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Kihara S, Ohira S, Kanayama N, Ikawa T, Ueda Y, Inui S, Minami H, Sagawa T, Miyazaki M, Koizumi M, Konishi K. The effects of distance between the imaging isocenter and brain center on the image quality of cone-beam computed tomography for brain stereotactic irradiation. Phys Eng Sci Med 2024; 47:597-609. [PMID: 38353926 DOI: 10.1007/s13246-024-01389-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 01/08/2024] [Indexed: 06/12/2024]
Abstract
In linear accelerator-based stereotactic irradiation (STI) for brain metastasis, cone-beam computed tomography (CBCT) image quality is essential for ensuring precise patient setup and tumor localization. However, CBCT images may be degraded by the deviation of the CBCT isocenter from the brain center. This study aims to investigate the effects of the distance from the brain center to the CBCT isocenter (DBI) on the image quality in STI. An anthropomorphic phantom was scanned with varying DBI in right, anterior, superior, and inferior directions. Thirty patients undergoing STI were prospectively recruited. Objective metrics, utilizing regions of interest included contrast-to-noise ratio (CNR) at the centrum semiovale, lateral ventricle, and basal ganglia levels, gray and white matter noise at the basal ganglia level, artifact index (AI), and nonuniformity (NU). Two radiation oncologists assessed subjective metrics. In this phantom study, objective measures indicated a degradation in image quality for non-zero DBI. In this patient study, there were significant correlations between the CNR at the centrum semiovale and lateral ventricle levels (rs = - 0.79 and - 0.77, respectively), gray matter noise (rs = 0.52), AI (rs = 0.72), and NU (rs = 0.91) and DBI. However, no significant correlations were observed between the CNR at the basal ganglia level, white matter noise, and subjective metrics and DBI (rs < ± 0.3). Our results demonstrate the effects of DBI on contrast, noise, artifacts in the posterior fossa, and uniformity of CBCT images in STI. Aligning the CBCT isocenter with the brain center can aid in improving image quality.
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Affiliation(s)
- Sayaka Kihara
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan.
| | - Shingo Ohira
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Naoyuki Kanayama
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Toshiki Ikawa
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Yoshihiro Ueda
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Shoki Inui
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Hikari Minami
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Tomohiro Sagawa
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Masayoshi Miyazaki
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Masahiko Koizumi
- Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Koji Konishi
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
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Samanci Y, Ali Tepebasili M, Deniz Ardor G, Haluk Duzkalir A, Orbay Askeroglu M, Peker S. Efficacy of hypofractionated Gamma Knife radiosurgery in treating surgical beds of metastatic brain tumors. J Clin Neurosci 2024; 121:105-113. [PMID: 38387112 DOI: 10.1016/j.jocn.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/01/2024] [Accepted: 02/17/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVE Surgery alone for metastatic brain tumors (METs) often results in local recurrence due to microscopic residual tumor tissue. While stereotactic radiosurgery (SRS) is commonly used post-surgery, hypofractionation may be required for large surgical beds. This study evaluated the efficacy and safety of hypofractionated Gamma Knife radiosurgery (hf-GKRS) for the first time as a post-operative adjuvant therapy. METHODS This retrospective study involved 24 patients (28 surgical beds) who underwent hf-GKRS within four weeks after surgery. The study primarily focused on local control (LC) rate and analyzed distant intracranial failure (DICF), intracranial progression-free survival (PFS), leptomeningeal disease (LMD), overall survival (OS), and radiation necrosis (RN). RESULTS During a median follow-up of 9 months, LC was achieved in 89.3 % of surgical beds. LC estimates at 6, 12, and 24 months were 96.4 %, 82.7 %, and 82.7 %, respectively. DICF was observed in 45.8 % of patients, and LMD was identified in two patients (8.3 %). At the end of the follow-up, 58.3 % of patients were alive, and the median OS was 20 months. RN occurred in only one surgical bed (3.6 %). No grade 5 toxicity was observed. The univariate analysis identified a longer interval to GKRS (HR 11.842, p = 0.042) and a larger treatment volume (HR 1.103, p = 0.037) as significant factors for local failure. CONCLUSIONS hf-GKRS shows potential as an effective and safe adjuvant treatment for surgical beds. It offers an alternative to SRS, SRT, or WBRT, particularly for larger volumes or tumors near critical structures. Further research is needed to confirm these results and optimize treatment approaches.
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Affiliation(s)
- Yavuz Samanci
- Koc University School of Medicine, Department of Neurosurgery, Istanbul, Turkey
| | | | - Gokce Deniz Ardor
- Koc University Hospital, Department of Neurosurgery, Gamma Knife Center, Istanbul, Turkey
| | - Ali Haluk Duzkalir
- Koc University Hospital, Department of Neurosurgery, Gamma Knife Center, Istanbul, Turkey
| | - M Orbay Askeroglu
- Koc University Hospital, Department of Neurosurgery, Gamma Knife Center, Istanbul, Turkey
| | - Selcuk Peker
- Koc University School of Medicine, Department of Neurosurgery, Istanbul, Turkey.
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Kübler J, Wester-Ebbinghaus M, Wenz F, Stieler F, Bathen B, Mai SK, Wolff R, Hänggi D, Blanck O, Giordano FA. Postoperative stereotactic radiosurgery and hypofractionated radiotherapy for brain metastases using Gamma Knife and CyberKnife: a dual-center analysis. J Neurosurg Sci 2024; 68:22-30. [PMID: 32031357 DOI: 10.23736/s0390-5616.20.04830-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
BACKGROUND Postoperative stereotactic radiosurgery (SRS) and hypofractionated stereotactic radiotherapy (hFSRT) to tumor cavities is emerging as a new standard of care after resection of brain metastases. Both Gamma Knife (GK) and CyberKnife (CK) are modalities commonly used for stereotactic radiotherapy, but fractional schemes are not consistent. The objective of this study was to evaluate outcomes in patients receiving postoperative stereotactic radiotherapy of resected brain metastases (BM) using different fractionation schedules and modalities in two large centers. METHODS Patients with newly diagnosed BM who underwent postoperative SRS or hFSRT with either GK or CK at two large cancer centers were retrospectively evaluated. We analyzed local control (LC), regional control (RC) and overall survival (OS). RESULTS From April 14th to May 18th, 2020, 79 patients with 81 resection cavities were treated. Forty-seven patients (59.5%) received GK and 32 patients (40.5%) received CK treatment. Fifty-four cavities (66.7%) were treated with hFSRT and 27 (33.3%) with SRS. The most common hFSRT and SRS scheme was 3x10 Gy and 1x16 Gy, respectively. Median OS was 11.7 months with survival rates of 44.7% at 1 year and 18.5% at 2 years. LC was 83.3% after 1 year. Median time to regional progression was 12.0 months with RC rates of 61.1% at 6 months and 41.0% at 12 months. There was no difference in OS, LC or RC between GK and CK treatments or SRS and hFSRT. CONCLUSIONS Both SRS and hFSRT provide high local control rates in resected BM regardless of the applied modality.
