1
|
Nicosia L, Navarria P, Pinzi V, Giraffa M, Russo I, Tini P, Giaj-Levra N, Alongi F, Minniti G. Stereotactic radiosurgery for the treatment of brainstem metastases: a multicenter retrospective study. Radiat Oncol 2022; 17:140. [PMID: 35945597 PMCID: PMC9364508 DOI: 10.1186/s13014-022-02111-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background Brainstem metastases (BSM) are associated with a poor prognosis and their management represents a therapeutic challenge. BSM are often inoperable and, in absence of randomized trials, the optimal radiation treatment of BSM remains to be defined. We evaluated the efficacy and toxicity of linear accelerator (linac)-based stereotactic radiosurgery (SRS) and hypofractionated steretotactic radiotherapy (HSRT) in the treatment of BSM in a series of patients treated in different clinical centers. Methods We conducted a multicentric retrospective study of patients affected by 1–2 BSM from different histologies who underwent SRS/HSRT. Freedom from local progression (FLP), cancer-specific survival (CSS), overall survival (OS), and treatment-related toxicity were evaluated. In addition, predictors of treatment response and survivals were evaluated. Results Between 2008 and 2021, 105 consecutive patients with 111 BMS who received SRS or HSRT for 1–2 BSM were evaluated. Median follow-up time was 10 months (range 3–130). One-year FLP rate was 90.4%. At the univariate analysis, tumor volume ≤ 0.4 cc, and concurrent targeted therapy were associated with longer FLP, with combined treatment that remained a significant independent predictor [0.058, HR 0.139 (95% CI 0.0182–1.064]. Median OS and CSS were 11 months and 14.6 months, respectively. At multivariate analysis, concurrent targeted therapy administration was significantly associated with longer OS [HR 0.514 (95%CI 0.302–0.875); p = 0.01]. Neurological death occurred in 30.4% of patients, although this was due to local progression in only 3 (2.8%) patients. Conclusion Linac-based SRS/HSRT offers excellent local control to patients with BSM, with low treatment-related toxicity and no apparent detrimental effects on OS. When treated with ablative intent, BSM are an uncommon cause of neurological death. The present results indicates that patients with BSM should not be excluded a priori from clinical trials.
Collapse
Affiliation(s)
- Luca Nicosia
- Advanced Radiation Oncology Department, Cancer Care Center, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy
| | - Piera Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Hospital-IRCCS, Rozzano, MI, Italy
| | - Valentina Pinzi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C Besta, Via Celoria 11, 20133, Milan, Italy
| | - Martina Giraffa
- UPMC Hillman Cancer Center, San Pietro Hospital FBF, Rome, Italy
| | - Ivana Russo
- UPMC Hillman Cancer Center, Villa Maria, Mirabella Eclano, AV, Italy
| | - Paolo Tini
- Department of Medicine, Surgery and Neurosciences, University of Siena, Policlinico Le Scotte, 53100, Siena, Italy
| | - Niccolò Giaj-Levra
- Advanced Radiation Oncology Department, Cancer Care Center, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy
| | - Filippo Alongi
- Advanced Radiation Oncology Department, Cancer Care Center, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy.,University of Brescia, Brescia, Italy
| | - Giuseppe Minniti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Policlinico Le Scotte, 53100, Siena, Italy. .,IRCCS Neuromed, 86077, Pozzilli, IS, Italy.
| |
Collapse
|
2
|
Chen WC, Baal UH, Baal JD, Pai JS, Boreta L, Braunstein SE, Raleigh DR. Efficacy and Safety of Stereotactic Radiosurgery for Brainstem Metastases: A Systematic Review and Meta-analysis. JAMA Oncol 2021; 7:1033-1040. [PMID: 33983393 DOI: 10.1001/jamaoncol.2021.1262] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Owing to the proximity to critical neurologic structures, treatment options for brainstem metastases (BSM) are limited, and BSM growth can cause acute morbidity or death. Stereotactic radiosurgery (SRS) is the only local therapy for BSM, but efficacy and safety of this approach are incompletely understood because patients with BSM are excluded from most clinical trials. Objective To perform a systematic review and comparative meta-analysis of SRS studies for BSM in the context of prospective trials of SRS or molecular therapy for nonbrainstem brain metastases (BM). Data Sources A comprehensive search of Pubmed/MEDLINE and Embase was performed on December 6, 2019. Study Selection English-language studies of SRS for BSM with at least 10 patients and reporting 1 or more outcomes of interest were included. Duplicate studies or studies with overlapping data sets were excluded. Studies were independently evaluated by 2 reviewers, and discrepancies were resolved by consensus. A total of 32 retrospective studies published between 1999 and 2019 were included in the analysis. Data Extraction and Synthesis Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify studies. Study quality was assessed using Methodological Index for Non-Randomized Studies criteria. Fixed and random-effects meta-analyses and meta-regressions were performed for the outcomes of interest. Main Outcomes and Measures Primary study outcomes included 1-year and 2-year local control and overall survival, objective response rate, symptom response rate, neurological death rate, and rate of grade 3 to 5 toxic effects as described in Common Terminology Criteria for Adverse Events, version 4.0. Results The 32 retrospective studies included in the analysis comprised 1446 patients with 1590 BSM that were treated with SRS (median [range] dose, 16 [11-39] Gy; median [range] fractions, 1 [1-13]). Local control at 1 year was 86% (95% CI, 83%-88%; I2 = 38%) in 1410 patients across 31 studies, objective response rate was 59% (95% CI, 47%-71%; I2 = 88%) in 642 patients across 17 studies, and symptom improvement was 55% (95% CI, 47%-63%; I2 = 41%) in 323 patients across 13 studies. Deaths from BSM progression after SRS were rare (19 of 703 [2.7%] deaths across 19 studies), and the neurologic death rate in patients with BSM (24%; 95% CI, 19%-31%; I2 = 62%) was equivalent to the neurologic death rate in patients with BM who were treated on prospective trials. The rate of treatment-related grade 3 to 5 toxic effects was 2.4% (95% CI, 1.5%-3.7%; I2 = 33%) in 1421 patients across 31 studies. These results compared favorably to trials of targeted or immunotherapy for BM, which had a wide objective response rate range from 17% to 56%. Conclusions and Relevance Results of this systematic review and meta-analysis show that SRS for BSM was associated with effectiveness and safety and was comparable to SRS for nonbrainstem BM, suggesting that patients with BSM should be eligible for clinical trials of SRS. In this analysis, patients treated with SRS for BSM rarely died from BSM progression and often experienced symptomatic improvement. Given the apparent safety and efficacy of SRS for BSM in the context of acute morbidity or death from BSM growth, consideration of SRS at the time of enrollment on emerging trials of targeted therapy for BM should be considered.
