 123:203-208. [PMID: 28390657 DOI: 10.1016/j.radonc.2017.03.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/22/2017] [Accepted: 03/22/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND PURPOSE Hypofractionated conformal radiotherapy (hfCRT) is used for larger brain metastases or metastases near critical structures. We investigated hfCRT outcomes for newly diagnosed brain metastases. MATERIALS AND METHODS We identified 195 patients with 1-3 brain metastases who underwent 5×6Gy hfCRT for 231 lesions from 2007 to 2013. Associations among clinical factors, local control (LC), distant brain control (DC) and overall survival (OS) were tested using univariate and multivariate (MVA) Cox regression analysis and Kaplan-Meier method. RESULTS Median follow-up was 12.8months. One hundred forty-three (62%) lesions were treated with hfCRT post-operatively, and 88 (38%) with definitive hfCRT. LC for all lesions was 83% at 1year. For lesions treated with post-operative hfCRT, tumor size (HR=4.7, p=0.04) and subtotal resection (HR=2.7, p=0.02) were predictive of local failure on MVA. For lesions ≥2.8cm in size, LC was 61% at 12months for lesions status-post subtotal resection, compared to 84% status-post gross total resection (p=0.004). Extracranial disease presence was associated with worse DC (HR=1.8, p=0.008) and OS (HR=3.1, p<0.001). CONCLUSIONS We showed 5×6Gy hfCRT provides acceptable LC at 1year for limited brain metastases. For large lesions not grossly resected, more aggressive strategies can be considered to improve LC.
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Pessina F, Navarria P, Cozzi L, Tomatis S, Ascolese AM, Franzese C, Toschi L, Santoro A, De Rose F, Franceschini D, Bello L, Scorsetti M. Outcome appraisal of patients with limited brain metastases (BMs) from non small cell lung cancer (NSCLC) treated with different local therapeutic strategies: a single institute evaluation. Br J Radiol 2017; 90:20170022. [PMID: 28256924 DOI: 10.1259/bjr.20170022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To evaluate the outcome of patients with non-small-cell lung cancer (NSCLC) with limited brain metastases (BMs) treated with local approaches omitting whole-brain radiation therapy (WBRT). METHODS Surgery was performed in case of a single, large BM, controlled extracranial disease and Karnofsky Performance Status (KPS) 90-100; stereotactic radiosurgery (SRS) or hypofractionated stereotactic radiosurgery (HSRS) was performed in all other cases. The prescribed dose was 24 Gy/1 fraction for lesions <2.5 cm, and a median of 30 Gy (24-40 Gy) in 3-5 fractions for lesions >2.5 cm. RESULTS 156 patients treated for 228 BMs were retrospectively evaluated. The median age was 62 years. The majority of patients had a KPS 90-100, recursive partitioning analysis Class II, diagnosis-specific graded prognostic assessment score 2.5-3 and 1-2 BMs. Surgical resection was performed in 18 cases, and SRS/HSRS was performed in 210 cases. The 1-2-year local control was 87.2 ± 3.0% and 72.8 ± 5.0%; the 1.2-year brain distant failure was 30.8 ± 4.0% and 58.1 ± 6.0%; the 1-2-year overall survival was 60.9 ± 3.9% and 31.4 ± 4.0%. On univariate and multivariate analysis, the following factors influenced survival: age (p = 0.01), the presence of lymph node involvement (p = 0.03), KPS (p << 0.01), the presence of extracranial metastases at the time of BM treatment (p < 0.01), the number of BMs (p = 0.02) and the treatment performed (p < 0.01). CONCLUSION The choice of an adequate local treatment can impact on survival in patients with limited BMs from NSCLC. A careful evaluation of prognostic and predictive factors is a pivotal additional aid. Advances in knowledge: Radiosurgery or surgery followed by radiosurgery on the tumour bed in place of WBRT proved to be an effective treatment influencing outcome. Surgical resection followed by SRS on the tumour bed has to be considered for lesions ≥15 mm, in patients with good KPS, age ≤70 years, adenocarcinoma histology and oligometastatic disease.
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Affiliation(s)
- Federico Pessina
- 1 Neurooncological Surgery, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Pierina Navarria
- 2 Radiotherapy and Radiosurgery, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Luca Cozzi
- 2 Radiotherapy and Radiosurgery, Humanitas Cancer Center and Research Hospital, Rozzano, Italy.,4 Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
| | - Stefano Tomatis
- 2 Radiotherapy and Radiosurgery, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Anna M Ascolese
- 2 Radiotherapy and Radiosurgery, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Ciro Franzese
- 2 Radiotherapy and Radiosurgery, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Luca Toschi
- 3 Haematology and Oncology, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Armando Santoro
- 3 Haematology and Oncology, Humanitas Cancer Center and Research Hospital, Rozzano, Italy.,4 Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
| | - Fiorenza De Rose
- 2 Radiotherapy and Radiosurgery, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Davide Franceschini
- 2 Radiotherapy and Radiosurgery, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Lorenzo Bello
- 1 Neurooncological Surgery, Humanitas Cancer Center and Research Hospital, Rozzano, Italy
| | - Marta Scorsetti
- 2 Radiotherapy and Radiosurgery, Humanitas Cancer Center and Research Hospital, Rozzano, Italy.,4 Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
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Baliga S, Garg MK, Fox J, Kalnicki S, Lasala PA, Welch MR, Tomé WA, Ohri N. Fractionated stereotactic radiation therapy for brain metastases: a systematic review with tumour control probability modelling. Br J Radiol 2016; 90:20160666. [PMID: 27936894 DOI: 10.1259/bjr.20160666] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Fractionated stereotactic radiotherapy (FSRT) is a relatively new option for the treatment of brain metastases. We performed a quantitative systematic review to determine if local control (LC) following is affected by FSRT dosing regimen. METHODS We reviewed articles describing LC following FSRT for brain metastases. LC data from each study were extracted from actuarial survival curves and aggregated to form a single data set. LC curves were generated using the Kaplan-Meier method. Log-rank testing and Cox proportional hazards modelling were utilized to test for associations between the biologically effective dose (BED) and LC. Tumour control probability modelling was performed to illustrate the relationship between the BED and the likelihood of LC after FSRT. RESULTS 10 studies (720 metastases) met inclusion criteria. Prescription doses ranged from 18 to 42 Gy, delivered in 3-12 fractions (BED range: 29-100 Gy10). 1- and 2-year actuarial LC rates were 80% and 69%, respectively. Increasing BED was associated with improved LC (HR = 0.77 per increase of 10 Gy10, p = 0.009). Tumour control probability models demonstrated that the BEDs of 40, 50 and 60 Gy10 yield predicted 1-year LC rates of 73%, 78% and 84%, respectively. The BEDs of 40, 50 and 60 Gy10 yield 2-year LC rates of 62%, 69% and 81%, respectively. CONCLUSION FSRT provides high rates of LC for patients with brain metastases. We found evidence for a dose-response relationship that should be explored in prospective trials. Advances in knowledge: This review identified a dose-response relationship for LC in patients treated with FSRT for brain metastases.