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Affiliation(s)
- Jens Kübler
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Michael Wester-Ebbinghaus
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Florian Stieler
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Bastian Bathen
- Saphir Radiosurgery Center Frankfurt, Frankfurt am Main, Germany
- Department of Radiation Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Sabine K Mai
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Robert Wolff
- Saphir Radiosurgery Center Frankfurt, Frankfurt am Main, Germany
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Oliver Blanck
- Saphir Radiosurgery Center Frankfurt, Frankfurt am Main, Germany
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany -
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Putz F, Bock M, Schmitt D, Bert C, Blanck O, Ruge MI, Hattingen E, Karger CP, Fietkau R, Grigo J, Schmidt MA, Bäuerle T, Wittig A. Quality requirements for MRI simulation in cranial stereotactic radiotherapy: a guideline from the German Taskforce "Imaging in Stereotactic Radiotherapy". Strahlenther Onkol 2024; 200:1-18. [PMID: 38163834 PMCID: PMC10784363 DOI: 10.1007/s00066-023-02183-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/06/2023] [Indexed: 01/03/2024]
Abstract
Accurate Magnetic Resonance Imaging (MRI) simulation is fundamental for high-precision stereotactic radiosurgery and fractionated stereotactic radiotherapy, collectively referred to as stereotactic radiotherapy (SRT), to deliver doses of high biological effectiveness to well-defined cranial targets. Multiple MRI hardware related factors as well as scanner configuration and sequence protocol parameters can affect the imaging accuracy and need to be optimized for the special purpose of radiotherapy treatment planning. MRI simulation for SRT is possible for different organizational environments including patient referral for imaging as well as dedicated MRI simulation in the radiotherapy department but require radiotherapy-optimized MRI protocols and defined quality standards to ensure geometrically accurate images that form an impeccable foundation for treatment planning. For this guideline, an interdisciplinary panel including experts from the working group for radiosurgery and stereotactic radiotherapy of the German Society for Radiation Oncology (DEGRO), the working group for physics and technology in stereotactic radiotherapy of the German Society for Medical Physics (DGMP), the German Society of Neurosurgery (DGNC), the German Society of Neuroradiology (DGNR) and the German Chapter of the International Society for Magnetic Resonance in Medicine (DS-ISMRM) have defined minimum MRI quality requirements as well as advanced MRI simulation options for cranial SRT.
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Affiliation(s)
- Florian Putz
- Strahlenklinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
| | - Michael Bock
- Klinik für Radiologie-Medizinphysik, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Daniela Schmitt
- Klinik für Strahlentherapie und Radioonkologie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Christoph Bert
- Strahlenklinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Oliver Blanck
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Maximilian I Ruge
- Klinik für Stereotaxie und funktionelle Neurochirurgie, Zentrum für Neurochirurgie, Universitätsklinikum Köln, Cologne, Germany
| | - Elke Hattingen
- Institut für Neuroradiologie, Universitätsklinikum Frankfurt, Frankfurt am Main, Germany
| | - Christian P Karger
- Abteilung Medizinische Physik in der Strahlentherapie, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
- Nationales Zentrum für Strahlenforschung in der Onkologie (NCRO), Heidelberger Institut für Radioonkologie (HIRO), Heidelberg, Germany
| | - Rainer Fietkau
- Strahlenklinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Johanna Grigo
- Strahlenklinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Manuel A Schmidt
- Neuroradiologisches Institut, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Tobias Bäuerle
- Radiologisches Institut, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Andrea Wittig
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Würzburg, Würzburg, Germany
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Willems YCP, Vaassen F, Zegers CML, Postma AA, Jaspers J, Romero AM, Unipan M, Swinnen A, Anten M, Teernstra O, Compter I, van Elmpt W, Eekers DBP. Anatomical changes in resection cavity during brain radiotherapy. J Neurooncol 2023; 165:479-486. [PMID: 38095775 DOI: 10.1007/s11060-023-04505-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/09/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND AND PURPOSE Brain tumors are in general treated with a maximal safe resection followed by radiotherapy of remaining tumor including the resection cavity (RC) and chemotherapy. Anatomical changes of the RC during radiotherapy can have impact on the coverage of the target volume. The aim of the current study was to quantify the potential changes of the RC and to identify risk factors for RC changes. MATERIALS AND METHODS Sixteen patients treated with pencil beam scanning proton therapy between October 2019 and April 2020 were retrospectively analyzed. The RC was delineated on pre-treatment computed tomography (CT) and magnetic resonance imaging, and weekly CT-scans during treatment. Isotropic expansions were applied to the pre-treatment RC (1-5 mm). The percentage of volume of the RC during treatment within the expanded pre-treatment volumes was quantified. Potential risk factors (volume of RC, time interval surgery-radiotherapy and relationship of RC to the ventricles) were evaluated using Spearman's rank correlation coefficient. RESULTS The average variation in relative RC volume during treatment was 26.1% (SD 34.6%). An expansion of 4 mm was required to cover > 95% of the RC volume in > 90% of patients. There was a significant relationship between the absolute volume of the pre-treatment RC and the volume changes during treatment (Spearman's ρ = - 0.644; p = 0.007). CONCLUSION RCs are dynamic after surgery. Potentially, an additional margin in brain cancer patients with an RC should be considered, to avoid insufficient target coverage. Future research on local recurrence patterns is recommended.
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Affiliation(s)
- Yves C P Willems
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Femke Vaassen
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands.
| | - Catharina M L Zegers
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Alida A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Jaap Jaspers
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Alejandra Méndez Romero
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mirko Unipan
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Ans Swinnen
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Monique Anten
- Department of Neurology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Onno Teernstra
- Department of Neurosurgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Inge Compter
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Wouter van Elmpt
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Daniëlle B P Eekers
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
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Diehl CD, Giordano FA, Grosu AL, Ille S, Kahl KH, Onken J, Rieken S, Sarria GR, Shiban E, Wagner A, Beck J, Brehmer S, Ganslandt O, Hamed M, Meyer B, Münter M, Raabe A, Rohde V, Schaller K, Schilling D, Schneider M, Sperk E, Thomé C, Vajkoczy P, Vatter H, Combs SE. Opportunities and Alternatives of Modern Radiation Oncology and Surgery for the Management of Resectable Brain Metastases. Cancers (Basel) 2023; 15:3670. [PMID: 37509330 PMCID: PMC10377800 DOI: 10.3390/cancers15143670] [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: 04/18/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Postsurgical radiotherapy (RT) has been early proven to prevent local tumor recurrence, initially performed with whole brain RT (WBRT). Subsequent to disadvantageous cognitive sequalae for the patient and the broad distribution of modern linear accelerators, focal irradiation of the tumor has omitted WBRT in most cases. In many studies, the effectiveness of local RT of the resection cavity, either as single-fraction stereotactic radiosurgery (SRS) or hypo-fractionated stereotactic RT (hFSRT), has been demonstrated to be effective and safe. However, whereas prospective high-level incidence is still lacking on which dose and fractionation scheme is the best choice for the patient, further ablative techniques have come into play. Neoadjuvant SRS (N-SRS) prior to resection combines straightforward target delineation with an accelerated post-surgical phase, allowing an earlier start of systemic treatment or rehabilitation as indicated. In addition, low-energy intraoperative RT (IORT) on the surgical bed has been introduced as another alternative to external beam RT, offering sterilization of the cavity surface with steep dose gradients towards the healthy brain. This consensus paper summarizes current local treatment strategies for resectable brain metastases regarding available data and patient-centered decision-making.