Collapse
Affiliation(s)
- William C Chen
- Department of Radiation Oncology, University of California, San Francisco
| | - Ulysis H Baal
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Joe D Baal
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Jon S Pai
- Department of Internal Medicine, University of Southern California, Los Angeles
| | - Lauren Boreta
- Department of Radiation Oncology, University of California, San Francisco
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California, San Francisco
| | - David R Raleigh
- Department of Radiation Oncology, University of California, San Francisco.,Department of Neurological Surgery, University of California, San Francisco
| |
Collapse
|
3
|
Redmond KJ, Gui C, Benedict S, Milano MT, Grimm J, Vargo JA, Soltys SG, Yorke E, Jackson A, El Naqa I, Marks LB, Xue J, Heron DE, Kleinberg LR. Tumor Control Probability of Radiosurgery and Fractionated Stereotactic Radiosurgery for Brain Metastases. Int J Radiat Oncol Biol Phys 2020; 110:53-67. [PMID: 33390244 DOI: 10.1016/j.ijrobp.2020.10.034] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/25/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE As part of the American Association of Physicists in Medicine Working Group on Stereotactic Body Radiotherapy, tumor control probability (TCP) after stereotactic radiosurgery (SRS) and fractionated stereotactic radiosurgery (fSRS) for brain metastases was modeled based on pooled dosimetric and clinical data from published English-language literature. METHODS AND MATERIALS PubMed-indexed studies published between January 1995 and September 2017 were used to evaluate dosimetric and clinical predictors of TCP after SRS or fSRS for brain metastases. Eligible studies had ≥10 patients and included detailed dose-fractionation data with corresponding ≥1-year local control (LC) data, typically evaluated as a >20% increase in diameter of the targeted lesion using the pre-SRS diameter as a reference. RESULTS Of 2951 potentially eligible manuscripts, 56 included sufficient dose-volume data for analyses. Accepting that necrosis and pseudoprogression can complicate the assessment of LC, for tumors ≤20 mm, single-fraction doses of 18 and 24 Gy corresponded with >85% and 95% 1-year LC rates, respectively. For tumors 21 to 30 mm, an 18 Gy single-fraction dose was associated with 75% LC. For tumors 31 to 40 mm, a 15 Gy single-fraction dose yielded ∼69% LC. For 3- to 5-fraction fSRS using doses in the range of 27 to 35 Gy, 80% 1-year LC has been achieved for tumors of 21 to 40 mm in diameter. CONCLUSIONS TCP for SRS and fSRS are presented. For small lesions ≤20 mm, single doses of ≈18 Gy appear generally associated with excellent rates of LC; for melanoma, higher doses seem warranted. For larger lesions >20 mm, local control rates appear to be ≈ 70% to 75% with usual doses of 15 to 18 Gy, and in this setting, fSRS regimens should be considered. Greater consistency in reporting of dosimetric and LC data is needed to facilitate future pooled analyses. As systemic and biologic therapies evolve, updated analyses will be needed to further assess the necessity, efficacy, and toxicity of SRS and fSRS.
Collapse
Affiliation(s)
- Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Chengcheng Gui
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stanley Benedict
- Department of Radiation Oncology, University of California at Davis Comprehensive Cancer Center, Sacramento, California
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Jimm Grimm
- Department of Radiation Oncology, Geisinger Medical Center, Danville, Pennsylvania
| | - J Austin Vargo
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Ellen Yorke
- Medical Physics Department, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Jackson
- Medical Physics Department, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Issam El Naqa
- Department of Machine Learning and Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Lawrence B Marks
- Department of Radiation Oncology and the Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Jinyu Xue
- Department of Radiation Oncology, New York University, New York, New York
| | - Dwight E Heron
- Department of Radiation Oncology, Bon Secours Mercy Health System, Youngstown, Ohio
| | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
4
|
Lehrer EJ, Snyder MH, Desai BD, Li CE, Narayan A, Trifiletti DM, Schlesinger D, Sheehan JP. Clinical and radiographic adverse events after Gamma Knife radiosurgery for brainstem lesions: A dosimetric analysis. Radiother Oncol 2020; 147:200-209. [PMID: 32413528 DOI: 10.1016/j.radonc.2020.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/30/2020] [Accepted: 05/08/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To analyze the association between dosvolume relationships and adverse events in brainstem lesions treated with Gamma Knife radiosurgery (GKRS). METHODS Treatment plans were generated on BrainLab Elements and GammaPlan software. Dosimetric data were analyzed as continuous variables for patients who received GKRS to brain metastases or arteriovenous malformations (AVM) within or abutting the brainstem. Adverse events were classified as clinical and/or radiographic. Logistic and cox regression were used to assess the relationship between dosimetric variables and adverse events. RESULTS Sixty-one patients who underwent single fraction GKRS for brain metastases or AVM were retrospectively analyzed. Median age was 62 years (range: 12-92 years) and the median prescription dose was 18 Gy (range: 13-25 Gy). Median follow-up was 6months. Clinical and radiographic complications were seen in ten (16.4%) and 17 (27.9%) patients, respectively. On logistic regression, increasing D05% was found to be associated with an increased probability of developing a clinical complication post-GKRS (OR: 1.18; 95% CI: 1.01-1.39; p = 0.04). Furthermore, mean brainstem dose (HR: 1.43; 95% CI: 1.05-1.94; p < 0.02), D05% (HR: 1.09; 95% CI: 1.01-1.18; p = 0.03), and D95% (HR: 2.37; 95% CI: 0.99-5.67; p = 0.05) were associated with an increased hazard of experiencing post-GKRS complications over time. CONCLUSIONS Increasing D05% to the brainstem is associated with an increased risk of developing clinical complications. Clinicians may consider this parameter in addition to fractionated stereotactic radiation therapy when well-established dose constraints are not met in this patient population. Additional data are needed to further validate these findings.