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Affiliation(s)
- Sujith Baliga
- 1 Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Madhur K Garg
- 1 Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Jana Fox
- 1 Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Shalom Kalnicki
- 1 Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Patrick A Lasala
- 2 Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Mary R Welch
- 3 Department of Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Wolfgang A Tomé
- 1 Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Nitin Ohri
- 1 Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
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Arvold ND, Lee EQ, Mehta MP, Margolin K, Alexander BM, Lin NU, Anders CK, Soffietti R, Camidge DR, Vogelbaum MA, Dunn IF, Wen PY. Updates in the management of brain metastases. Neuro Oncol 2016; 18:1043-65. [PMID: 27382120 PMCID: PMC4933491 DOI: 10.1093/neuonc/now127] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/09/2016] [Indexed: 12/16/2022] Open
Abstract
The clinical management/understanding of brain metastases (BM) has changed substantially in the last 5 years, with key advances and clinical trials highlighted in this review. Several of these changes stem from improvements in systemic therapy, which have led to better systemic control and longer overall patient survival, associated with increased time at risk for developing BM. Development of systemic therapies capable of preventing BM and controlling both intracranial and extracranial disease once BM are diagnosed is paramount. The increase in use of stereotactic radiosurgery alone for many patients with multiple BM is an outgrowth of the desire to employ treatments focused on local control while minimizing cognitive effects associated with whole brain radiotherapy. Complications from BM and their treatment must be considered in comprehensive patient management, especially with greater awareness that the majority of patients do not die from their BM. Being aware of significant heterogeneity in prognosis and therapeutic options for patients with BM is crucial for appropriate management, with greater attention to developing individual patient treatment plans based on predicted outcomes; in this context, recent prognostic models of survival have been extensively revised to incorporate molecular markers unique to different primary cancers.
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Affiliation(s)
| | | | | | - Kim Margolin
- St. Luke's Radiation Oncology Associates, St. Luke's Cancer Center, Whiteside Institute for Clinical Research and University of Minnesota Duluth, Duluth, Minnesota (N.D.A.); Center for Neuro-Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (E.Q.L., P.Y.W.); Harvard Medical School, Boston, Massachusetts (E.Q.L., B.M.A., N.U.L., I.F.D., P.Y.W.); Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland (M.P.M.); Department of Medical Oncology, City of Hope, Duarte, California (K.M.); Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (B.M.A.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (N.U.L.); Department of Medicine, Division of Hematology-Oncology, University of North Carolina, Chapel Hill, North Carolina (C.K.A.); Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy (R.S.); Division of Medical Oncology, University of Colorado Denver, Denver, Colorado (D.R.C.); Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.A.V.); Department of Neurosurgery, Brigham & Women's Hospital, Boston, Massachusetts (I.F.D.)
| | - Brian M. Alexander
- St. Luke's Radiation Oncology Associates, St. Luke's Cancer Center, Whiteside Institute for Clinical Research and University of Minnesota Duluth, Duluth, Minnesota (N.D.A.); Center for Neuro-Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (E.Q.L., P.Y.W.); Harvard Medical School, Boston, Massachusetts (E.Q.L., B.M.A., N.U.L., I.F.D., P.Y.W.); Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland (M.P.M.); Department of Medical Oncology, City of Hope, Duarte, California (K.M.); Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (B.M.A.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (N.U.L.); Department of Medicine, Division of Hematology-Oncology, University of North Carolina, Chapel Hill, North Carolina (C.K.A.); Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy (R.S.); Division of Medical Oncology, University of Colorado Denver, Denver, Colorado (D.R.C.); Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.A.V.); Department of Neurosurgery, Brigham & Women's Hospital, Boston, Massachusetts (I.F.D.)
| | - Nancy U. Lin
- St. Luke's Radiation Oncology Associates, St. Luke's Cancer Center, Whiteside Institute for Clinical Research and University of Minnesota Duluth, Duluth, Minnesota (N.D.A.); Center for Neuro-Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (E.Q.L., P.Y.W.); Harvard Medical School, Boston, Massachusetts (E.Q.L., B.M.A., N.U.L., I.F.D., P.Y.W.); Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland (M.P.M.); Department of Medical Oncology, City of Hope, Duarte, California (K.M.); Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (B.M.A.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (N.U.L.); Department of Medicine, Division of Hematology-Oncology, University of North Carolina, Chapel Hill, North Carolina (C.K.A.); Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy (R.S.); Division of Medical Oncology, University of Colorado Denver, Denver, Colorado (D.R.C.); Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.A.V.); Department of Neurosurgery, Brigham & Women's Hospital, Boston, Massachusetts (I.F.D.)