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Affiliation(s)
- Christian D Diehl
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 80336 München, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Anca-L Grosu
- Department of Radiation Oncology, University Medical Center, Medical Faculty, 79106 Freiburg, Germany
| | - Sebastian Ille
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Klaus-Henning Kahl
- Department of Radiation Oncology, University Medical Center Augsburg, 86156 Augsburg, Germany
| | - Julia Onken
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
- Berlin Institute of Health, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- German Cancer Consortium (DKTK), Partner Site Berlin, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, 37075 Göttingen, Germany
- Comprehensive Cancer Center Niedersachsen (CCC-N), 37075 Göttingen, Germany
| | - Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Ehab Shiban
- Department of Neurosurgery, University Medical Center Augsburg, 86156 Augsburg, Germany
| | - Arthur Wagner
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Jürgen Beck
- Department of Neurosurgery, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Stefanie Brehmer
- Department of Neurosurgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Oliver Ganslandt
- Neurosurgical Clinic, Klinikum Stuttgart, 70174 Stuttgart, Germany
| | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Marc Münter
- Department of Radiation Oncology, Klinikum Stuttgart Katharinenhospital, 70174 Stuttgart, Germany
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Veit Rohde
- Department of Neurosurgery, Universitätsmedizin Göttingen, 37075 Göttingen, Germany
| | - Karl Schaller
- Department of Neurosurgery, University of Geneva Medical Center & Faculty of Medicine, 1211 Geneva, Switzerland
| | - Daniela Schilling
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Elena Sperk
- Mannheim Cancer Center, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 80336 München, Germany
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Ng SK, Yue Y, Shiue K, Shah MV, Le Y. Dosimetric Impact of Source Displacement in GammaTile Surgically Targeted Radiation Therapy for Gliomas. Cureus 2023; 15:e38463. [PMID: 37273347 PMCID: PMC10234842 DOI: 10.7759/cureus.38463] [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] [Accepted: 05/02/2023] [Indexed: 06/06/2023] Open
Abstract
Background This study aims to evaluate dosimetric changes that happened during the first month after GammaTile surgically targeted radiation therapy (STaRT) for gliomas due to Cesium-131 (Cs-131) seed displacement caused by cavity shrinkage in brain brachytherapy. Methodology In this study, 10 glioma patients had 4-11 GammaTiles placed along the resection bed after maximal safe resection during craniotomy. Each GammaTile is composed of four Cs-131 seeds embedded in a biodegradable collagen sponge to minimize seed movement and maintain seed-to-cavity surface distance. The Cs-131 seed positions were identified using VariSeed on day one. On day 30, post-implant computed tomography (CT) images and dosimetry parameters were calculated. An iterative closest point (ICP) algorithm was used to compute rigid transformation between the day one and day 30 seed clouds. The seed displacement was calculated after registration. The volume receiving 100% of the prescription dose (V100), the dose received by 90% of the planning target volume (D90_PTV), the planning target volume receiving 100% of the prescription dose (V100_PTV), and the dose to organs at risk (OARs) were calculated for both CT images to determine the dosimetric changes from any seed displacement. Results The mean seed displacement of 1.8 ± 1.0 mm for all patients was observed between day one and day 30. The maximum seed displacement for each patient ranged from 2.3 mm to 7.3 mm. The mean V100 difference between day one and day 30 was 2.5 cc (range = 0.5-6.5 cc). The mean D90_PTVs were 95.5% (range = 69.0%-131.0%) and 98.1% (range = 19.9%-149.0%) on day one and day 30, respectively. The mean V100_PTVs were 88.4% (range = 81.3%-99.1%) and 87.9% (range = 47.0%-99.7%) on day one and day 30, respectively. On day one, the brainstem dose was 63.5 Gy for one case and 28.1 Gy for another case; while on day 30, the brainstem dose was 55.8 Gy and 20.6 Gy for the same patients, contributing to 7.7 Gy (12.8%) and 7.5 Gy (12.5%) dose reductions to brainstem for these patients, respectively. Only two patients received a dose to the optic nerves (34.1 Gy and 5.2 Gy). There were small changes (1.8 Gy and 0.5 Gy, respectively) in the dose to optic nerves when comparing the dose calculated on day one and the dose calculated on day 30 CT images. The same two patients received 30.4 Gy and 6.8 Gy to the chiasm, respectively. Small changes in the dose to the chiasm (≤1.1 Gy) were noted between day one and day 30. Conclusions A maximum seed displacement of up to 7.3 mm and a mean seed displacement of 1.8 mm caused by cavity shrinkage were observed during the first month after GammaTile STaRT for gliomas. There were noticeable changes in dosimetry parameters. Changes in the doses to OARs, particularly the brainstem, were large (up to 12.8% of the prescription dose). These changes in dosimetry should be considered when evaluating treatment outcomes and planning future GammaTile treatments.
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Affiliation(s)
- Sook Kien Ng
- Radiation Oncology, Indiana University School of Medicine, Indianapolis, USA
| | - Yong Yue
- Radiation Oncology, Indiana University School of Medicine, Indianapolis, USA
| | - Kevin Shiue
- Radiation Oncology, Indiana University School of Medicine, Indianapolis, USA
| | - Mitesh V Shah
- Neurological Surgery, Indiana University Health, Indianapolis, USA
| | - Yi Le
- Radiation Oncology, Oklahoma Proton Center, Oklahoma City, USA
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Acker G, Nachbar M, Soffried N, Bodnar B, Janas A, Krantchev K, Kalinauskaite G, Kluge A, Shultz D, Conti A, Kaul D, Zips D, Vajkoczy P, Senger C. What if: A retrospective reconstruction of resection cavity stereotactic radiosurgery to mimic neoadjuvant stereotactic radiosurgery. Front Oncol 2023; 13:1056330. [PMID: 37007157 PMCID: PMC10062706 DOI: 10.3389/fonc.2023.1056330] [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: 09/28/2022] [Accepted: 02/20/2023] [Indexed: 03/18/2023] Open
Abstract
Introduction Neoadjuvant stereotactic radiosurgery (NaSRS) of brain metastases has gained importance, but it is not routinely performed. While awaiting the results of prospective studies, we aimed to analyze the changes in the volume of brain metastases irradiated pre- and postoperatively and the resulting dosimetric effects on normal brain tissue (NBT). Methods We identified patients treated with SRS at our institution to compare hypothetical preoperative gross tumor and planning target volumes (pre-GTV and pre-PTV) with original postoperative resection cavity volumes (post-GTV and post-PTV) as well as with a standardized-hypothetical PTV with 2.0 mm margin. We used Pearson correlation to assess the association between the GTV and PTV changes with the pre-GTV. A multiple linear regression analysis was established to predict the GTV change. Hypothetical planning for the selected cases was created to assess the volume effect on the NBT exposure. We performed a literature review on NaSRS and searched for ongoing prospective trials. Results We included 30 patients in the analysis. The pre-/post-GTV and pre-/post-PTV did not differ significantly. We observed a negative correlation between pre-GTV and GTV-change, which was also a predictor of volume change in the regression analysis, in terms of a larger volume change for a smaller pre-GTV. In total, 62.5% of cases with an enlargement greater than 5.0 cm3 were smaller tumors (pre-GTV < 15.0 cm3), whereas larger tumors greater than 25.0 cm3 showed only a decrease in post-GTV. Hypothetical planning for the selected cases to evaluate the volume effect resulted in a median NBT exposure of only 67.6% (range: 33.2-84.5%) relative to the dose received by the NBT in the postoperative SRS setting. Nine published studies and twenty ongoing studies are listed as an overview. Conclusion Patients with smaller brain metastases may have a higher risk of volume increase when irradiated postoperatively. Target volume delineation is of great importance because the PTV directly affects the exposure of NBT, but it is a challenge when contouring resection cavities. Further studies should identify patients at risk of relevant volume increase to be preferably treated with NaSRS in routine practice. Ongoing clinical trials will evaluate additional benefits of NaSRS.
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Affiliation(s)
- Gueliz Acker
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Academy, Clinician Scientist Program, Berlin, Germany
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Marcel Nachbar
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Nina Soffried
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Bohdan Bodnar
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Anastasia Janas
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Kiril Krantchev
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Goda Kalinauskaite
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Anne Kluge
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - David Shultz
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Alfredo Conti
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum - Università di Bologna, Bologna, Italy
| | - David Kaul
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
- German Cancer Consortium (DKTK), Partner Site Berlin, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Daniel Zips
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Carolin Senger
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
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Guerini AE, Nici S, Magrini SM, Riga S, Toraci C, Pegurri L, Facheris G, Cozzaglio C, Farina D, Liserre R, Gasparotti R, Ravanelli M, Rondi P, Spiazzi L, Buglione M. Adoption of Hybrid MRI-Linac Systems for the Treatment of Brain Tumors: A Systematic Review of the Current Literature Regarding Clinical and Technical Features. Technol Cancer Res Treat 2023; 22:15330338231199286. [PMID: 37774771 PMCID: PMC10542234 DOI: 10.1177/15330338231199286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/24/2023] [Accepted: 08/08/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Possible advantages of magnetic resonance (MR)-guided radiation therapy (MRgRT) for the treatment of brain tumors include improved definition of treatment volumes and organs at risk (OARs) that could allow margin reductions, resulting in limited dose to the OARs and/or dose escalation to target volumes. Recently, hybrid systems integrating a linear accelerator and an magnetic resonance imaging (MRI) scan (MRI-linacs, MRL) have been introduced, that could potentially lead to a fully MRI-based treatment workflow. METHODS We performed a systematic review of the published literature regarding the adoption of MRL for the treatment of primary or secondary brain tumors (last update November 3, 2022), retrieving a total of 2487 records; after a selection based on title and abstracts, the full text of 74 articles was analyzed, finally resulting in the 52 papers included in this review. RESULTS AND DISCUSSION Several solutions have been implemented to achieve a paradigm shift from CT-based radiotherapy to MRgRT, such as the management of geometric integrity and the definition of synthetic CT models that estimate electron density. Multiple sequences have been optimized to acquire images with adequate quality with on-board MR scanner in limited times. Various sophisticated algorithms have been developed to compensate the impact of magnetic field on dose distribution and calculate daily adaptive plans in a few minutes with satisfactory dosimetric parameters for the treatment of primary brain tumors and cerebral metastases. Dosimetric studies and preliminary clinical experiences demonstrated the feasibility of treating brain lesions with MRL. CONCLUSIONS The adoption of an MRI-only workflow is feasible and could offer several advantages for the treatment of brain tumors, including superior image quality for lesions and OARs and the possibility to adapt the treatment plan on the basis of daily MRI. The growing body of clinical data will clarify the potential benefit in terms of toxicity and response to treatment.
