Hypofractionated frameless stereotactic intensity-modulated radiotherapy with whole brain radiotherapy for the treatment of 1-3 brain metastases

LC3 Accelerated Brain-Lung Axis Abscopal Effects after Fractionated Whole-Brain Radiation by Promoting Motoneurons to Secrete Periostin

The effect of autophagy on the radiation-induced bystander effect (RIBE) in vivo is unclear. Here, the whole brains of microtubule-associated protein 1A/1B-light chain 3 (LC3) and C57BL/6 (B6) mice were irradiated once (10 Gy)(IR1), given 3 fractions in three weeks (IR3), or 6 fractions in six weeks (IR6). The median survival of LC3 mice was 56.5 days, and that of B6 mice was 65 days after IR6. LC3 mice showed more congestion and fibrosis in the lung after the IR3 and IR6 irradiation protocols than B6 mice. Quantitative proteomics of serum samples and lung RNA sequencing of the LC3 group showed that the common most clustered pathway of the IR3 group was the elastic fiber formation pathway, which contained Periostin (POSTN). POSTN in the motoneurons increased with increasing number of radiation fractions in LC3 mice. A 1 μg/g POSTN neutralizing antibody reduced the lung fibrosis of LC3 mice exposed to IR3 by one-third, and significantly prolonged the survival time of LC3 mice exposed to IR6. LDN-214117 and LRRK2-in-1 were the best two of sixteen transforming growth factor-beta1 (TGF-β) receptor and autophagy mediators to decrease Postn mRNA. These data led us to conclude that LC3 accelerated motoneuron secretion of POSTN and aggravated the RIBE in the lung after brain irradiation.

Hypofractionated adjuvant surgical cavity radiotherapy following resection of limited brain metastasis

BACKGROUND

Following surgical resection of oligometastatic disease to the brain there is a high rate of local relapse which is reduced by the addition of focal radiation therapy, often delivered as single fraction stereotactic radiosurgery (SRS) to the surgical cavity. This study audited the outcomes of an alternative approach using hypofractionated radiation therapy (HFRT) to the surgical resection cavity.

METHODS AND MATERIALS

Seventy-nine patients who received surgical resection and focal radiation therapy to the surgical cavity using HFRT with intensity modulated radiation therapy with or without stereotactic radiotherapy were identified. Doses were delivered in five fractions every second day for 10 days. Follow-up involved MRI surveillance with three-monthly MRI scans post resection. The major endpoints were local control at the surgical cavity site, and presence of radiation necrosis at the treated site.

RESULTS

Seventy-nine patients were included for the analysis with a median follow-up of 10.8 months. Of the cohort, 56% experienced intracranial progression, with all patients progressing distant to the resection cavity, and 7% progressing locally in addition. The one-year local control rate was 89.8%. The median progression-free survival was 10.0 months and median overall survival was 14.3 months. There was one CTCAE grade 3 toxicity of symptomatic radiation necrosis with no grade 4-5 toxicities seen.

CONCLUSIONS

The rate of local relapse following HFRT to the surgical cavity is low with minimal risk of radiation necrosis. HFRT can be considered as an alternative to SRS for focal radiotherapy after brain metastasis resection.

Estimation of technical treatment accuracy in fractionated stereotactic radiosurgery

Aim:

The purpose of this study was to estimate technical treatment accuracy in fractionated stereotactic radiosurgery (fSRS) using the Extend™ system (ES) of Gamma Knife (GK).

Methods and materials:

The fSRS with GK relies on a re-locatable ES where the reference treatment position is estimated using repositioning check tool (RCT). A patient surveillance unit (PSU) monitors the head and neck movement of the patient during treatment and imaging. The quality assurance test of RCT was performed to evaluate a standard error (SE) associated with a measurement tool called digital probe. A ‘4-mm collimator shot’ dose plan for a head–neck phantom was investigated using EBT3 films. CT and MR distortion measurement studies were combined to evaluate SEimaging. The combined uncertainty from all measurements was evaluated using statistical methods, and the resultant treatment accuracy was investigated for the ES.

Results:

Four sets of RCT measurements and 20 observations of associated digital probe showed SERCT of ±0·0186 mm and SEdigital probe of ±0·0002 mm. The mean positional shift of 0·2752 mm (σ = 0·0696 mm) was observed for 20 treatment settings of the phantom. The differences between radiological and predefined isocentres were 0·4650 and 0·4270 mm for two independent experiments. SEimaging and SEdiode  tool were evaluated as ±0·1055 and ±0·0096 mm, respectively. An expanded uncertainty of ±0·2371 mm (at 95% confidence level) was observed with our system.