Collapse
Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - M Harrison Snyder
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Bhargav D Desai
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Chelsea E Li
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Aditya Narayan
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | | | - David Schlesinger
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| |
Collapse
|
5
|
Mei G, Liu X, Song K, Lv Y, Xu M, Xu H, Wang E. Cyberknife radiosurgery on the brainstem metastases of non-small cell lung cancer. Int J Neurosci 2020; 131:462-467. [PMID: 32295456 DOI: 10.1080/00207454.2020.1748622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Management of brainstem metastatic tumor is challenging. This study aimed to evaluate overall survival and quality-of-life in patients with non-small cell lung cancer (NSCLC) brainstem metastases who were treated with the Cyberknife stereotactic radiosurgery. METHODS From August 2007 through August 2016, a total of 32 patients with 34 brainstem metastases of NSCLC were consecutively enrolled and treated with the Cyberknife radiosurgery (CKRS) at The Huashan Hospital. The study was limited to patients with NSCLC, which was confirmed by postoperative pathological examination. Patients were treated by CKRS as an initial treatment or a second treatment after whole-brain radiation therapy (WBRT). Quality of life was assessed by the SF-12 score and neurological examination. RESULTS Four out of the 32 (12.5%) patients received WBRT before or concurrent with CKRS treatment. The mean survival time after CKRS was 10.0 (95%CI: 6.0-14.0) months. Karnofsky performance score was not the independent predictor of survival after radiosurgery as analyzed by log-rank test (p = 0.392). Age, however, was a significant predictor of improved survival as analyzed by multivariate analysis (p = 0.024). SF-12 physical component scores demonstrated no significant change after treatment. CONCLUSIONS The CKSR is a non-invasive, safe, and effective modality in the treatment of patients with brainstem metastases of NSCLC. Better therapeutic outcomes of CKSR for brainstem metastasis might be achieved in the patients older than 65 years old.
Collapse
Affiliation(s)
- Guanghai Mei
- Department of Cyberknife Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoxia Liu
- Department of Cyberknife Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Kun Song
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yizheng Lv
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Ming Xu
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Hongzhi Xu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Enmin Wang
- Department of Cyberknife Center, Huashan Hospital, Fudan University, Shanghai, China
| |
Collapse
|
6
|
Linac-Based Fractionated Stereotactic Radiotherapy with a Micro-Multileaf Collimator for Brainstem Metastasis. World Neurosurg 2019; 132:e680-e686. [DOI: 10.1016/j.wneu.2019.08.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/08/2019] [Accepted: 08/09/2019] [Indexed: 11/18/2022]
|
7
|
Sinclair G, Benmakhlouf H, Martin H, Maeurer M, Dodoo E. Adaptive hypofractionated gamma knife radiosurgery in the acute management of brainstem metastases. Surg Neurol Int 2019; 10:14. [PMID: 30783544 PMCID: PMC6367951 DOI: 10.4103/sni.sni_53_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 10/29/2018] [Indexed: 12/15/2022] Open
Abstract
Background: Intrinsic brainstem metastases are life-threatening neoplasms requiring rapid, effective intervention. Microsurgery is considered not feasible in most cases and systemic treatment seldom provides a successful outcome. In this context, radiation therapy remains the best option but adverse radiation effects (ARE) remain a major concern. A dose-adaptive gamma knife procedure coined as Rapid Rescue Radiosurgery (3R) offers the possibility to treat these lesions whilst reducing the risk of ARE evolvement. We report the results of 3R applied to a group of patients with brainstem metastases. Methods: Eight patients with nine brainstem metastases, having undergone three separate, dose-adapted gamma knife radiosurgery (GKRS) procedures over 7 days, were retrospectively analyzed in terms of tumor volume reduction, local control rates, and ARE-development under the period of treatment and at least 6 months after treatment completion. Results: Mean peripheral doses at GKRS 1, GKRS 2, and GKRS 3 were 7.4, 7.7, and 8.2 Gy (range 6–9 Gy) set at the 35–50% isodose lines. Mean tumor volume reduction between GKRS 1 and GKRS 3 was −15% and −56% at first follow-up. Four patients developed radiologic signs of ARE but remained clinically asymptomatic. One patient developed a local recurrence at 34 months. Mean survival from GKRS 1 was 13 months. Two patients were still alive at the time of paper submission (10 and 23 months from GKRS 1). Conclusions: In this study, 3R proved effective in terms of tumor volume reduction, rescue/preservation of neurological function, and limited ARE evolvement.
Collapse
Affiliation(s)
- Georges Sinclair
- Department of Neurosurgery, Karolinska University Hospital, Solna, Sweden
| | - Hamza Benmakhlouf
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Solna, Sweden
| | - Heather Martin
- Department of Neuroradiology, Karolinska University Hospital, Solna, Sweden
| | - Markus Maeurer
- Department of Laboratory Medicine (LABMED), Therapeutic Immunology Unit (TIM), Karolinska Institutet, Stockholm, Sweden.,Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institute, Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Solna, Sweden
| | - Ernest Dodoo
- Department of Neurosurgery, Karolinska University Hospital, Solna, Sweden
| |
Collapse
|
8
|
Patel A, Dong T, Ansari S, Cohen-Gadol A, Watson GA, Moraes FYD, Nakamura M, Murovic J, Chang SD, Hatiboglu MA, Chung C, Miller JC, Lautenschlaeger T. Toxicity of Radiosurgery for Brainstem Metastases. World Neurosurg 2018; 119:e757-e764. [PMID: 30096494 DOI: 10.1016/j.wneu.2018.07.263] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 07/28/2018] [Accepted: 07/30/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although stereotactic radiosurgery (SRS) is an effective modality in the treatment of brainstem metastases (BSM), radiation-induced toxicity remains a critical concern. To better understand how severe or life-threatening toxicity is affected by the location of lesions treated in the brainstem, a review of all available studies reporting SRS treatment for BSM was performed. METHODS Twenty-nine retrospective studies investigating SRS for BSM were reviewed. RESULTS The rates of grade 3 or greater toxicity, based on the Common Terminology Criteria for Adverse Events, varied from 0 to 9.5% (mean 3.4 ± 2.9%). Overall, the median time to toxicity after SRS was 3 months, with 90% of toxicities occurring before 9 months. A total of 1243 cases had toxicity and location data available. Toxicity rates for lesions located in the medulla were 0.8% (1/131), compared with midbrain and pons, respectively, 2.8% (8/288) and 3.0% (24/811). CONCLUSIONS Current data suggest that brainstem substructure location does not predict for toxicity and lesion volume within this cohort with median tumor volumes 0.04-2.8 cc does not predict for toxicity.