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Affiliation(s)
- Andrea Emanuele Guerini
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
- Co-first authors
| | - Stefania Nici
- Medical Physics Department, ASST Spedali Civili Hospital, Brescia, Italy
- Co-first authors
| | - Stefano Maria Magrini
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
| | - Stefano Riga
- Medical Physics Department, ASST Spedali Civili Hospital, Brescia, Italy
| | - Cristian Toraci
- Medical Physics Department, ASST Spedali Civili Hospital, Brescia, Italy
| | - Ludovica Pegurri
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
| | - Giorgio Facheris
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
| | - Claudia Cozzaglio
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
- Medical Physics Department, ASST Spedali Civili Hospital, Brescia, Italy
| | - Davide Farina
- Radiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Roberto Liserre
- Department of Radiology, Neuroradiology Unit, ASST Spedali Civili University Hospital, Brescia, Italy
| | - Roberto Gasparotti
- Neuroradiology Unit, Department of Medical-Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Ravanelli
- Radiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Paolo Rondi
- Radiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Luigi Spiazzi
- Medical Physics Department, ASST Spedali Civili Hospital, Brescia, Italy
- Co-last author
| | - Michela Buglione
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
- Co-last author
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10
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Diehl CD, Rosenkranz E, Schwendner M, Mißlbeck M, Sollmann N, Ille S, Meyer B, Combs SE, Krieg SM. Dose Reduction to Motor Structures in Adjuvant Fractionated Stereotactic Radiotherapy of Brain Metastases: nTMS-Derived DTI-Based Motor Fiber Tracking in Treatment Planning. Cancers (Basel) 2022; 15:cancers15010282. [PMID: 36612277 PMCID: PMC9818359 DOI: 10.3390/cancers15010282] [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: 11/09/2022] [Revised: 12/07/2022] [Accepted: 12/19/2022] [Indexed: 01/03/2023] Open
Abstract
Background: Resection of brain metastases (BM) close to motor structures is challenging for treatment. Navigated transcranial magnetic stimulation (nTMS) motor mapping, combined with diffusion tensor imaging (DTI)-based fiber tracking (DTI-FTmot.TMS), is a valuable tool in neurosurgery to preserve motor function. This study aimed to assess the practicability of DTI-FTmot.TMS for local adjuvant radiotherapy (RT) planning of BM. Methods: Presurgically generated DTI-FTmot.TMS-based corticospinal tract (CST) reconstructions (FTmot.TMS) of 24 patients with 25 BM resected during later surgery were incorporated into the RT planning system. Completed fractionated stereotactic intensity-modulated RT (IMRT) plans were retrospectively analyzed and adapted to preserve FTmot.TMS. Results: In regular plans, mean dose (Dmean) of complete FTmot.TMS was 5.2 ± 2.4 Gy. Regarding planning risk volume (PRV-FTTMS) portions outside of the planning target volume (PTV) within the 17.5 Gy (50%) isodose line, the DTI-FTmot.TMS Dmean was significantly reduced by 33.0% (range, 5.9−57.6%) from 23.4 ± 3.3 Gy to 15.9 ± 4.7 Gy (p < 0.001). There was no significant decline in the effective treatment dose, with PTV Dmean 35.6 ± 0.9 Gy vs. 36.0 ± 1.2 Gy (p = 0.063) after adaption. Conclusions: The DTI-FTmot.TMS-based CST reconstructions could be implemented in adjuvant IMRT planning of BM. A significant dose reduction regarding motor structures within critical dose levels seems possible.
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Affiliation(s)
- Christian D. Diehl
- Department of Radiation Oncology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site, 81675 Munich, Germany
- Correspondence:
| | - Enrike Rosenkranz
- Department of Radiation Oncology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Maximilian Schwendner
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Martin Mißlbeck
- Department of Radiation Oncology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Nico Sollmann
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, 89081 Ulm, Germany
| | - Sebastian Ille
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site, 81675 Munich, Germany
| | - Sandro M. Krieg
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
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11
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Diehl CD, Pigorsch SU, Gempt J, Krieg SM, Reitz S, Waltenberger M, Barz M, Meyer HS, Wagner A, Wilkens J, Wiestler B, Zimmer C, Meyer B, Combs SE. Low-Energy X-Ray Intraoperative Radiation Therapy (Lex-IORT) for Resected Brain Metastases: A Single-Institution Experience. Cancers (Basel) 2022; 15:cancers15010014. [PMID: 36612015 PMCID: PMC9817795 DOI: 10.3390/cancers15010014] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Resection followed by local radiation therapy (RT) is the standard of care for symptomatic brain metastases. However, the optimal technique, fractionation scheme and dose are still being debated. Lately, low-energy X-ray intraoperative RT (lex-IORT) has been of increasing interest. METHOD Eighteen consecutive patients undergoing BM resection followed by immediate lex-IORT with 16-30 Gy applied to the spherical applicator were retrospectively analyzed. Demographic, RT-specific, radiographic and clinical data were reviewed to evaluate the effectiveness and safety of IORT for BM. Descriptive statistics and Kaplan-Meyer analysis were applied. RESULTS The mean follow-up time was 10.8 months (range, 0-39 months). The estimated local control (LC), distant brain control (DBC) and overall survival (OS) at 12 months post IORT were 92.9% (95%-CI 79.3-100%), 71.4% (95%-CI 50.2-92.6%) and 58.0% (95%-CI 34.1-81.9%), respectively. Two patients developed radiation necrosis (11.1%) and wound infection (CTCAE grade III); both had additional adjuvant treatment after IORT. For five patients (27.8%), the time to the start or continuation of systemic treatment was ≤15 days and hence shorter than wound healing and adjuvant RT would have required. CONCLUSION In accordance with previous series, this study demonstrates the effectiveness and safety of IORT in the management of brain metastases despite the small cohort and the retrospective characteristic of this analysis.