Conclusions:

The combined result of the positional shift and expanded uncertainty showed close agreement with film investigations.

The use of Hypofractionated Radiosurgery for the Treatment of Intracranial Lesions Unsuitable for Single-Fraction Radiosurgery

Stereotactic radiosurgery (SRS) is commonly used in the treatment of brain metastases, benign tumors, and arteriovenous malformations (AVM). Single-fraction radiosurgery, though ubiquitous, is limited by lesion size and location. In these cases, hypofractionated radiosurgery (hfSRS) offers comparable efficacy and toxicity. We review the recent literature concerning hfSRS in the treatment of brain metastases, benign tumors, and AVMs that are poorly suited for single-fraction SRS. Published retrospective analyses suggest that local control rates for brain metastases and benign tumors, as well as the rates of AVM obliteration, following hfSRS treatment are comparable to those reported for single-fraction SRS. Additionally, the toxicities from hypofractionated treatment appear comparable to those seen with single-fractioned SRS to small lesions.

Survival and quality of life after whole brain radiotherapy with 3D conformal boost in the treatment of brain metastases

Background

Brain metastases are the most frequent intracranial neoplasms in adults. Although overall survival (OS) is an important endpoint in patients receiving radiotherapy, given their poor life expectancy in general, quality of life is becoming an increasingly useful endpoint. Objectives: to evaluate whole brain radiotherapy (WBRT) with 3D conformal boost in brain metastases patients with regard to OS and quality of life.

Methods

During April 2015-May 2017, a total of 35 patients with ≤5, previously untreated, inoperable brain metastases were included prospectively. All patients underwent WBRT followed by 3D conformal boost to the metastatic lesions. EORTC quality of life questionnaires QLQ-C30 and QLQ-BN20 were used at baseline and at end of treatment. The mean initial and final scores were compared using Student test. One-year OS with brain metastases was computed with Kaplan Maier method.

Results

Median survival with brain metastases was 4.43 months (0.73-78.53). The one-year OS for patients with one metastasis was 42% versus 15% for more than one (p<0.04). The presence of extracerebral metastases significantly decreased OS from 39% without extracerebral metastases to 19%. (p<0.05). Quality of life improved significantly in several functional domains: physical (48 vs 60.29), role functioning (28.1 vs 44.7), emotional (47.1 vs 80.2), global health status (40.9 vs 62.3). Symptom scores decreased significantly in most items, corresponding to an improvement in the symptom burden: headache (61.9 vs 0.9), nausea and vomiting (45.7 vs 7.1), visual disorder (26.3 vs 9.2), seizures (30.4 vs 0.9), motor dysfunction (46.6 vs 17.1). Symptom scores for fatigue and drowsiness increased significantly (51.1 vs 74.9, respectively 37.1 vs 70.4), indicating worsening of symptoms.

Conclusions

WBRT with 3D conformal boost is a feasible technique which improves quality of life in brain metastases patients. Since survival is limited, the assessment of quality of life is a good indicator of the treatment outcome.

[Hypofractionated stereotactic radiotherapy for brain metastasis: Benefit of additional whole brain radiotherapy?]

PURPOSE

To study overall survival, risk of neurological death, local recurrence and development of new brain metastasis in patients treated for brain oligometastases with hypofractionated stereotactic radiotherapy with CyberKnife^®, according to the association or not with an additional whole brain irradiation.

PATIENTS AND METHODS

Institutional retrospective study of 102 patients treated for one to three brain metastasis: 76 with exclusive hypofractionated stereotactic radiotherapy and 26 with hypofractionated stereotactic radiotherapy and whole brain irradiation. Objectives were assessed and compared between these two groups according to the Kaplan-Meier method and Cox model.

RESULTS

Median follow-up was 18.8 months. There were no difference between exclusive hypofractionated stereotactic radiotherapy and hypofractionated stereotactic radiotherapy with whole brain irradiation for overall survival (respective median 21.5 and 20.1 months), risk of neurological death (respectively 9.2% and 15.4% at one year). At one year: the risk of cerebral progressive disease was greater in the group receiving exclusive hypofractionated stereotactic radiotherapy (respectively 43.4% vs. 26.2%, P=0.043), the risk of local recurrence was 25% versus 17.6% (P=0.28) and the development of new brain metastasis was 23.7% versus 11.5% (P=0.27). After salvage treatments, crude local control was similar in the two groups, respectively 78.6% and 73.5%. Whole brain irradiation has been avoided for 72.4% of patients in the group receving exclusive hypofractionated stereotactic radiotherapy.