Collapse
Affiliation(s)
- Ajay Patel
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Tuo Dong
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA; Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shaheryar Ansari
- Goodman Campbell Brain and Spine and Department of Neurological Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Aaron Cohen-Gadol
- Goodman Campbell Brain and Spine and Department of Neurological Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Gordon A Watson
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA; Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Fabio Ynoe de Moraes
- Department of Radiation Oncology, University of Toronto - Princess Margaret Cancer Centre, Toronto, Canada
| | - Masaki Nakamura
- Department of Radiation Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Judith Murovic
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Steven D Chang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Mustafa Aziz Hatiboglu
- Department of Neurosurgery, Bezmialem Vakif University Vatan Caddesi, Fatih, Istanbul, Turkey
| | - Caroline Chung
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - James C Miller
- Goodman Campbell Brain and Spine and Department of Neurological Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Tim Lautenschlaeger
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA; Indiana University School of Medicine, Indianapolis, Indiana, USA.
| |
Collapse
|
9
|
Patel A, Mohammadi H, Dong T, Shiue KRY, Frye D, Le Y, Ansari S, Watson GA, Miller JC, Lautenschlaeger T. Brainstem metastases treated with Gamma Knife stereotactic radiosurgery: the Indiana University Health experience. CNS Oncol 2017; 7:15-23. [PMID: 29239214 PMCID: PMC6001560 DOI: 10.2217/cns-2017-0029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Brainstem metastases offer a unique challenge in cancer treatment, yet stereotactic radiosurgery (SRS) has proven to be an effective modality in treating these tumors. This report discusses the clinical outcomes of patients with brainstem metastases treated at Indiana University with Gamma Knife (GK) radiosurgery from 2008 to 2016. 19 brainstem metastases from 14 patients who had follow-up brain imaging were identified. Median tumor volume was 0.04 cc (range: 0.01–2.0 cc). Median prescribed dose was 17.5 Gy to the 50% isodose line (range: 14–22 Gy). Median survival after GK SRS treatment to brainstem lesion was 17.2 months (range: 2.8–45.6 months). The experience at Indiana University confirms the safety and efficacy of range of GK SRS prescription doses (14–22 Gy) to brainstem metastases.
Collapse
Affiliation(s)
- Ajay Patel
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Homan Mohammadi
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Tuo Dong
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | | | - Douglas Frye
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Yi Le
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Shaheryar Ansari
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Gordon A Watson
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - James C Miller
- Goodman Campbell Brain & Spine & Department of Neurological Surgery, Indiana University, Indianapolis, IN 46202, USA
| | - Tim Lautenschlaeger
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| |
Collapse
|
10
|
Radiotherapy for Brain Metastases From Renal Cell Carcinoma in the Targeted Therapy Era: The University of Rochester Experience. Am J Clin Oncol 2017; 40:439-443. [PMID: 25730604 DOI: 10.1097/coc.0000000000000186] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Radiotherapy remains the standard approach for brain metastases from renal cell carcinoma (RCC). Kinase inhibitors (KI) have become standard of care for metastatic RCC. They also increase the radiosensitivity of various tumor types in preclinical models. Data are lacking regarding the effect of KIs among RCC patients undergoing radiotherapy for brain metastases. We report our experience of radiotherapy for brain metastatic RCC in the era of targeted therapy and analyzed effects of concurrent KI therapy. METHODS We retrospectively analyzed 25 consecutive patients who received radiotherapy for brain metastases from RCC with whole-brain radiotherapy (WBRT), stereotactic radiosurgery (SRS), or both. Kaplan-Meier rates of overall survival (OS) and brain progression-free survival (BPFS) were calculated and univariate analyses performed. RESULTS Lower diagnosis-specific graded prognostic assessment (DS-GPA) score and multiple intracranial metastases were associated with decreased OS and BPFS on univariate analysis; DS-GPA is also a prognostic factor on multivariate analysis. There was no significant difference in OS or BPFS for SRS compared with WBRT or WBRT and SRS combined. The concurrent use of KI was not associated with any change in OS or BPFS. CONCLUSIONS This hypothesis-generating analysis suggests among patients with brain metastatic RCC treated with the most current therapies, those selected to undergo SRS did not experience significantly different survival or control outcomes than those selected to undergo WBRT. From our experience to date, limited in patient numbers, there seems to be neither harm nor benefit in using concurrent KI therapy during radiotherapy. Given that most patients progress systemically, we would recommend considering KI use during brain radiotherapy in these patients.
Collapse
|
11
|
Zhao B, Wen N, Chetty IJ, Huang Y, Brown SL, Snyder KC, Siddiqui F, Movsas B, Siddiqui MS. A prediction model of radiation-induced necrosis for intracranial radiosurgery based on target volume. Med Phys 2017; 44:4360-4367. [PMID: 28543402 DOI: 10.1002/mp.12360] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 03/22/2017] [Accepted: 05/11/2017] [Indexed: 11/08/2022] Open
Abstract
PURPOSE This study aims to extend the observation that the 12 Gy-radiosurgical-volume (V12Gy) correlates with the incidence of radiation necrosis in patients with intracranial tumors treated with radiosurgery by using target volume to predict V12Gy. V12Gy based on the target volume was used to predict the radiation necrosis probability (P) directly. Also investigated was the reduction in radiation necrosis rates (ΔP) as a result of optimizing the prescription isodose lines for linac-based SRS. METHODS Twenty concentric spherical targets and 22 patients with brain tumors were retrospectively studied. For each case, a standard clinical plan and an optimized plan with prescription isodose lines based on gradient index were created. V12Gy were extracted from both plans to analyze the correlation between V12Gy and target volume. The necrosis probability P as a function of V12Gy was evaluated. To account for variation in prescription, the relation between V12Gy and prescription was also investigated. RESULTS A prediction model for radiation-induced necrosis was presented based on the retrospective study. The model directly relates the typical prescribed dose and the target volume to the radionecrosis probability; V12Gy increased linearly with the target volume (R2 > 0.99). The linear correlation was then integrated into a logistic model to predict P directly from the target volume. The change in V12Gy as a function of prescription was modeled using a single parameter, s (=-1.15). Relatively large ΔP was observed for target volumes between 7 and 28 cm3 with the maximum reduction (8-9%) occurring at approximately 18 cm3 . CONCLUSIONS Based on the model results, optimizing the prescription isodose line for target volumes between 7 and 28 cm3 results in a significant reduction in necrosis probability. V12Gy based on the target volume could provide clinicians a predictor of radiation necrosis at the contouring stage thus facilitating treatment decisions.