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Affiliation(s)
- Christian D. Diehl
- Department of Radiation Oncology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site, 81675 Munich, Germany
- Correspondence:
| | - Steffi U. Pigorsch
- Department of Radiation Oncology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site, 81675 Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Sandro M. Krieg
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- TUM-Neuroimaging Center, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Silvia Reitz
- Department of Radiation Oncology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Maria Waltenberger
- Department of Radiation Oncology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Melanie Barz
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Hanno S. Meyer
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Arthur Wagner
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Jan Wilkens
- Department of Radiation Oncology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Benedikt Wiestler
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site, 81675 Munich, Germany
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12
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Tan H, Stewart J, Ruschin M, Wang MH, Myrehaug S, Tseng CL, Detsky J, Husain Z, Chen H, Sahgal A, Soliman H. Inter-fraction dynamics during post-operative 5 fraction cavity hypofractionated stereotactic radiotherapy with a MR LINAC: a prospective serial imaging study. J Neurooncol 2022; 156:569-577. [PMID: 34981300 DOI: 10.1007/s11060-021-03938-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/27/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE/OBJECTIVE(S) This study examined changes in the clinical target volume (CTV) and associated clinical implications on a magnetic resonance imaging linear accelerator (MR LINAC) during hypofractionated stereotactic radiotherapy (HSRT) to resected brain metastases. In addition, the suitability of using T2/FLAIR (T2f) sequence to define CTV was explored by assessing contouring variability between gadolinium-enhanced T1 (T1c) and T2f sequences. MATERIALS/METHODS Fifteen patients treated to either 27.5 or 30 Gy with five fraction HSRT were imaged with T1c and T2f sequences during treatment; T1c was acquired at planning (FxSim), and fraction 3 (Fx3), and T2f was acquired at FxSim and all five fractions. The CTV were contoured on all acquired images. Inter-fraction cavity dynamics and CTV contouring variability were quantified using absolute volume, Dice similarity coefficient (DSC), and Hausdorff distance (HD) metrics. RESULTS The median CTV on T1c and T2f sequences at FxSim were 12.0cm3 (range, 1.2-30.1) and 10.2cm3 (range, 2.9-27.9), respectively. At Fx3, the median CTV decreased in both sequences to 9.3cm3 (range, 3.7-25.9) and 8.6cm3 (range, 3.3-22.5), translating to a median % relative reduction of - 11.4% on T1c (p = 0.009) and - 8.4% on T2f (p = 0.032). We observed a median % relative reduction in CTV between T1c and T2f at FxSim of - 6.0% (p = 0.040). The mean DSC was 0.85 ± 0.10, and the mean HD was 5.3 ± 2.7 mm when comparing CTV on T1c and T2f at FxSim. CONCLUSION Statistically significant reductions in cavity CTV was observed during HSRT, supporting the use of MR image guided radiation therapy and treatment adaptation to mitigate toxicity. Significant CTV contouring variability was seen between T1c and T2f sequences. Trial registration NCT04075305 - August 30, 2019.
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Affiliation(s)
- Hendrick Tan
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- GenesisCare, Perth, WA, Australia
| | - James Stewart
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Department of Medical Physics, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Michael H Wang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
- Department of Radiation Oncology, University of Toronto, Toronto, Canada.
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13
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Intraoperative radiotherapy with low-energy x-rays after neurosurgical resection of brain metastases-an Augsburg University Medical Center experience. Strahlenther Onkol 2021; 197:1124-1130. [PMID: 34415358 PMCID: PMC8604815 DOI: 10.1007/s00066-021-01831-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/18/2021] [Indexed: 12/11/2022]
Abstract
Purpose External-beam radiotherapy (EBRT) is the predominant method for localized brain radiotherapy (LBRT) after resection of brain metastases (BM). Intraoperative radiotherapy (IORT) with 50-kV x‑rays is an alternative way to focally irradiate the resection cavity after BM surgery, with the option of shortening the overall treatment time and limiting normal tissue irradiation. Methods We retrospectively analyzed the outcomes of all patients who underwent neurosurgical resection of BM and 50-kV x‑ray IORT between 2013 and 2020 at Augsburg University Medical Center. Results We identified 40 patients with 44 resected BM treated with 50-kV x‑ray IORT. Median diameter of the resected metastases was 2.8 cm (range 1.5–5.9 cm). Median applied dose was 20 Gy. All patients received standardized follow-up (FU) including 3‑monthly MRI of the brain. Mean FU was 14.4 months, with a median MRI FU for alive patients of 12.2 months. Median overall survival (OS) of all treated patients was 26.4 months (estimated 1‑year OS 61.6%). The observed local control (LC) rate of the resection cavity was 88.6% (estimated 1‑year LC 84.3%). Distant brain control (DC) was 47.5% (estimated 1‑year DC 33.5%). Only 25% of all patients needed WBI in the further course of disease. The observed radionecrosis rate was 2.5%. Conclusion IORT with 50-kV x‑rays is a safe and appealing way to apply LBRT after neurosurgical resection of BM, with low toxicity and excellent LC. Close MRI FU is paramount to detect distant brain failure (DBF) early.
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Postsurgical geometrical variations of tumor bed and brainstem during photon and proton therapy for pediatric tumors of the posterior fossa: dosimetric impact and predictive factors. Strahlenther Onkol 2021; 197:1113-1123. [PMID: 34351450 DOI: 10.1007/s00066-021-01828-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 07/04/2021] [Indexed: 12/22/2022]
Abstract
PURPOSE Brainstem radionecrosis is an important issue during the irradiation of tumors of the posterior fossa. The aim of the present study is to analyze postsurgical geometrical variations of tumor bed (TB) and brainstem (BS) and their impact on dosimetry. METHODS Retrospective collection of data from pediatric patients treated at a single institution. Availability of presurgical magnetic resonance imaging (MRI) was verified; availability of at least two postsurgical MRIs was considered a further inclusion criterion. The following metrics were analyzed: total volume, Dice similarity coefficient (DSC), and Haudsdorff distances (HD). RESULTS Fourteen patients were available for the quantification of major postsurgical geometrical variations of TB. DSC, HD max, and HD average values were 0.47 (range: 0.08;0.76), 11.3 mm (7.7;24.5), and 2.6 mm (0.7;6.7) between the first and the second postoperative MRI, respectively. Postsurgical geometrical variations of the BS were also observed. Coverage to the TB was reduced in one patient (D95: -2.9 Gy), while D2 to the BS was increased for the majority of patients. Overall, predictive factors for significant geometrical changes were presurgical gross tumor volume (GTV) > 33 mL, hydrocephaly at diagnosis, Luschka foramen involvement, and younger age (≤ 8 years). CONCLUSION Major volume changes were observed in this cohort, with some dosimetric impact. The use of a recent co-registration MRI is advised. The 2-3 mm HD average observed should be considered in the planning target volume/planning organ at risk volume (PTV/PRV) margin and/or robust optimization planning. Results from wider efforts are needed to verify our findings.
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15
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Dietzsch S, Braesigk A, Seidel C, Remmele J, Kitzing R, Schlender T, Mynarek M, Geismar D, Jablonska K, Schwarz R, Pazos M, Weber DC, Frick S, Gurtner K, Matuschek C, Harrabi SB, Glück A, Lewitzki V, Dieckmann K, Benesch M, Gerber NU, Obrecht D, Rutkowski S, Timmermann B, Kortmann RD. Types of deviation and review criteria in pretreatment central quality control of tumor bed boost in medulloblastoma-an analysis of the German Radiotherapy Quality Control Panel in the SIOP PNET5 MB trial. Strahlenther Onkol 2021; 198:282-290. [PMID: 34351451 PMCID: PMC8863746 DOI: 10.1007/s00066-021-01822-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/02/2021] [Indexed: 12/31/2022]
Abstract
Purpose In Germany, Austria, and Switzerland, pretreatment radiotherapy quality control (RT-QC) for tumor bed boost (TB) in non-metastatic medulloblastoma (MB) was not mandatory but was recommended for patients enrolled in the SIOP PNET5 MB trial between 2014 and 2018. This individual case review (ICR) analysis aimed to evaluate types of deviations in the initial plan proposals and develop uniform review criteria for TB boost. Patients and methods A total of 78 patients were registered in this trial, of whom a subgroup of 65 patients were available for evaluation of the TB treatment plans. Dose uniformity was evaluated according to the definitions of the protocol. Additional RT-QC criteria for standardized review of target contours were elaborated and data evaluated accordingly. Results Of 65 initial TB plan proposals, 27 (41.5%) revealed deviations of target volume delineation. Deviations according to the dose uniformity criteria were present in 14 (21.5%) TB plans. In 25 (38.5%) cases a modification of the RT plan was recommended. Rejection of the TB plans was rather related to unacceptable target volume delineation than to insufficient dose uniformity. Conclusion In this analysis of pretreatment RT-QC, protocol deviations were present in a high proportion of initial TB plan proposals. These findings emphasize the importance of pretreatment RT-QC in clinical trials for MB. Based on these data, a proposal for RT-QC criteria for tumor bed boost in non-metastatic MB was developed. Supplementary Information The online version of this article (10.1007/s00066-021-01822-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stefan Dietzsch
- Department of Radiation Oncology, University of Leipzig Medical Center, Stephanstr. 9a, 04103, Leipzig, Germany. .,Clinic for Particle Therapy, West German Proton Therapy Centre, University of Essen, Essen, Germany.