| | - Carey K. Anders
- St. Luke's Radiation Oncology Associates, St. Luke's Cancer Center, Whiteside Institute for Clinical Research and University of Minnesota Duluth, Duluth, Minnesota (N.D.A.); Center for Neuro-Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (E.Q.L., P.Y.W.); Harvard Medical School, Boston, Massachusetts (E.Q.L., B.M.A., N.U.L., I.F.D., P.Y.W.); Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland (M.P.M.); Department of Medical Oncology, City of Hope, Duarte, California (K.M.); Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (B.M.A.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (N.U.L.); Department of Medicine, Division of Hematology-Oncology, University of North Carolina, Chapel Hill, North Carolina (C.K.A.); Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy (R.S.); Division of Medical Oncology, University of Colorado Denver, Denver, Colorado (D.R.C.); Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.A.V.); Department of Neurosurgery, Brigham & Women's Hospital, Boston, Massachusetts (I.F.D.)
| | - Riccardo Soffietti
- St. Luke's Radiation Oncology Associates, St. Luke's Cancer Center, Whiteside Institute for Clinical Research and University of Minnesota Duluth, Duluth, Minnesota (N.D.A.); Center for Neuro-Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (E.Q.L., P.Y.W.); Harvard Medical School, Boston, Massachusetts (E.Q.L., B.M.A., N.U.L., I.F.D., P.Y.W.); Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland (M.P.M.); Department of Medical Oncology, City of Hope, Duarte, California (K.M.); Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (B.M.A.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (N.U.L.); Department of Medicine, Division of Hematology-Oncology, University of North Carolina, Chapel Hill, North Carolina (C.K.A.); Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy (R.S.); Division of Medical Oncology, University of Colorado Denver, Denver, Colorado (D.R.C.); Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.A.V.); Department of Neurosurgery, Brigham & Women's Hospital, Boston, Massachusetts (I.F.D.)
| | - D. Ross Camidge
- St. Luke's Radiation Oncology Associates, St. Luke's Cancer Center, Whiteside Institute for Clinical Research and University of Minnesota Duluth, Duluth, Minnesota (N.D.A.); Center for Neuro-Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (E.Q.L., P.Y.W.); Harvard Medical School, Boston, Massachusetts (E.Q.L., B.M.A., N.U.L., I.F.D., P.Y.W.); Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland (M.P.M.); Department of Medical Oncology, City of Hope, Duarte, California (K.M.); Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (B.M.A.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (N.U.L.); Department of Medicine, Division of Hematology-Oncology, University of North Carolina, Chapel Hill, North Carolina (C.K.A.); Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy (R.S.); Division of Medical Oncology, University of Colorado Denver, Denver, Colorado (D.R.C.); Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.A.V.); Department of Neurosurgery, Brigham & Women's Hospital, Boston, Massachusetts (I.F.D.)
| | - Michael A. Vogelbaum
- St. Luke's Radiation Oncology Associates, St. Luke's Cancer Center, Whiteside Institute for Clinical Research and University of Minnesota Duluth, Duluth, Minnesota (N.D.A.); Center for Neuro-Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (E.Q.L., P.Y.W.); Harvard Medical School, Boston, Massachusetts (E.Q.L., B.M.A., N.U.L., I.F.D., P.Y.W.); Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland (M.P.M.); Department of Medical Oncology, City of Hope, Duarte, California (K.M.); Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (B.M.A.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (N.U.L.); Department of Medicine, Division of Hematology-Oncology, University of North Carolina, Chapel Hill, North Carolina (C.K.A.); Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy (R.S.); Division of Medical Oncology, University of Colorado Denver, Denver, Colorado (D.R.C.); Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.A.V.); Department of Neurosurgery, Brigham & Women's Hospital, Boston, Massachusetts (I.F.D.)
| | - Ian F. Dunn
- St. Luke's Radiation Oncology Associates, St. Luke's Cancer Center, Whiteside Institute for Clinical Research and University of Minnesota Duluth, Duluth, Minnesota (N.D.A.); Center for Neuro-Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (E.Q.L., P.Y.W.); Harvard Medical School, Boston, Massachusetts (E.Q.L., B.M.A., N.U.L., I.F.D., P.Y.W.); Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland (M.P.M.); Department of Medical Oncology, City of Hope, Duarte, California (K.M.); Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (B.M.A.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (N.U.L.); Department of Medicine, Division of Hematology-Oncology, University of North Carolina, Chapel Hill, North Carolina (C.K.A.); Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy (R.S.); Division of Medical Oncology, University of Colorado Denver, Denver, Colorado (D.R.C.); Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.A.V.); Department of Neurosurgery, Brigham & Women's Hospital, Boston, Massachusetts (I.F.D.)
| | - Patrick Y. Wen
- St. Luke's Radiation Oncology Associates, St. Luke's Cancer Center, Whiteside Institute for Clinical Research and University of Minnesota Duluth, Duluth, Minnesota (N.D.A.); Center for Neuro-Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (E.Q.L., P.Y.W.); Harvard Medical School, Boston, Massachusetts (E.Q.L., B.M.A., N.U.L., I.F.D., P.Y.W.); Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland (M.P.M.); Department of Medical Oncology, City of Hope, Duarte, California (K.M.); Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts (B.M.A.); Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (N.U.L.); Department of Medicine, Division of Hematology-Oncology, University of North Carolina, Chapel Hill, North Carolina (C.K.A.); Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy (R.S.); Division of Medical Oncology, University of Colorado Denver, Denver, Colorado (D.R.C.); Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio (M.A.V.); Department of Neurosurgery, Brigham & Women's Hospital, Boston, Massachusetts (I.F.D.)