Collapse
Affiliation(s)
- Bo Zhao
- Department of Radiation Oncology, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - Ning Wen
- Department of Radiation Oncology, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - Indrin J Chetty
- Department of Radiation Oncology, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - Yimei Huang
- Department of Radiation Oncology, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - Stephen L Brown
- Department of Radiation Oncology, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - Karen C Snyder
- Department of Radiation Oncology, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - Farzan Siddiqui
- Department of Radiation Oncology, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - Benjamin Movsas
- Department of Radiation Oncology, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - M Salim Siddiqui
- Department of Radiation Oncology, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| |
Collapse
|
12
|
The impact of different stereotactic radiation therapy regimens for brain metastases on local control and toxicity. Adv Radiat Oncol 2017; 2:391-397. [PMID: 29114607 PMCID: PMC5605319 DOI: 10.1016/j.adro.2017.05.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 03/04/2017] [Accepted: 05/30/2017] [Indexed: 11/24/2022] Open
Abstract
Purpose Stereotactic radiation therapy (SRT) enables focused, short course, high dose per fraction radiation delivery to brain tumors that are less ideal for single fraction treatment because of size, shape, or close proximity to sensitive structures. We sought to identify optimal SRT treatment regimens for maximizing local control while minimizing morbidity. Methods and materials We performed a retrospective review of patients treated with SRT for solid brain metastases using variable dose schedules between 2001 and 2011 at 3 academic hospitals. Endpoints included (1) local control, (2) acute toxicity (Common Toxicity Criteria for Adverse Events v3.0), and (3) symptomatic radionecrosis. Kaplan-Meier and a competing risks methodology were used to estimate the actuarial rate of local failure and assess the association of clinical and treatment covariates with time to local failure. Results A total of 156 patients was identified. Common tumor histologies included breast (21%), non-small cell lung (32%), melanoma (22%), small cell lung (9%), and renal cell carcinoma (6%). The majority of lesions were supratentorial (57%). Median target volume was 3.99 mL (range, 0.04-58.42). Median total SRT dose was 25 Gy (range, 12-36), median fractional dose was 5 Gy (range, 2.5-11), and median number of fractions was 5 (range, 2-10). Cumulative incidence of local progression at 3, 6, 12, 18, and 24 months was 11%, 22%, 29%, 34%, and 36%. Total prescription dose was the only factor significantly associated with time to local progression on univariate (P = .02) and multivariable analysis (P = .01, adjusted hazards ratio, 0.87). Five patients experienced seizures within 10 days of SRT and 5 patients developed radionecrosis. All patients with documented radionecrosis received prior radiation to the index lesion. Conclusions Our series of SRT for brain metastases found total prescription dose to be the only factor associated with local control. Both acute and long-term toxicity events from SRT were modest.
Collapse
|
13
|
Murray L, Menard C, Zadeh G, Au K, Bernstein M, Millar BA, Laperriere N, Chung C. Radiosurgery for brainstem metastases with and without whole brain radiotherapy: clinical series and literature review. ACTA ACUST UNITED AC 2016; 6:21-30. [PMID: 28367275 PMCID: PMC5357261 DOI: 10.1007/s13566-016-0281-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/09/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The objective of this study was to investigate outcomes for patients with brainstem metastases treated with stereotactic radiosurgery (SRS). METHODS Patients with brainstem metastases treated with SRS between April 2006 and June 2012 were identified from a prospective database. Patient and treatment-related factors were recorded. Kaplan-Meier analysis was used to calculate survival and freedom from local and distant brain progression. Univariate and multivariate Cox regression was used to identify factors important for overall survival. RESULTS In total, 44 patients received SRS for 48 brainstem metastases of whom 33 (75 %) also received whole brain radiotherapy (WBRT): 23 patients (52 %) WBRT prior to SRS, 6 (13.6 %) WBRT concurrently with SRS and 4 (9.0 %) WBRT after SRS. Eight patients received a second course of WBRT at further progression. Median target volume was 1.33 cc (range 0.04-12.17) and median prescribed marginal dose was 15 Gy (range 10-22). There were four cases of local failure, and 6-month and 1-year freedom from local failure was 84.6 and 76.9 %, respectively. Median overall survival (OS) was 5.4 months. There were four cases of radionecrosis, 2 (4.8 %) of which were symptomatic. The absence of external beam brain radiotherapy (predominantly WBRT) showed a trend towards improved OS on univariate analysis. Neither local nor distant brain failure significantly impacted OS. CONCLUSION This retrospective series of patients treated with SRS for brainstem metastases, largely in combination with at least one course of WBRT, demonstrates that this approach is safe and results in good local control. In this cohort, no variables significantly impacted OS, including intracranial control.
Collapse
Affiliation(s)
- Louise Murray
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Cynthia Menard
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, ON Canada
| | - Karolyn Au
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, ON Canada
| | - Mark Bernstein
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, ON Canada
| | - Barbara-Ann Millar
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Normand Laperriere
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Caroline Chung
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| |
Collapse
|
14
|
Trifiletti DM, Lee CC, Kano H, Cohen J, Janopaul-Naylor J, Alonso-Basanta M, Lee JYK, Simonova G, Liscak R, Wolf A, Kvint S, Grills IS, Johnson M, Liu KD, Lin CJ, Mathieu D, Héroux F, Silva D, Sharma M, Cifarelli CP, Watson CN, Hack JD, Golfinos JG, Kondziolka D, Barnett G, Lunsford LD, Sheehan JP. Stereotactic Radiosurgery for Brainstem Metastases: An International Cooperative Study to Define Response and Toxicity. Int J Radiat Oncol Biol Phys 2016; 96:280-288. [PMID: 27478166 DOI: 10.1016/j.ijrobp.2016.06.009] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 05/22/2016] [Accepted: 06/07/2016] [Indexed: 11/17/2022]
Abstract
PURPOSE To pool data across multiple institutions internationally and report on the cumulative experience of brainstem stereotactic radiosurgery (SRS). METHODS AND MATERIALS Data on patients with brainstem metastases treated with SRS were collected through the International Gamma Knife Research Foundation. Clinical, radiographic, and dosimetric characteristics were compared for factors prognostic for local control (LC) and overall survival (OS) using univariate and multivariate analyses. RESULTS Of 547 patients with 596 brainstem metastases treated with SRS, treatment of 7.4% of tumors resulted in severe SRS-induced toxicity (grade ≥3, increased odds with increasing tumor volume, margin dose, and whole-brain irradiation). Local control at 12 months after SRS was 81.8% and was improved with increasing margin dose and maximum dose. Overall survival at 12 months after SRS was 32.7% and impacted by age, gender, number of metastases, tumor histology, and performance score. CONCLUSIONS Our study provides additional evidence that SRS has become an option for patients with brainstem metastases, with an excellent benefit-to-risk ratio in the hands of experienced clinicians. Prior whole-brain irradiation increases the risk of severe toxicity in brainstem metastasis patients undergoing SRS.