| | - Annett Braesigk
- Department of Radiation Oncology, University of Leipzig Medical Center, Stephanstr. 9a, 04103, Leipzig, Germany
| | - Clemens Seidel
- Department of Radiation Oncology, University of Leipzig Medical Center, Stephanstr. 9a, 04103, Leipzig, Germany
| | - Julia Remmele
- Department of Radiation Oncology, University of Leipzig Medical Center, Stephanstr. 9a, 04103, Leipzig, Germany
| | - Ralf Kitzing
- Department of Radiation Oncology, University of Leipzig Medical Center, Stephanstr. 9a, 04103, Leipzig, Germany
| | - Tina Schlender
- Department of Radiation Oncology, University of Leipzig Medical Center, Stephanstr. 9a, 04103, Leipzig, Germany
| | - Martin Mynarek
- Departement of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dirk Geismar
- Clinic for Particle Therapy, West German Proton Therapy Centre, University of Essen, Essen, Germany
| | - Karolina Jablonska
- Faculty of Medicine, Department of Radiation Oncology, University of Cologne, Cologne, Germany
| | - Rudolf Schwarz
- Department of Radiation Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Montserrat Pazos
- Department of Radiotherapy and Radiation Oncology, Ludwig Maximilian University Munich, Munich, Germany
| | - Damien C Weber
- Center for Protontherapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Silke Frick
- Department of Radiotherapy and Radiation Oncology, Hospital Bremen Mitte, Bremen, Germany
| | - Kristin Gurtner
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital, Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Semi Ben Harrabi
- Department of Radiation Oncology and Radiotherapy, Heidelberg University Hospital, Heidelberg, Germany
| | - Albrecht Glück
- Radiation Oncology, Munich-Schwabing Municipal Hospital, Munich, Germany
| | - Victor Lewitzki
- Department of Radiotherapy, University of Wuerzburg, Wuerzburg, Germany
| | - Karin Dieckmann
- Department of Radiotherapy, Medical University of Vienna, Vienna, Austria
| | - Martin Benesch
- Division of Pediatric Hematology/Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Nicolas U Gerber
- Department of Oncology, University Children's Hospital, Zurich, Switzerland
| | - Denise Obrecht
- Departement of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Rutkowski
- Departement of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Beate Timmermann
- Clinic for Particle Therapy, West German Proton Therapy Centre, University of Essen, Essen, Germany
| | - Rolf-Dieter Kortmann
- Department of Radiation Oncology, University of Leipzig Medical Center, Stephanstr. 9a, 04103, Leipzig, Germany
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16
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Reibelt A, Mayinger M, Borm KJ, Combs SE, Duma MN. Neuroanatomical changes seen in MRI in patients with cerebral metastasized breast cancer after radiotherapy. TUMORI JOURNAL 2021; 108:486-494. [PMID: 34256653 PMCID: PMC9500168 DOI: 10.1177/03008916211031301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose: To quantify neuroanatomical changes using magnetic resonance imaging (MRI) in patients with cerebral metastasized breast cancer after brain radiotherapy (RT). Methods: Fifteen patients with breast cancer with brain metastases who underwent whole brain RT (WBR), radiosurgery (RS), and/or hypofractionated stereotactic treatment (STX) were examined at four time points (TPs). A total of 48 MRIs were available: prior to RT (TP1), 5–8 months after RT (TP2), 9–11 months after RT (TP3), and >20 months after RT (TP4). Using automatic segmentation, 25 subcortical structures were analyzed. Patients were split into three groups: STX (receiving STX and RS), RS (receiving RS only), and WBR (receiving WBR at least once). After testing for a normal distribution for all values using the Kolmogorov-Smirnov test, a two-sided paired t test was used to analyze volumetric changes. For those values that were not normally distributed, the nonparametric Mann-Whitney test was employed. Results: The left cerebellum white matter (p = 0.028), the right pallidum (p = 0.038), and the left thalamus (p = 0.039) significantly increased at TP2 compared to TP1. The third ventricle increased at all TPs (p = 0.034–0.046). The left choroid plexus increased at TP3 (p = 0.037) compared to TP1. The left lateral ventricle increased at TP3 (p = 0.012) and TP4 (p = 0.027). Total gray matter showed a trend of volume decline in STX and WBR groups. Conclusions: These findings indicate that alterations in the volume of subcortical structures may act as a sensitive parameter when evaluating neuroanatomical changes and brain atrophy due to radiotherapy. Differences observed for patients who received STX and WBR, but not those treated with RS, need to be validated further.
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Affiliation(s)
- Antonia Reibelt
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Munich, Bayern, Germany
| | - Michael Mayinger
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Munich, Bayern, Germany
- Department of Radiation Oncology, University of Zurich, Zurich, Switzerland
- Michael Mayinger, Department of Radiation Oncology, Technical University Munich, Ismaninger Str. 22, München, 81675, Germany.
| | - Kai J. Borm
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Munich, Bayern, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Munich, Bayern, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK)–Partner Site Munich, Munich, Germany
- Institute of Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Neuherberg, Germany
| | - Marciana N. Duma
- Department of Radiation Oncology, University of Jena, Jena, Germany
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17
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Minniti G, Niyazi M, Andratschke N, Guckenberger M, Palmer JD, Shih HA, Lo SS, Soltys S, Russo I, Brown PD, Belka C. Current status and recent advances in resection cavity irradiation of brain metastases. Radiat Oncol 2021; 16:73. [PMID: 33858474 PMCID: PMC8051036 DOI: 10.1186/s13014-021-01802-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 04/07/2021] [Indexed: 12/04/2022] Open
Abstract
Despite complete surgical resection brain metastases are at significant risk of local recurrence without additional radiation therapy. Traditionally, the addition of postoperative whole brain radiotherapy (WBRT) has been considered the standard of care on the basis of randomized studies demonstrating its efficacy in reducing the risk of recurrence in the surgical bed as well as the incidence of new distant metastases. More recently, postoperative stereotactic radiosurgery (SRS) to the surgical bed has emerged as an effective and safe treatment option for resected brain metastases. Published randomized trials have demonstrated that postoperative SRS to the resection cavity provides superior local control compared to surgery alone, and significantly decreases the risk of neurocognitive decline compared to WBRT, without detrimental effects on survival. While studies support the use of postoperative SRS to the resection cavity as the standard of care after surgery, there are several issues that need to be investigated further with the aim of improving local control and reducing the risk of leptomeningeal disease and radiation necrosis, including the optimal dose prescription/fractionation, the timing of postoperative SRS treatment, and surgical cavity target delineation. We provide a clinical overview on current status and recent advances in resection cavity irradiation of brain metastases, focusing on relevant strategies that can improve local control and minimize the risk of radiation-induced toxicity.
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Affiliation(s)
- Giuseppe Minniti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Policlinico Le Scotte, 53100, Siena, Italy. .,IRCCS Neuromed, Pozzilli, IS, Italy.