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Navarria P, Pessina F, Cozzi L, Ascolese AM, De Rose F, Fogliata A, Franzese C, Franceschini D, Tozzi A, D'Agostino G, Comito T, Iftode C, Maggi G, Reggiori G, Bello L, Scorsetti M. Hypo-fractionated stereotactic radiotherapy alone using volumetric modulated arc therapy for patients with single, large brain metastases unsuitable for surgical resection. Radiat Oncol 2016; 11:76. [PMID: 27249940 PMCID: PMC4890257 DOI: 10.1186/s13014-016-0653-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 05/26/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypo-fractionated stereotactic radiotherapy (HSRT) is emerging as a valid treatment option for patients with single, large brain metastases (BMs). We analyzed a set of our patients treated with HSRT. The aim of this study was to evaluate local control (LC), brain distant progression (BDP), toxicity and overall survival (OS). METHODS From July 2011 to May 2015, 102 patients underwent HSRT consisting of 27Gy/3fractions for lesions 2.1-3 cm and 32Gy/4 fractions for lesions 3.1-5 cm. Local progression was defined as increase of the enhancing abnormality on MRI, and distant progression as new brain metastases outside the irradiated volume. Toxicity in terms of radio-necrosis was assessed using contrast enhanced T1MRI, T2 weighted-MRI and perfusion- MRI. RESULT The median maximum diameter of BM was 2.9 cm (range 2.1-5 cm), the median gross target volume (GTV) was 16.3 cm(3) and the median planning target volume (PTV) was 33.7 cm(3) The median,1,2-year local control rate was 30 months, 96, 96 %; the median, 1-2-year rate of BDP was 24 months, 12, 24 %; the median,1,2-year OS was 14 months, 69, 33 %. KPS and controlled extracranial disease were associated with significant survival benefit (p <0.01). Brain radio-necrosis occurred in six patients (5.8 %). CONCLUSION In patients with single, large BMs unsuitable for surgical resection, HSRT is a safe and feasible treatment, with good brain local control and limited toxicity.
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Affiliation(s)
- Pierina Navarria
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Federico Pessina
- Neuro Surgery Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Luca Cozzi
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy.
| | - Anna Maria Ascolese
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Fiorenza De Rose
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Antonella Fogliata
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Ciro Franzese
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Davide Franceschini
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Angelo Tozzi
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Giuseppe D'Agostino
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Tiziana Comito
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Cristina Iftode
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Giulia Maggi
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Giacomo Reggiori
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Lorenzo Bello
- Neuro Surgery Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | - Marta Scorsetti
- Radiosurgery and Radiotherapy Department, Istituto Clinico Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
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Hypofractionated stereotactic radiotherapy for brain metastases from lung cancer : Evaluation of indications and predictors of local control. Strahlenther Onkol 2016; 192:386-93. [PMID: 27169391 DOI: 10.1007/s00066-016-0963-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 02/24/2016] [Indexed: 10/21/2022]
Abstract
AIM To evaluate the efficacy and toxicity of hypofractionated stereotactic radiotherapy (HSRT) for brain metastases (BMs) from lung cancer, and to explore prognostic factors associated with local control (LC) and indication. PATIENTS AND METHODS We evaluated patients who were treated with linac-based HSRT for BMs from lung cancer. Lesions treated with stereotactic radiosurgery (SRS) in the same patients during the same periods were analysed and compared with HSRT in terms of LC or toxicity. There were 53 patients with 214 lesions selected for this analysis (HSRT: 76 lesions, SRS: 138 lesions). For HSRT, the median prescribed dose was 35 Gy in 5 fractions. RESULTS The 1‑year LC rate was 83.6 % in HSRT; on multivariate analysis, a planning target volume (PTV) of <4 cm(3), biologically effective dose (BED10) of ≥51 Gy, and adenocarcinoma were significantly associated with better LC. Moreover, in PTVs ≥ 4 cm(3), there was a significant difference in LC between BED10 < 51 Gy and ≥ 51 Gy (p = 0.024). On the other hand, in PTVs < 4 cm(3), both HSRT and SRS had good LC with no significant difference (p = 0.195). Radiation necrosis emerged in 5 of 76 lesions (6.6 %) treated with HSRT and 21 of 138 (15.2 %) lesions treated with SRS (p = 0.064). CONCLUSION Linac-based HSRT was safe and effective for BMs from lung cancer, and hence might be particularly useful in or near an eloquent area. PTV, BED10, and pathological type were significant prognostic factors. Furthermore, in BMs ≥ 4 cm(3), a dose of BED ≥ 51 Gy should be considered.
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Experiences on two different stereotactic radiosurgery modalities of Gamma Knife and Cyberknife in treating brain metastases. Acta Neurochir (Wien) 2015; 157:2003-9; discussion 2009. [PMID: 26381540 DOI: 10.1007/s00701-015-2585-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 09/07/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND In this study, we compared the dosimetric properties between Gamma Knife (GK) and Cyberknife (CK), and investigated the clinical implications in treating brain metastases (BMs). METHODS Between 2011 and 2013, 77 patients treated with either single-fraction GK for small BMs (n = 40) or fractionated CK for large BMs >3 cm (n = 37) were analyzed. Among a total of 160 lesions, 81 were treated with GK (median, 22 Gy) and 38 (large lesions) with three- or five-fraction CK (median, 35 Gy). The median tumor volume was 1.0 cc (IQR, 0.12-4.4 cc) for GK and 17.6 cc (IQR, 12.8-23.7 cc) for fractionated CK. A lesion-to-lesion dosimetric comparison was performed using the identical contour set in both systems. RESULTS The mean dose to tumor was significantly higher in GK by 1.25-fold (P < 0.001), whereas normal tissue volume receiving 90-10 % of prescription dose was significantly larger in CK by 1.26-fold (P < 0.001). Nevertheless, no differences were observed in local tumor control (rates at 1 year, 89.7 % vs 87.0 %; P = 0.594) and overall survival (median, 14 vs 16 months; P = 0.493) between GK and fractionated CK groups. The incidences of radiation necrosis were also not different (12.3 % vs 15.8 %; P = 0.443). CONCLUSIONS Despite slightly inferior dosimetric properties of CK, fractionated CK for large BMs appears to be as effective and safe as single-fraction GK for small BMs, representing fractionation as an effective strategy for enhancing efficacy and moderating toxicity in stereotactic radiosurgery for BMs.