Collapse
Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia.
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, People's Republic of China
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jonathan Cohen
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James Janopaul-Naylor
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - John Y K Lee
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gabriela Simonova
- Department of Radiation and Stereotactic Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Roman Liscak
- Department of Radiation and Stereotactic Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Amparo Wolf
- Department of Neurosurgery, New York University Lagone Medical Center, New York, New York
| | - Svetlana Kvint
- Department of Neurosurgery, New York University Lagone Medical Center, New York, New York
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Matthew Johnson
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Kang-Du Liu
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, People's Republic of China
| | - Chung-Jung Lin
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, People's Republic of China
| | - David Mathieu
- Division of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Québec, Canada
| | - France Héroux
- Division of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Québec, Canada
| | - Danilo Silva
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Mayur Sharma
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Christopher P Cifarelli
- Departments of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown, West Virginia
| | - Christopher N Watson
- Departments of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown, West Virginia
| | - Joshua D Hack
- Departments of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown, West Virginia
| | - John G Golfinos
- Department of Neurosurgery, New York University Lagone Medical Center, New York, New York
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Lagone Medical Center, New York, New York
| | - Gene Barnett
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia; Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| |
Collapse
|
15
|
Alongi F, Fiorentino A, Mancosu P, Navarria P, Giaj Levra N, Mazzola R, Scorsetti M. Stereotactic radiosurgery for intracranial metastases: linac-based and gamma-dedicated unit approach. Expert Rev Anticancer Ther 2016; 16:731-40. [DOI: 10.1080/14737140.2016.1190648] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Filippo Alongi
- Radiation Oncology Department, Sacro Cuore Hospital, Negrar, Italy
| | - Alba Fiorentino
- Radiation Oncology Department, Sacro Cuore Hospital, Negrar, Italy
| | - Pietro Mancosu
- Radiation Oncology Department, Istituto Clinico Humanitas, Milan, Italy
| | - Pierina Navarria
- Radiation Oncology Department, Istituto Clinico Humanitas, Milan, Italy
| | | | - Rosario Mazzola
- Radiation Oncology Department, Sacro Cuore Hospital, Negrar, Italy
| | - Marta Scorsetti
- Radiation Oncology Department, Istituto Clinico Humanitas, Milan, Italy
| |
Collapse
|
16
|
Sinclair G, Bartek J, Martin H, Barsoum P, Dodoo E. Adaptive hypofractionated gamma knife radiosurgery for a large brainstem metastasis. Surg Neurol Int 2016; 7:S130-8. [PMID: 26958430 PMCID: PMC4765246 DOI: 10.4103/2152-7806.176138] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 12/28/2015] [Indexed: 11/24/2022] Open
Abstract
Background: To demonstrate how adaptive hypofractionated radiosurgery by gamma knife (GK) can be successfully utilized to treat a large brainstem metastasis - a novel approach to a challenging clinical situation. Case Description: A 42-year-old woman, diagnosed with metastatic nonsmall cell lung cancer in July 2011, initially treated with chemotherapy and tyrosine kinase inhibitors, developed multiple brain metastases March 2013, with subsequent whole brain radiotherapy, after which a magnetic resonance imaging (MRI) showed a significant volume regression of all brain metastases. A follow-up MRI in October 2013 revealed a growing brainstem lesion of 26 mm. Linear accelerator-based radiotherapy and microsurgery were judged contraindicated, why the decision was made to treat the patient with three separate radiosurgical sessions during the course of 1 week, with an 18% tumor volume reduction demonstrated after the last treatment. Follow-up MRI 2.5 months after her radiosurgical treatment showed a tumor volume reduction of 67% compared to the 1st day of treatment. Later on, the patient developed a radiation-induced perilesional edema although without major clinical implications. An MRI at 12 months and 18-fluoro-deoxyglucose positron emission tomography of the brain at 13 months showed decreased edema with no signs of tumor recurrence. Despite disease progression during the last months of her life, the patient's condition remained overall acceptable. Conclusion: GK-based stereotactic adaptive hypofractionation proved to be effective to achieve tumor control while limiting local adverse reactions. This surgical modality should be considered when managing larger brain lesions in critical areas.
Collapse
Affiliation(s)
- Georges Sinclair
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Jiri Bartek
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden; Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Heather Martin
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Pierre Barsoum
- Department of Medical Physics, Karolinska University Hospital, Stockholm, Sweden
| | - Ernest Dodoo
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
17
|
Liu SH, Murovic J, Wallach J, Cui G, Soltys SG, Gibbs IC, Chang SD. CyberKnife radiosurgery for brainstem metastases: Management and outcomes and a review of the literature. J Clin Neurosci 2016; 25:105-10. [PMID: 26778047 DOI: 10.1016/j.jocn.2015.10.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 10/10/2015] [Indexed: 11/20/2022]
Abstract
To our knowledge this paper is the first to use recursive partitioning analysis (RPA) for brainstem metastasis (BSM) patient outcomes, after CyberKnife radiosurgery (CKRS; Accuray, Sunnyvale, CA, USA); nine similar previous publications used mainly Gamma Knife radiosurgery (Elekta AB, Stockholm, Sweden). Retrospective chart reviews from 2006-2013 of 949 CKRS-treated brain metastasis patients showed 54 BSM patients (5.7%): 35 RPA Class II (65%) and 19 Class III (35%). There were 30 women (56%) and 24 men (44%). The median age was 59 years (range 36-80) and median follow-up was 5 months (range 1-52). Twenty-three patients (43%) had lung carcinoma BSM and 12 (22%) had breast cancer BSM. Fifty-four RPA Class II and III BSM patients had a median overall survival (OS) of 5 months, and for each Class 8 and 2 months, respectively. Of 36 RPA Class II and III patients with available symptoms (n=31) and findings (n=33), improvement/stability occurred in the majority for symptoms (86%) and findings (92%). Of 35 cases, 28 (80%) achieved BSM local control (LC); 13/14 with breast histology (93%) and 10/13 with lung histology (77%). All six RPA Class II and III patients with controlled extracranial systemic disease (ESD) experienced LC. Median tumor volume was 0.14 cm(3); of 34 RPA Class II and III cases, 26 LC patients had a 0,13 cm(3) median tumor volume while it was 0.27 cm(3) in the eight local failures. Of 35 cases, single session equivalent dosages less than the median (n=13), at the 17.9 Gy median (n=5) and greater than the median (n=17) had BSM LC in 10 (77%), four (80%) and 14 cases (82%), respectively. Univariate analysis showed Karnofsky Performance Score, RPA Class and ESD-control predicted OS. CKRS is useful for RPA Class II and III BSM patients with effective clinical and local BSM control.