CONCLUSION

Whole brain irradiation improves local control of brain metastatic disease in addition to hypofractionated stereotactic radiotherapy. Sparing whole brain irradiation for salvage treatments only does not affect overall survival or risk of neurological death in selected patients with favourable prognosis.

Use of Helical TomoTherapy for the Focal Hypofractionated Treatment of Limited Brain Metastases in the Initial and Recurrent Setting

Background: Whole-brain radiation therapy (WBRT), stereotactic radiosurgery (SRS), or both are commonly employed in the treatment of limited brain metastases in the initial or recurrent setting. Hypofractionated partial volume irradiation is also employed, however, published experience using helical TomoTherapy (HT) for this purposes is limited. We reviewed our institutional experience to assess patient selection factors, fractionation scheme, and outcomes associated with this technique.

Methods: A retrospective chart review was performed to evaluate patients treated with partial volume hypofractionated HT-based IMRT for brain metastases at our institution.

Results: Thirteen patients (7M/6F, median age 62, median KPS 90) with a limited (1–9) number of brain metastases in the primary or recurrent setting were identified. Primary malignancies included colorectal (3), NSCLC (5), RCC (1), breast (1), melanoma (1), uterine (1), and ovarian (1). The median time from initial diagnosis to brain metastases was 20.7 months (range 0–61.3). Treatment was delivered to intact metastases in six patients, to a single resection cavity in six patients, and to both in one patient. A total of 27 lesions were treated. The median number of intact metastases treated was two (range 1–9). Previous treatments included WBRT (5), WBRT + SRS (3), SRS alone (1), and none (4). The most common fractionation schemes were 25 Gy in five fractions and 27.5 Gy in five fractions to each lesion. At a median of 6 months follow up (range 1.26–20.13) after TomoTherapy, 10 patients were deceased, 2 were alive, and 1 was lost to follow up. Systemic progression occurred in seven patients and intracranial progression occurred in five. The median intracranial progression free survival and overall survival after TomoTherapy was 6.3 months. Freedom from local failure for treated lesions was 71% and 59% at 6 and 12 months.

Conclusion: TomoTherapy-based hypofractionated radiotherapy to a limited number of metastatic lesions is associated with acceptable intracranial disease control and survival outcomes and represents a viable treatment option in the primary and recurrent setting for select patients.

Whole brain radiotherapy plus simultaneous in-field boost with image guided intensity-modulated radiotherapy for brain metastases of non-small cell lung cancer

Background

Whole brain radiotherapy (WBRT) plus sequential focal radiation boost is a commonly used therapeutic strategy for patients with brain metastases. However, recent reports on WBRT plus simultaneous in-field boost (SIB) also showed promising outcomes. The objective of present study is to retrospectively evaluate the efficacy and toxicities of WBRT plus SIB with image guided intensity-modulated radiotherapy (IG-IMRT) for inoperable brain metastases of NSCLC.

Methods

Twenty-nine NSCLC patients with 87 inoperable brain metastases were included in this retrospective study. All patients received WBRT at a dose of 40 Gy/20 f, and SIB boost with IG-IMRT at a dose of 20 Gy/5 f concurrent with WBRT in the fourth week. Prior to each fraction of IG-IMRT boost, on-line positioning verification and correction were used to ensure that the set-up errors were within 2 mm by cone beam computed tomography in all patients.

Results

The one-year intracranial control rate, local brain failure rate, and distant brain failure rate were 62.9%, 13.8%, and 19.2%, respectively. The two-year intracranial control rate, local brain failure rate, and distant brain failure rate were 42.5%, 30.9%, and 36.4%, respectively. Both median intracranial progression-free survival and median survival were 10 months. Six-month, one-year, and two-year survival rates were 65.5%, 41.4%, and 13.8%, corresponding to 62.1%, 41.4%, and 10.3% of intracranial progression-free survival rates. Patients with Score Index for Radiosurgery in Brain Metastases (SIR) >5, number of intracranial lesions <3, and history of EGFR-TKI treatment had better survival. Three lesions (3.45%) demonstrated radiation necrosis after radiotherapy. Grades 2 and 3 cognitive impairment with grade 2 radiation leukoencephalopathy were observed in 4 (13.8%) and 4 (13.8%) patients. No dosimetric parameters were found to be associated with these late toxicities. Patients received EGFR-TKI treatment had higher incidence of grades 2–3 cognitive impairment with grade 2 leukoencephalopathy.