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Lischalk JW, Oermann E, Collins SP, Nair MN, Nayar VV, Bhasin R, Voyadzis JM, Rudra S, Unger K, Collins BT. Five-fraction stereotactic radiosurgery (SRS) for single inoperable high-risk non-small cell lung cancer (NSCLC) brain metastases. Radiat Oncol 2015; 10:216. [PMID: 26503609 PMCID: PMC4624578 DOI: 10.1186/s13014-015-0525-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 10/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Achieving durable local control while limiting normal tissue toxicity with definitive radiation therapy in the management of high-risk brain metastases remains a radiobiological challenge. The objective of this study was to examine the local control and toxicity of a 5-fraction stereotactic radiosurgical approach for treatment of patients with inoperable single high-risk NSCLC brain metastases. METHODS This retrospective analysis examines 20 patients who were deemed to have "high-risk" brain metastases. High-risk tumors were defined as those with a maximum diameter greater than 2 cm and/or those located within an eloquent cortex. Patients were evaluated by a neurosurgeon prior to treatment and determined to be inoperable due to tumor or patient characteristics. Patients were treated using the CyberKnife® SRS system in 5 fractions to a total dose of 30 Gy, 35 Gy, or 40 Gy. RESULTS Twenty patients with a median age of 65.5 years were treated from April 2010 to August 2014 in 5 fractions to a median total dose of 35 Gy. At a median follow up of 11.3 months local tumor control was observed in 18 of 20 metastases (90 %). Both local failures were observed in patients receiving a lower dose of 30 Gy. Median pre-treatment dexamethasone dose was 10 mg/day and median post-treatment nadir dose was 0 mg/day. Salvage intracranial therapy was required in 45 % of patients. Symptomatic radionecrosis was observed in 4 of 20 patients (20 %), two of which were treated to 40 Gy and the remainder to 35 Gy. Kaplan-Meier 1-year, 2-year, and median survival were calculated to be 45 %, 20 %, and 13.2 months, respectively. CONCLUSIONS Five-fraction SRS to a total dose of 35 Gy appears to be a safe and effective management strategy for single high-risk NSCLC brain metastases, while a total dose of 40 Gy leads to an excess risk of neurotoxicity.
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Affiliation(s)
- Jonathan W Lischalk
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Lower Level Bles, 3800 Reservoir Road, N.W., Washington, DC, 20007, USA.
| | - Eric Oermann
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Lower Level Bles, 3800 Reservoir Road, N.W., Washington, DC, 20007, USA.
| | - Sean P Collins
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Lower Level Bles, 3800 Reservoir Road, N.W., Washington, DC, 20007, USA.
| | - Mani N Nair
- Department of Neurosurgery, Georgetown University Hospital, Pasquerilla Healthcare Center (PHC), 7th floor, 3800 Reservoir Road, N.W., Washington, DC, 20007, USA.
| | - Vikram V Nayar
- Department of Neurosurgery, Georgetown University Hospital, Pasquerilla Healthcare Center (PHC), 7th floor, 3800 Reservoir Road, N.W., Washington, DC, 20007, USA.
| | - Richa Bhasin
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Lower Level Bles, 3800 Reservoir Road, N.W., Washington, DC, 20007, USA.
| | - Jean-Marc Voyadzis
- Department of Neurosurgery, Georgetown University Hospital, Pasquerilla Healthcare Center (PHC), 7th floor, 3800 Reservoir Road, N.W., Washington, DC, 20007, USA.
| | - Sonali Rudra
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Lower Level Bles, 3800 Reservoir Road, N.W., Washington, DC, 20007, USA.
| | - Keith Unger
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Lower Level Bles, 3800 Reservoir Road, N.W., Washington, DC, 20007, USA.
| | - Brian T Collins
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Lower Level Bles, 3800 Reservoir Road, N.W., Washington, DC, 20007, USA.
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Jeong WJ, Park JH, Lee EJ, Kim JH, Kim CJ, Cho YH. Efficacy and Safety of Fractionated Stereotactic Radiosurgery for Large Brain Metastases. J Korean Neurosurg Soc 2015; 58:217-24. [PMID: 26539264 PMCID: PMC4630352 DOI: 10.3340/jkns.2015.58.3.217] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 06/01/2015] [Accepted: 08/20/2015] [Indexed: 01/19/2023] Open
Abstract
Objective To investigate the efficacy and safety of fractionated stereotactic radiosurgery for large brain metastases (BMs). Methods Between June 2011 and December 2013, a total of 38 large BMs >3.0 cm in 37 patients were treated with fractionated Cyberknife radiosurgery. These patients comprised 16 men (43.2%) and 21 women, with a median age of 60 years (range, 38-75 years). BMs originated from the lung (n=19, 51.4%), the gastrointestinal tract (n=10, 27.0%), the breast (n=5, 13.5%), and other tissues (n=3, 8.1%). The median tumor volume was 17.6 cc (range, 9.4-49.6 cc). For Cyberknife treatment, a median peripheral dose of 35 Gy (range, 30-41 Gy) was delivered in 3 to 5 fractions. Results With a median follow-up of 10 months (range, 1-37 months), the crude local tumor control (LTC) rate was 86.8% and the estimated LTC rates at 12 and 24 months were 87.0% and 65.2%, respectively. The median overall survival (OS) and progression-free survival (PFS) rates were 16 and 11 months, respectively. The estimated OS and PFS rates at 6, 12, and 18 months were 81.1% and 65.5%, 56.8% and 44.9%, and 40.7% and 25.7%, respectively. Patient performance status and preoperative focal neurologic deficits improved in 20 of 35 (57.1%) and 12 of 17 patients (70.6%), respectively. Radiation necrosis with a toxicity grade of 2 or 3 occurred in 6 lesions (15.8%). Conclusion These results suggest a promising role of fractionated stereotactic radiosurgery in treating large BMs in terms of both efficacy and safety.