Collapse
Affiliation(s)
- Szu-Hao Liu
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, R225, Stanford, CA 94305-5327, USA
| | - Judith Murovic
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, R225, Stanford, CA 94305-5327, USA
| | - Jonathan Wallach
- Department of Radiation Oncology, Stanford University School of Medicine, 875 Blake Wilbur Drive, Stanford, CA 94305-5327, USA
| | - Guosheng Cui
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, R225, Stanford, CA 94305-5327, USA
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University School of Medicine, 875 Blake Wilbur Drive, Stanford, CA 94305-5327, USA
| | - Iris C Gibbs
- Department of Radiation Oncology, Stanford University School of Medicine, 875 Blake Wilbur Drive, Stanford, CA 94305-5327, USA
| | - Steven D Chang
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, R225, Stanford, CA 94305-5327, USA.
| |
Collapse
|
18
|
Trifiletti DM, Lee CC, Winardi W, Patel NV, Yen CP, Larner JM, Sheehan JP. Brainstem metastases treated with stereotactic radiosurgery: safety, efficacy, and dose response. J Neurooncol 2015; 125:385-92. [PMID: 26341374 DOI: 10.1007/s11060-015-1927-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 09/01/2015] [Indexed: 11/28/2022]
Abstract
The safety and efficacy of stereotactic radiosurgery (SRS) in the brainstem is questioned by some over concern of violating historical brainstem SRS dose tolerance. Our purpose was to report on the clinical outcomes of patients treated at our institution with radiosurgery for brainstem metastases. Patients with metastatic tumors within or directly abutting the brainstem from 1992 to 2014 were analyzed. Patient and tumor characteristics, SRS parameters, and toxicity were recorded and analyzed for associations with local control and survival. Multivariate statistical analysis was performed using Cox proportional hazards modeling. One-hundred and eighty-nine (189) brainstem metastases from 161 patients were included in our analysis. Whole brain irradiation was administered prior to SRS in 52 % of patients. The median margin dose was 18 Gy prescribed to the 50 % isodose line. Median imaging follow up was 5.4 months and median survival was 5.5 months after SRS. At last follow up, local control was achieved in 87.3 % of brainstem lesions treated. There were 3 recorded events of grade 3-5 toxicity (1.8 %). On multivariate analysis, a margin dose ≥16 Gy was associated with improved local control (p = 0.049) and greater KPS score was associated with improved overall survival following SRS (p = 0.024). Patients with brainstem metastases who have limited intracranial disease and/or who have received whole brain irradiation should be considered for SRS. Margin doses of at least 16 Gy are associated with superior local control, and serious radiation toxicity in SRS for brainstem metastasis appears rare.
Collapse
Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia, 1240 Lee Street, Box 800383, Charlottesville, VA, 22908, USA.
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, ROC
| | - William Winardi
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Nirav V Patel
- Department of Radiation Oncology, University of Virginia, 1240 Lee Street, Box 800383, Charlottesville, VA, 22908, USA
| | - Chun-Po Yen
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, ROC
| | - James M Larner
- Department of Radiation Oncology, University of Virginia, 1240 Lee Street, Box 800383, Charlottesville, VA, 22908, USA
| | - Jason P Sheehan
- Department of Radiation Oncology, University of Virginia, 1240 Lee Street, Box 800383, Charlottesville, VA, 22908, USA.,Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, ROC
| |
Collapse
|
19
|
Stereotactic Radiosurgery for Metastases in Eloquent Central Brain Locations. Can J Neurol Sci 2015; 42:333-7. [DOI: 10.1017/cjn.2015.55] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractBackground: To examine stereotactic radiosurgery (SRS) following whole brain radiotherapy for metastases in eloquent, central brain locations: brainstem, thalamus, and basal ganglia. Methods: We conducted a retrospective review of patients with metastases in eloquent, central brain locations who were treated with SRS between January 2000 and April 2012. All patients had whole brain radiotherapy. Patients eligible for SRS had one to three brain metastases, metastasis size ≤4 cm, and Karnofsky performance status ≥70. Local progression-free survival and overall survival were calculated using the Kaplan-Meier method. Results: For 24 patients, the median age was 50 years (range, 36-73). Metastases by location were: 11 brainstem, 9 thalamus, and 5 basal ganglia. The median metastasis size was 15 mm (range, 2-33) and the median SRS dose prescription was 15 Gy (range, 12-24). The median local progression-free survival was 13.7 months and median overall survival was 16.4 months. Compared with a cohort of 188 patients with noneloquent brain metastases receiving a median dose of 24 Gy, overall survival of 10.8 months was not significantly different (p=0.16). The only symptomatic complication was grade 2 headache in 8.3%. Asymptomatic adverse radiologic events were radionecrosis in two (8.3%), peritumoural edema in four (16.7%), and hemorrhage in one patient (4.2%). Conclusions: Lower SRS marginal doses do not appear to compromise survival in patients with eloquently located brain metastases compared with higher doses for other brain metastases, with minimal symptomatic complications.
Collapse
|
20
|
Pinkham MB, Whitfield GA, Brada M. New developments in intracranial stereotactic radiotherapy for metastases. Clin Oncol (R Coll Radiol) 2015; 27:316-23. [PMID: 25662094 DOI: 10.1016/j.clon.2015.01.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 12/16/2014] [Accepted: 01/22/2015] [Indexed: 11/19/2022]
Abstract
Brain metastases are common and the prognosis for patients with multiple brain metastases treated with whole brain radiotherapy is limited. As systemic disease control continues to improve, the expectations of radiotherapy for brain metastases are growing. Stereotactic radiosurgery (SRS) as a high precision localised irradiation given in a single fraction prolongs survival in patients with a single brain metastasis and functional independence in those with up to three brain metastases. SRS technology has become commonplace and is available in many radiation oncology and neurosurgery departments. With increasing use there is a need for appropriate patient selection, refinement of dose-fractionation and safe integration of SRS with other treatment modalities. We review the evidence for current practice and new developments in the field, with a specific focus on patient-relevant outcomes.