Conclusions

WBRT plus SIB with IG-IMRT is a tolerable and effective treatment for NSCLC patients with inoperable brain metastases. However, the results of present study need to be examined by the prospective investigations.

Hypofractionated radiosurgery for intact or resected brain metastases: defining the optimal dose and fractionation

Background

Hypofractionated Radiosurgery (HR) is a therapeutic option for delivering partial brain radiotherapy (RT) to large brain metastases or resection cavities otherwise not amenable to single fraction radiosurgery (SRS). The use, safety and efficacy of HR for brain metastases is not well characterized and the optimal RT dose-fractionation schedule is undefined.

Methods

Forty-two patients treated with HR in 3-5 fractions for 20 (48%) intact and 22 (52%) resected brain metastases with a median maximum dimension of 3.9 cm (0.8-6.4 cm) between May 2008 and August 2011 were reviewed. Twenty-two patients (52%) had received prior radiation therapy. Local (LC), intracranial progression free survival (PFS) and overall survival (OS) are reported and analyzed for relationship to multiple RT variables through Cox-regression analysis.

Results

The most common dose-fractionation schedules were 21 Gy in 3 fractions (67%), 24 Gy in 4 fractions (14%) and 30 Gy in 5 fractions (12%). After a median follow-up time of 15 months (range 2-41), local failure occurred in 13 patients (29%) and was a first site of failure in 6 patients (14%). Kaplan-Meier estimates of 1 year LC, intracranial PFS, and OS are: 61% (95% CI 0.53 – 0.70), 55% (95% CI 0.47 – 0.63), and 73% (95% CI 0.65 – 0.79), respectively. Local tumor control was negatively associated with PTV volume (p = 0.007) and was a significant predictor of OS (HR 0.57, 95% CI 0.33 - 0.98, p = 0.04). Symptomatic radiation necrosis occurred in 3 patients (7%).

Conclusions

HR is well tolerated in both new and recurrent, previously irradiated intact or resected brain metastases. Local control is negatively associated with PTV volume and a significant predictor of overall survival, suggesting a need for dose escalation when using HR for large intracranial lesions.

Hypofractionated stereotactic radiotherapy of limited brain metastases: a single-centre individualized treatment approach

Background

We retrospectively report treatment results of our single-centre experience with hypofractionated stereotactic radiotherapy (hfSRT) of limited brain metastases in primary and recurrence disease situations. Our aim was to find the most effective and safe dose concept.

Methods

From 04/2006 to 12/2010, 75 patients, with 108 intracranial metastases, were treated with hfSRT. 52 newly diagnosed metastases (48%), without up-front whole brain radiotherapy (WBRT), received hfSRT as a primary treatment. 56 metastases (52%) received a prior WBRT and were treated in this study in a recurrence situation. Main fractionation concepts used for primary hfSRT were 6-7x5 Gy (61.5%) and 5x6 Gy (19.2%), for recurrent hfSRT 7-10x4 Gy (33.9%) and 5-6x5 Gy (33.9%).

Results

Median overall survival (OS) of all patients summed up to 9.1 months, actuarial 6-and 12-month-OS was 59% and 35%, respectively. Median local brain control (LC) was 11.9 months, median distant brain control (DC) 3.9 months and intracranial control (IC) 3.4 months, respectively. Variables with significant influence on OS were Gross Tumour Volume (GTV) (p = 0.019), the biological eqivalent dose (calculated on a 2 Gy single dose, EQD2, α/β = 10) < and ≥ median of 39 Gy (p = 0.012), extracerebral activity of the primary tumour (p < 0.001) and the steroid uptake during hfSRT (p = 0.03). LC was significantly influenced by the EQD2, ≤ and > 35 Gy (p = 0.004) in both uni- and multivariate Cox regression analysis. Median LC was 14.9 months for EQD2 >35 Gy and 3.4 months for doses ≤35 Gy, respectively. Early treatment related side effects were usually mild. Nevertheless, patients with a EQD2 >35 Gy had higher rates of toxicity (31%) than ≤35 Gy (8.3%, p=0.026).

Conclusion

Comparing different dose concepts in hfSRT, a cumulative EQD2 of ≥35 Gy seems to be the most effective concept in patients with primary or recurrent limited brain metastases. Despite higher rates of only mild toxicity, this concept represents a safe treatment option.