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Affiliation(s)
- Won Joo Jeong
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Hong Park
- Radiosurgery Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Jung Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Jin Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Hyun Cho
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Hypofractionated radiosurgery has a better safety profile than single fraction radiosurgery for large resected brain metastases. J Neurooncol 2015; 123:103-11. [PMID: 25862006 DOI: 10.1007/s11060-015-1767-4] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 04/02/2015] [Indexed: 11/12/2022]
Abstract
The purpose of this study is to compare the safety and efficacy of single fraction radiosurgery (SFR) with hypofractionated radiosurgery (HR) for the adjuvant treatment of large, surgically resected brain metastases. Seventy-five patients with 76 resection cavities ≥ 3 cm received 15 Gray (Gy) × 1 SFR (n = 40) or 5-8 Gy × 3-5 HR (n = 36). Cumulative incidence of local failure (LF) and radiation necrosis (RN) was estimated accounting for death as a competing risk and compared with Gray's test. The effect of multiple covariates was evaluated with the Fine-Gray proportional hazards model. The most common HR dose-fractionation schedules were 6 Gy × 5 (44%), 7-8 Gy × 3 (36%), and 6 Gy × 4 (8%). The median follow-up was 11 months (range 2-71). HR patients had larger median resection cavity volumes (24.0 vs. 13.3 cc, p < 0.001), planning target volumes (PTV) (37.7 vs. 20.5 cc, p < 0.001), and cavity to PTV expansion margins (2 vs. 1.5 mm, p = 0.002) than SFR patients. Cumulative incidence of LF (95% CI) at 6 and 12-months for HR versus SFR was 18.9% (0.07-0.34) versus 15.9% (0.06-0.29), and 25.6% (0.12-0.42) versus 27.2% (0.14-0.42), p = 0.80. Cumulative incidence of RN (95% CI) at 6 and 12 months for HR vs. SFR was 3.3% (0.00-0.15) versus 10.7% (0.03-0.23), and 10.3% (0.02-0.25) versus 19.2% (0.08-0.34), p = 0.28. On multivariable analysis, SFR was significantly associated with an increased risk of RN, with a HR of 3.81 (95% CI 1.04-13.93, p = 0.043). Hypofractionated radiosurgery may be the more favorable treatment approach for radiosurgery of cavities 3-4 cm in size and greater.
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Elson A, Walker A, Bovi JA, Schultz C. Use of Helical TomoTherapy for the Focal Hypofractionated Treatment of Limited Brain Metastases in the Initial and Recurrent Setting. Front Oncol 2015; 5:27. [PMID: 25709970 PMCID: PMC4321406 DOI: 10.3389/fonc.2015.00027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 01/26/2015] [Indexed: 01/12/2023] Open
Abstract
Background: Whole-brain radiation therapy (WBRT), stereotactic radiosurgery (SRS), or both are commonly employed in the treatment of limited brain metastases in the initial or recurrent setting. Hypofractionated partial volume irradiation is also employed, however, published experience using helical TomoTherapy (HT) for this purposes is limited. We reviewed our institutional experience to assess patient selection factors, fractionation scheme, and outcomes associated with this technique. Methods: A retrospective chart review was performed to evaluate patients treated with partial volume hypofractionated HT-based IMRT for brain metastases at our institution. Results: Thirteen patients (7M/6F, median age 62, median KPS 90) with a limited (1–9) number of brain metastases in the primary or recurrent setting were identified. Primary malignancies included colorectal (3), NSCLC (5), RCC (1), breast (1), melanoma (1), uterine (1), and ovarian (1). The median time from initial diagnosis to brain metastases was 20.7 months (range 0–61.3). Treatment was delivered to intact metastases in six patients, to a single resection cavity in six patients, and to both in one patient. A total of 27 lesions were treated. The median number of intact metastases treated was two (range 1–9). Previous treatments included WBRT (5), WBRT + SRS (3), SRS alone (1), and none (4). The most common fractionation schemes were 25 Gy in five fractions and 27.5 Gy in five fractions to each lesion. At a median of 6 months follow up (range 1.26–20.13) after TomoTherapy, 10 patients were deceased, 2 were alive, and 1 was lost to follow up. Systemic progression occurred in seven patients and intracranial progression occurred in five. The median intracranial progression free survival and overall survival after TomoTherapy was 6.3 months. Freedom from local failure for treated lesions was 71% and 59% at 6 and 12 months. Conclusion: TomoTherapy-based hypofractionated radiotherapy to a limited number of metastatic lesions is associated with acceptable intracranial disease control and survival outcomes and represents a viable treatment option in the primary and recurrent setting for select patients.