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital of Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital of Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Joshua D Palmer
- Department of Radiation Oncology, Arthur G. James Cancer Hospital, The Ohio State University, Columbus, OH, USA
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Scott Soltys
- Department of Radiation Oncology, Stanford University, Stanford, CA, USA
| | - Ivana Russo
- Radiation Oncology Unit, University of Pittsburgh Medical Center Hillman Cancer Center, San Pietro Hospital FBF, Rome, and Villa Maria Hospital, Mirabella, AV, Italy
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
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18
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Gutschenritter T, Venur VA, Combs SE, Vellayappan B, Patel AP, Foote M, Redmond KJ, Wang TJC, Sahgal A, Chao ST, Suh JH, Chang EL, Ellenbogen RG, Lo SS. The Judicious Use of Stereotactic Radiosurgery and Hypofractionated Stereotactic Radiotherapy in the Management of Large Brain Metastases. Cancers (Basel) 2020; 13:cancers13010070. [PMID: 33383817 PMCID: PMC7795798 DOI: 10.3390/cancers13010070] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/11/2020] [Accepted: 12/18/2020] [Indexed: 12/31/2022] Open
Abstract
Simple Summary Brain metastases are the most common cause of cancerous brain tumors in adults. Large brain metastases are an especially difficult clinical scenario as patients often have debilitating symptoms from these tumors, and large tumors are more difficult to control with traditional single treatment radiation regimens alone or after surgery. Hypofractionated stereotactic radiotherapy is a novel way to deliver the higher doses of radiation to control large tumors either after surgery (most common), alone (common), or potentially before surgery (uncommon). Herein, we describe how delivering high doses over three or five treatments may improve tumor control and decrease complication rates compared to more traditional single treatment regimens for brain metastases larger than 2 cm in maximum dimension. Abstract Brain metastases are the most common intracranial malignant tumor in adults and are a cause of significant morbidity and mortality for cancer patients. Large brain metastases, defined as tumors with a maximum dimension >2 cm, present a unique clinical challenge for the delivery of stereotactic radiosurgery (SRS) as patients often present with neurologic symptoms that require expeditious treatment that must also be balanced against the potential consequences of surgery and radiation therapy—namely, leptomeningeal disease (LMD) and radionecrosis (RN). Hypofractionated stereotactic radiotherapy (HSRT) and pre-operative SRS have emerged as novel treatment techniques to help improve local control rates and reduce rates of RN and LMD for this patient population commonly managed with post-operative SRS. Recent literature suggests that pre-operative SRS can potentially half the risk of LMD compared to post-operative SRS and that HSRT can improve risk of RN to less than 10% while improving local control when meeting the appropriate goals for biologically effective dose (BED) and dose-volume constraints. We recommend a 3- or 5-fraction regimen in lieu of SRS delivering 15 Gy or less for large metastases or resection cavities. We provide a table comparing the BED of commonly used SRS and HSRT regimens, and provide an algorithm to help guide the management of these challenging clinical scenarios.
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Affiliation(s)
- Tyler Gutschenritter
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA 98195, USA;
| | - Vyshak A. Venur
- Division of Medical Oncology, University of Washington School of Medicine, Seattle, WA 98195, USA;
| | - Stephanie E. Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany;
- Institute for Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
| | - Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute, Singapore 119074, Singapore;
| | - Anoop P. Patel
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA 98195, USA; (A.P.P.); (R.G.E.)
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, University of Queensland, ICON Cancer Care, Brisbane 4072, Australia;
| | - Kristin J. Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, MD 21093, USA;
| | - Tony J. C. Wang
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY 10032, USA;
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Toronto, ON M4N 3M5, Canada;
| | - Samuel T. Chao
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA; (S.T.C.); (J.H.S.)
| | - John H. Suh
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA; (S.T.C.); (J.H.S.)
| | - Eric L. Chang
- Department of Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA;
| | - Richard G. Ellenbogen
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA 98195, USA; (A.P.P.); (R.G.E.)
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA 98195, USA;
- Correspondence: ; Tel.: +1-206-598-4100
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19
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Scharl S, Kessel KA, Diehl C, Gempt J, Meyer B, Zimmer C, Straube C, Combs SE. Is local radiotherapy a viable option for patients with an opening of the ventricles during surgical resection of brain metastases? Radiat Oncol 2020; 15:276. [PMID: 33303000 PMCID: PMC7730779 DOI: 10.1186/s13014-020-01725-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/06/2020] [Indexed: 11/10/2022] Open
Abstract
Background Local hypofractionated stereotactic radiotherapy (HFSRT) of the resection cavity is emerging as the standard of care in the treatment of patients with a limited number of brain metastases as it warrants less neurological impairment compared to whole brain radiotherapy. In periventricular metastases surgical resection can lead to an opening of the ventricles and subsequently carries a potential risk of cerebrospinal tumour cell dissemination. The aim of this study was to assess whether local radiotherapy of the resection cavity is viable in these cases. Methods From our institutional database we analyzed the data of 125 consecutive patients with resected brain metastases treated in our institution with HFSRT between 2009 and 2017. The incidence of LMD, overall survival (OS), local recurrence (LC) and distant recurrence were evaluated depending on ventricular opening (VO) during surgery. Results From all 125 patients, the ventricles were opened during surgery in 14 cases (11.2%). None of the patients with VO and 7 patients without VO during surgery developed LMD (p = 0.371). OS (p = 0.817), LC (p = 0.524) and distant recurrence (p = 0.488) did not differ in relation to VO during surgical resection. However, the incidence of distant intraventricular recurrence was slightly increased in patients with VO (14.3% vs. 2.7%, p < 0.01). Conclusion VO during neurosurgical resection did not affect the outcome after HFSRT of the resection cavity in patients with brain metastases. Particularly, the incidence of LMD was not increased in patients receiving local HFSRT after VO. HFSRT can therefore be offered independently of VO as a local treatment of tumor bed after resection of brain metastases.
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Affiliation(s)
- Sophia Scharl
- Department of Radiation Oncology, Technische Universität München (TUM), Ismaninger Straße 22, Munich, Germany
| | - Kerstin A Kessel
- Department of Radiation Oncology, Technische Universität München (TUM), Ismaninger Straße 22, Munich, Germany.,Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Ingolstädter Landstraße 1, Neuherberg, Germany.,Deutsches Konsortium Für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Christian Diehl
- Department of Radiation Oncology, Technische Universität München (TUM), Ismaninger Straße 22, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Technische Universität München (TUM), Ismaninger Straße 22, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technische Universität München (TUM), Ismaninger Straße 22, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Technische Universität München (TUM), Ismaninger Straße 22, Munich, Germany
| | - Christoph Straube
- Department of Radiation Oncology, Technische Universität München (TUM), Ismaninger Straße 22, Munich, Germany.,Deutsches Konsortium Für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technische Universität München (TUM), Ismaninger Straße 22, Munich, Germany. .,Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Ingolstädter Landstraße 1, Neuherberg, Germany. .,Deutsches Konsortium Für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany.
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20
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Eitz KA, Lo SS, Soliman H, Sahgal A, Theriault A, Pinkham MB, Foote MC, Song AJ, Shi W, Redmond KJ, Gui C, Kumar AMS, Machtay M, Meyer B, Combs SE. Multi-institutional Analysis of Prognostic Factors and Outcomes After Hypofractionated Stereotactic Radiotherapy to the Resection Cavity in Patients With Brain Metastases. JAMA Oncol 2020; 6:1901-1909. [PMID: 33057566 PMCID: PMC7563677 DOI: 10.1001/jamaoncol.2020.4630] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/20/2020] [Indexed: 11/14/2022]
Abstract
IMPORTANCE For brain metastases, the combination of neurosurgical resection and postoperative hypofractionated stereotactic radiotherapy (HSRT) is an emerging therapeutic approach preferred to the prior practice of postoperative whole-brain radiotherapy. However, mature large-scale outcome data are lacking. OBJECTIVE To evaluate outcomes and prognostic factors after HSRT to the resection cavity in patients with brain metastases. DESIGN, SETTING, AND PARTICIPANTS An international, multi-institutional cohort study was performed in 558 patients with resected brain metastases and postoperative HSRT treated between December 1, 2003, and October 31, 2019, in 1 of 6 participating centers. Exclusion criteria were prior cranial radiotherapy (including whole-brain radiotherapy) and early termination of treatment. EXPOSURES A median total dose of 30 Gy (range, 18-35 Gy) and a dose per fraction of 6 Gy (range, 5-10.7 Gy) were applied. MAIN OUTCOMES AND MEASURES The primary end points were overall survival, local control (LC), and the analysis of prognostic factors associated with overall survival and LC. Secondary end points included distant intracranial failure, distant progression, and the incidence of neurologic toxicity. RESULTS A total of 558 patients (mean [SD] age, 61 [0.50] years; 301 [53.9%] female) with 581 resected cavities were analyzed. The median follow-up was 12.3 months (interquartile range, 5.0-25.3 months). Overall survival was 65% at 1 year, 46% at 2 years, and 33% at 3 years, whereas LC was 84% at 1 year, 75% at 2 years, and 71% at 3 years. Radiation necrosis was present in 48 patients (8.6%) and leptomeningeal disease in 73 patients (13.1%). Neurologic toxic events according to the Common Terminology Criteria for Adverse Events grade 3 or higher occurred in 16 patients (2.8%) less than 6 months and 24 patients (4.1%) greater than 6 months after treatment. Multivariate analysis identified a Karnofsky Performance Status score of 80% or greater (hazard ratio [HR], 0.61; 95% CI, 0.46-0.82; P < .001), 22 to 33 days between resection and radiotherapy (HR, 1.50; 95% CI, 1.07-2.10; P = .02), and a controlled primary tumor (HR, 0.69; 95% CI, 0.52-0.90; P = .007) as prognostic factors associated with overall survival. For LC, a single brain metastasis (HR, 0.57; 95% CI, 0.35-0.93; P = .03) and a controlled primary tumor (HR, 0.59; 95% CI, 0.39-0.92; P = .02) were significant in the multivariate analysis. CONCLUSIONS AND RELEVANCE To date, this cohort study includes one of the largest series of patients with brain metastases and postoperative HSRT and appears to confirm an excellent risk-benefit profile of local HSRT to the resection cavity. Additional studies will help determine radiation dose-volume parameters and provide a better understanding of synergistic effects with systemic and immunotherapies.
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Affiliation(s)
- Kerstin A. Eitz
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
- Institute for Radiation Medicine (IRM), Helmholtz Zentrum München, Neuherberg, Germany
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington, Seattle
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Aimee Theriault
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mark. B. Pinkham
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Department of Radiation Oncology, University of Queensland, Brisbane, Queensland, Australia
| | - Matthew C. Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Department of Radiation Oncology, University of Queensland, Brisbane, Queensland, Australia
| | - Andrew J. Song
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Wenyin Shi
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kristin J. Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chenchen Gui
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aryavarta M. S. Kumar
- Radiation Oncology Service, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio
| | - Mitchell Machtay
- Department of Radiation Oncology, University Hospital Cleveland Medical Center, Cleveland, Ohio
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University of Munich (TUM), Munich, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
- Institute for Radiation Medicine (IRM), Helmholtz Zentrum München, Neuherberg, Germany
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21
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Magnetic resonance imaging for brain stereotactic radiotherapy : A review of requirements and pitfalls. Strahlenther Onkol 2020; 196:444-456. [PMID: 32206842 PMCID: PMC7182639 DOI: 10.1007/s00066-020-01604-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/03/2020] [Indexed: 12/29/2022]
Abstract
Due to its superior soft tissue contrast, magnetic resonance imaging (MRI) is essential for many radiotherapy treatment indications. This is especially true for treatment planning in intracranial tumors, where MRI has a long-standing history for target delineation in clinical practice. Despite its routine use, care has to be taken when selecting and acquiring MRI studies for the purpose of radiotherapy treatment planning. Requirements on MRI are particularly demanding for intracranial stereotactic radiotherapy, where accurate imaging has a critical role in treatment success. However, MR images acquired for routine radiological assessment are frequently unsuitable for high-precision stereotactic radiotherapy as the requirements for imaging are significantly different for radiotherapy planning and diagnostic radiology. To assure that optimal imaging is used for treatment planning, the radiation oncologist needs proper knowledge of the most important requirements concerning the use of MRI in brain stereotactic radiotherapy. In the present review, we summarize and discuss the most relevant issues when using MR images for target volume delineation in intracranial stereotactic radiotherapy.
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Abstract
PURPOSE OF REVIEW Provide an overview, the indications for use, and a synopsis of current literature regarding two evolving neurosurgical interventions-GammaTile therapy (GTT) and laser interstitial thermal therapy (LITT). RECENT FINDINGS GTT delivers immediate, uniform, high-dose radiation with avoidance of direct brain-to-seed contact. Innate properties of the novel carrier system and cesium-131 source may explain lower observed rate of radiation-induced necrosis (RIN) and support use in larger and previously irradiated lesions. LITT delivers focal laser energy to cause heat-generated necrosis. Case series suggest use in difficult-to-access lesions and treatment of RIN. Collaboration among subspecialties and remaining up-to-date on evolving technology is critical in developing individualized treatment plans for patients with brain cancer. While patients should be thoroughly counseled that these interventions are not standard of care, in optimal clinical scenarios, GTT and LITT could extend quantity and quality of life for patients with few remaining options. Prospective studies are needed to establish specific treatment parameters.
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Scharl S, Kirstein A, Kessel KA, Diehl C, Oechsner M, Straube C, Meyer B, Zimmer C, Combs SE. Stereotactic irradiation of the resection cavity after surgical resection of brain metastases - when is the right timing? Acta Oncol 2019; 58:1714-1719. [PMID: 31368403 DOI: 10.1080/0284186x.2019.1643917] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Purpose: This study aimed to evaluate whether an early beginning of the adjuvant stereotactic radiotherapy after macroscopic complete resection of 1-3 brain metastases is essential or whether longer intervals between surgery and radiotherapy are feasible.Material and methods: Sixty-six patients with 69 resection cavities treated with HFSRT after macroscopic complete resection of 1-3 brain metastases between 2009 and 2016 in our institution were included in this study. Overall survival, local recurrence and locoregional recurrence were evaluated depending on the time interval from surgery to the start of radiation therapy.Results: Patients that started radiotherapy within 21 days from surgery had a significantly decreased OS compared to patients treated after a longer interval from surgery (p < .01). There was no significant difference between patients treated ≥ 34 and 22-33 days from surgery (p = .210). In the univariate analysis, local control was superior for patients starting treatment 22-33 days from surgery compared to a later start (p = .049). This effect did not prevail in a multivariate model. There was no significant difference between patients treated within 21 days and patients treated more than 33 days after surgery (p = .203). Locoregional control was not influenced by RT timing (p = .508).Conclusion: A short delay in the start of radiotherapy does not seem to negatively impact the outcome in patients with resected brain metastases. We even observed an unexpected reduction in OS in patients treated within 21 days from surgery. Further studies are needed to define the optimal timing of postoperative radiotherapy to the resection cavity.
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Affiliation(s)
- Sophia Scharl
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
| | - Anna Kirstein
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Oberschleißheim, Germany
| | - Kerstin A. Kessel
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Oberschleißheim, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site, Munich, Germany
| | - Christian Diehl
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
| | - Christoph Straube
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technische Universität München (TUM), Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Technische Universität München (TUM), Munich, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, Technische Universität München (TUM), Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Oberschleißheim, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site, Munich, Germany
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Yuan M, Behrami E, Pannullo S, Schwartz TH, Wernicke AG. The Relationship Between Tumor Volume and Timing of Post-resection Stereotactic Radiosurgery to Maximize Local Control: A Critical Review. Cureus 2019; 11:e5762. [PMID: 31723521 PMCID: PMC6825444 DOI: 10.7759/cureus.5762] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
After maximally safe neurosurgical resection of brain metastases, stereotactic radiosurgery (SRS) is now recommended as an alternative to whole-brain radiation therapy (WBRT), which has been associated with cognitive decline. One complicating factor associated with SRS is that postoperative cavity dynamics can change dramatically, creating significant variability in the recommended timing of SRS. While SRS has been shown to improve local control (LC) in smaller tumor cavities, achieving excellent LC rates still remains a challenge in larger ones. Furthermore, factors predicting the optimal timing of SRS in relation to the cavity size need to be defined and implemented. Variables such as the delay between postoperative MRI and treatment are critical but poorly understood. One potential treatment option that may improve outcomes is brachytherapy, but the widespread implementation of this technique has been slow. This critical review analyzes the relationship between preoperative tumor volume, resection cavity size, and timing of SRS and explores how these variables must be understood in order to achieve the highest LC possible.
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Affiliation(s)
- Melissa Yuan
- Neurological Surgery, NewYork-Presbyterian/Weill Cornell Medical Center, New York, USA
| | - Eltion Behrami
- Radiation Oncology, NewYork-Presbyterian/Weill Cornell Medical Center, New York, USA
| | - Susan Pannullo
- Neurological Surgery, NewYork-Presbyterian/Weill Cornell Medical Center, New York, USA
| | | | - A Gabriella Wernicke
- Radiation Oncology, NewYork-Presbyterian/Weill Cornell Medical Center, New York, USA
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