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Affiliation(s)
- Andrew Elson
- Department of Radiation Oncology, Medical College of Wisconsin , Milwaukee, WI , USA
| | - Ashley Walker
- Department of Radiation Oncology, Medical College of Wisconsin , Milwaukee, WI , USA
| | - Joseph A Bovi
- Department of Radiation Oncology, Medical College of Wisconsin , Milwaukee, WI , USA
| | - Christopher Schultz
- Department of Radiation Oncology, Medical College of Wisconsin , Milwaukee, WI , USA
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Wernicke AG, Yondorf MZ, Peng L, Trichter S, Nedialkova L, Sabbas A, Kulidzhanov F, Parashar B, Nori D, Clifford Chao KS, Christos P, Kovanlikaya I, Pannullo S, Boockvar JA, Stieg PE, Schwartz TH. Phase I/II study of resection and intraoperative cesium-131 radioisotope brachytherapy in patients with newly diagnosed brain metastases. J Neurosurg 2014; 121:338-48. [PMID: 24785322 PMCID: PMC4249933 DOI: 10.3171/2014.3.jns131140] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Resected brain metastases have a high rate of local recurrence without adjuvant therapy. Adjuvant whole-brain radiotherapy (WBRT) remains the standard of care with a local control rate > 90%. However, WBRT is delivered over 10-15 days, which can delay other therapy and is associated with acute and long-term toxicities. Permanent cesium-131 ((131)Cs) implants can be used at the time of metastatic resection, thereby avoiding the need for any additional therapy. The authors evaluated the safety, feasibility, and efficacy of a novel therapeutic approach with permanent (131)Cs brachytherapy at the resection for brain metastases. METHODS After institutional review board approval was obtained, 24 patients with a newly diagnosed metastasis to the brain were accrued to a prospective protocol between 2010 and 2012. There were 10 frontal, 7 parietal, 4 cerebellar, 2 occipital, and 1 temporal metastases. Histology included lung cancer (16), breast cancer (2), kidney cancer (2), melanoma (2), colon cancer (1), and cervical cancer (1). Stranded (131)Cs seeds were placed as permanent volume implants. The prescription dose was 80 Gy at a 5-mm depth from the resection cavity surface. Distant metastases were treated with stereotactic radiosurgery (SRS) or WBRT, depending on the number of lesions. The primary end point was local (resection cavity) freedom from progression (FFP). Secondary end points included regional FFP, distant FFP, median survival, overall survival (OS), and toxicity. RESULTS The median follow-up was 19.3 months (range 12.89-29.57 months). The median age was 65 years (range 45-84 years). The median size of resected tumor was 2.7 cm (range 1.5-5.5 cm), and the median volume of resected tumor was 10.31 cm(3) (range 1.77-87.11 cm(3)). The median number of seeds used was 12 (range 4-35), with a median activity of 3.82 mCi per seed (range 3.31-4.83 mCi) and total activity of 46.91 mCi (range 15.31-130.70 mCi). Local FFP was 100%. There was 1 adjacent leptomeningeal recurrence, resulting in a 1-year regional FFP of 93.8% (95% CI 63.2%-99.1%). One-year distant FFP was 48.4% (95% CI 26.3%-67.4%). Median OS was 9.9 months (95% CI 4.8 months, upper limit not estimated) and 1-year OS was 50.0% (95% CI 29.1%-67.8%). Complications included CSF leak (1), seizure (1), and infection (1). There was no radiation necrosis. CONCLUSIONS The use of postresection permanent (131)Cs brachytherapy implants resulted in no local recurrences and no radiation necrosis. This treatment was safe, well tolerated, and convenient for patients, resulting in a short radiation treatment course, high response rate, and minimal toxicity. These findings merit further study with a multicenter trial.
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Local control after fractionated stereotactic radiation therapy for brain metastases. J Neurooncol 2014; 120:339-46. [DOI: 10.1007/s11060-014-1556-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 07/05/2014] [Indexed: 10/25/2022]
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Zhou L, Liu J, Xue J, Xu Y, Gong Y, Deng L, Wang S, Zhong R, Ding Z, Lu Y. Whole brain radiotherapy plus simultaneous in-field boost with image guided intensity-modulated radiotherapy for brain metastases of non-small cell lung cancer. Radiat Oncol 2014; 9:117. [PMID: 24884773 PMCID: PMC4035738 DOI: 10.1186/1748-717x-9-117] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 04/28/2014] [Indexed: 02/05/2023] Open
Abstract
Background Whole brain radiotherapy (WBRT) plus sequential focal radiation boost is a commonly used therapeutic strategy for patients with brain metastases. However, recent reports on WBRT plus simultaneous in-field boost (SIB) also showed promising outcomes. The objective of present study is to retrospectively evaluate the efficacy and toxicities of WBRT plus SIB with image guided intensity-modulated radiotherapy (IG-IMRT) for inoperable brain metastases of NSCLC. Methods Twenty-nine NSCLC patients with 87 inoperable brain metastases were included in this retrospective study. All patients received WBRT at a dose of 40 Gy/20 f, and SIB boost with IG-IMRT at a dose of 20 Gy/5 f concurrent with WBRT in the fourth week. Prior to each fraction of IG-IMRT boost, on-line positioning verification and correction were used to ensure that the set-up errors were within 2 mm by cone beam computed tomography in all patients. Results The one-year intracranial control rate, local brain failure rate, and distant brain failure rate were 62.9%, 13.8%, and 19.2%, respectively. The two-year intracranial control rate, local brain failure rate, and distant brain failure rate were 42.5%, 30.9%, and 36.4%, respectively. Both median intracranial progression-free survival and median survival were 10 months. Six-month, one-year, and two-year survival rates were 65.5%, 41.4%, and 13.8%, corresponding to 62.1%, 41.4%, and 10.3% of intracranial progression-free survival rates. Patients with Score Index for Radiosurgery in Brain Metastases (SIR) >5, number of intracranial lesions <3, and history of EGFR-TKI treatment had better survival. Three lesions (3.45%) demonstrated radiation necrosis after radiotherapy. Grades 2 and 3 cognitive impairment with grade 2 radiation leukoencephalopathy were observed in 4 (13.8%) and 4 (13.8%) patients. No dosimetric parameters were found to be associated with these late toxicities. Patients received EGFR-TKI treatment had higher incidence of grades 2–3 cognitive impairment with grade 2 leukoencephalopathy. Conclusions WBRT plus SIB with IG-IMRT is a tolerable and effective treatment for NSCLC patients with inoperable brain metastases. However, the results of present study need to be examined by the prospective investigations.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - You Lu
- Department of Thoracic Cancer, Cancer Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
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Minniti G, Esposito V, Clarke E, Scaringi C, Bozzao A, Falco T, De Sanctis V, Enrici MM, Valeriani M, Osti MF, Enrici RM. Fractionated stereotactic radiosurgery for patients with skull base metastases from systemic cancer involving the anterior visual pathway. Radiat Oncol 2014; 9:110. [PMID: 24886280 PMCID: PMC4036429 DOI: 10.1186/1748-717x-9-110] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 03/16/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To analyze the tumor control, survival outcomes, and toxicity after stereotactic radiosurgery (SRS) for skull base metastases from systemic cancer involving the anterior visual pathway. PATIENTS AND METHODS We have analyzed 34 patients (23 females and 11 males, median age 59 years) who underwent multi-fraction SRS for a skull base metastasis compressing or in close proximity of optic nerves and chiasm. All metastases were treated with frameless LINAC-based multi-fraction SRS in 5 daily fractions of 5 Gy each. Local control, distant failure, and overall survival were estimated using the Kaplan-Meier method calculated from the time of SRS. Prognostic variables were assessed using log-rank and Cox regression analyses. RESULTS At a median follow-up of 13 months (range, 2-36.5 months), twenty-five patients had died and 9 were alive. The 1-year and 2-year local control rates were 89% and 72%, and respective actuarial survival rates were 63% and 30%. Four patients recurred with a median time to progression of 12 months (range, 6-27 months), and 17 patients had new brain metastases at distant brain sites. The 1-year and 2-year distant failure rates were 50% and 77%, respectively. On multivariate analysis, a Karnofsky performance status (KPS) >70 and the absence of extracranial metastases were prognostic factors associated with lower distant failure rates and longer survival. After multi-fraction SRS, 15 (51%) out of 29 patients had a clinical improvement of their preexisting cranial deficits. No patients developed radiation-induced optic neuropathy during the follow-up. CONCLUSIONS Multi-fraction SRS (5 x 5 Gy) is a safe treatment option associated with good local control and improved cranial nerve symptoms for patients with a skull base metastasis involving the anterior visual pathway.
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Affiliation(s)
- Giuseppe Minniti
- Radiation Oncology Unit, Sant' Andrea Hospital, University Sapienza, Via di Grottarossa 1035, 00189 Rome, Italy.
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Ammirati M, Kshettry VR, Lamki T, Wei L, Grecula JC. A Prospective Phase II Trial of Fractionated Stereotactic Intensity Modulated Radiotherapy With or Without Surgery in the Treatment of Patients With 1 to 3 Newly Diagnosed Symptomatic Brain Metastases. Neurosurgery 2014; 74:586-94; discussion 594. [DOI: 10.1227/neu.0000000000000325] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
ABSTRACT
BACKGROUND:
Several studies have demonstrated that omitting the routine use of adjuvant whole-brain radiation therapy for patients with newly diagnosed brain metastases may be a reasonable first-line strategy. Retrospective evidence suggests that fractionated stereotactic radiotherapy (fSRT) may have a lower level of toxicity with equivalent efficacy in comparison with radiosurgery.
OBJECTIVE:
To study the phase II efficacy of using a focally directed treatment strategy for symptomatic brain metastases by the use of fSRT with or without surgery and omitting the routine use of adjuvant whole-brain radiation therapy.
METHODS:
We used a Fleming single-stage design of 40 patients. Patients were eligible if they presented with 1 to 3 newly diagnosed symptomatic brain metastases, Karnofsky performance scale (KPS) greater than 60, and histological confirmation of primary disease. Patients underwent fSRT with the use of a dose of 30 Gy in 5 intensity-modulated fractions as primary or adjuvant treatment after surgical resection. The primary end point was the proportion of patients who experienced neurological death. Secondary end points were overall survival, time to KPS <70, and progression-free survival.
RESULTS:
Of 40 patients accrued, 39 were eligible for analysis. The proportion of patients dying of neurological causes was 13% (5 patients), which includes 3 patients with an unknown cause of death. Median overall survival, time to KPS <70, and progression-free survival were 16 (95% confidence interval, 9-23), 14 (95% confidence interval, 7-20), and 11 (95% confidence interval, 4-21) months, respectively.
CONCLUSION:
A focally directed treatment strategy using fSRT with or without surgery appears to be an effective initial strategy. Based on the results of this phase II clinical trial, further study is warranted.
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Affiliation(s)
- Mario Ammirati
- Department of Neurological Surgery, Ohio State University Medical Center, Columbus, Ohio
- Department of Radiation Oncology, Ohio State University Medical Center, Columbus, Ohio
| | - Varun R. Kshettry
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Tariq Lamki
- Department of Neurological Surgery, Ohio State University Medical Center, Columbus, Ohio
| | - Lai Wei
- Center for Biostatistics, Ohio State University Medical Center, Columbus, Ohio
| | - John C. Grecula
- Department of Radiation Oncology, Ohio State University Medical Center, Columbus, Ohio
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