Collapse
Affiliation(s)
- M B Pinkham
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK; School of Medicine, University of Queensland, Brisbane, Australia
| | - G A Whitfield
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK; The University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - M Brada
- University of Liverpool, Department of Clinical and Molecular Cancer Medicine and Academic Radiotherapy Unit, Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK.
| |
Collapse
|
21
|
Voong KR, Farnia B, Wang Q, Luo D, McAleer MF, Rao G, Guha-Thakurta N, Likhacheva A, Ghia AJ, Brown PD, Li J. Gamma knife stereotactic radiosurgery in the treatment of brainstem metastases: The MD Anderson experience. Neurooncol Pract 2015; 2:40-47. [PMID: 26034640 DOI: 10.1093/nop/npu032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Brainstem metastases (BSMs) represent a significant treatment challenge. Stereotactic radiosurgery (SRS) is often used to treat BSM. We report our experience in the treatment of BSM with Gamma Knife SRS (GK_SRS). METHODS The records of 1962 patients with brain metastases treated with GK_SRS between 2009 and 2013 were retrospectively reviewed. Seventy-four patients with 77 BSMs and follow-up brain imaging were identified. Local control (LC), overall survival (OS), progression-free survival (PFS), and toxicity were assessed. RESULTS Median follow-up was 5.5 months (range, 0.2-48.5 months). Median tumor volume was 0.13 cm3 (range, 0.003-5.58 cm3). Median treatment dose was 16 Gy (range, 10-20 Gy) prescribed to 50% isodose line (range, 40%-86%). Crude LC was 94% (72/77). Kaplan-Meier estimate of median OS was 8.5 months (95% CI, 5.6-9.4 months). Symptomatic lesions and larger lesions, especially size ≥2 cm3, were associated with worse LC (HR = 8.70, P = .05; HR = 14.55, P = .02; HR = 62.81, P < .001) and worse OS (HR = 2.00, P = .02; HR = 2.14, P = .03; HR = 2.81, P = .008). Thirty-six percent of BSMs were symptomatic, of which 36% (10/28) resolved after SRS and 50% (14/28) had stable or improved symptoms. Actuarial median PFS was 3.9 months (95% CI, 2.7-4.9 months). Midbrain location was significant for worse PFS (HR = 2.29, P = .03). Toxicity was low (8%, 6/74), with size and midbrain location associated with increased toxicity (HR 1.57, P = .05; HR = 5.25, P = .045). CONCLUSIONS GK_SRS is associated with high LC (94%) and low toxicity (8%) for BSMs. Presence of symptoms or lesion size ≥ 2 cm3 was predictive of worse LC and OS.
Collapse
Affiliation(s)
- Khinh Ranh Voong
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Benjamin Farnia
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Qianghu Wang
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Dershan Luo
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Mary F McAleer
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Ganesh Rao
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Nandita Guha-Thakurta
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Anna Likhacheva
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Amol J Ghia
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Paul D Brown
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Jing Li
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| |
Collapse
|
22
|
DU C, Li Z, Wang Z, Wang L, Tian YU. Stereotactic aspiration combined with gamma knife radiosurgery for the treatment of cystic brainstem metastasis originating from lung adenosquamous carcinoma: A case report. Oncol Lett 2015; 9:1607-1613. [PMID: 25789009 PMCID: PMC4356421 DOI: 10.3892/ol.2015.2968] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 01/22/2015] [Indexed: 11/23/2022] Open
Abstract
Brainstem metastases have a poor prognosis and are difficult to manage. The present study describes the first case of histopathologically-confirmed brainstem metastasis originating from lung adenosquamous carcinoma, and discusses the outcomes of treatment by stereotactic aspiration combined with gamma knife radiosurgery (GKRS). A 59-year-old female presented with a cystic mass (15×12×13 mm; volume, 1.3 cm3) located in the pons, two years following surgical treatment for adenosquamous carcinoma of the lung. The patient received initial GKRS for the lesion in the pons with a total dose of 54.0 Gy, however, the volume of the mass subsequently increased to 3.9 cm3 over a period of three months. Computed tomography-guided stereotactic biopsy and aspiration of the intratumoral cyst were performed, yielding 2.0 cm3 of yellow-white fluid. Histology confirmed the diagnosis of adenosquamous carcinoma. Aspiration provided immediate symptomatic relief, and was followed one week later by repeat GKRS with a dose of 12.0 Gy. The patient survived for 12 months following the repeat GKRS; however, later succumbed to the disease after lapsing into a two-week coma. The findings of this case suggest that stereotactic aspiration of cysts may improve the effects of GKRS for the treatment of cystic brainstem metastasis; the decrease in tumor volume allowed a higher radiation dose to be administered with a lower risk of radiation-induced side effects. Therefore, stereotactic aspiration combined with GKRS may be an effective treatment for brainstem metastasis originating from adenosquamous carcinoma.
Collapse
Affiliation(s)
- Chao DU
- Department of Neurosurgery, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Zhaohui Li
- Department of Neurosurgery, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Zhijia Wang
- Department of Radiology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Liping Wang
- Department of Pathology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Y U Tian
- Department of Neurosurgery, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| |
Collapse
|
23
|
Local control after fractionated stereotactic radiation therapy for brain metastases. J Neurooncol 2014; 120:339-46. [DOI: 10.1007/s11060-014-1556-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 07/05/2014] [Indexed: 10/25/2022]
|
24
|
Jung EW, Rakowski JT, Delly F, Jagannathan J, Konski AA, Guthikonda M, Kim H, Mittal S. Gamma Knife radiosurgery in the management of brainstem metastases. Clin Neurol Neurosurg 2013; 115:2023-8. [PMID: 23870233 DOI: 10.1016/j.clineuro.2013.06.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Revised: 06/15/2013] [Accepted: 06/19/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Metastases to the brainstem portend a poor prognosis and present a challenge in clinical management. Surgical resection is rarely a viable option. METHODS Post-treatment MRI scans of patients with brainstem metastases treated with radiosurgery were used to determine local control and disease progression. Median survival was calculated using Kaplan-Meier analysis. Univariate and multivariate analyses were performed using log-rank test and Cox proportional hazards model, respectively. RESULTS Thirty-two consecutive patients with brainstem metastasis underwent Gamma Knife radiosurgery. Median age was 50 years. Median tumor volume was 0.71 cm3 and median tumor margin dose was 13 Gy. Seventeen of 32 patients received WBRT prior to stereotactic radiosurgery. Median survival was 5.2 months. There was a statistically significant difference in survival based on RTOG recursive partition analysis (RPA) class. Median survival of patients categorized as RPA class I was 19.2 months, RPA class II was 8.4 months, and RPA class III was 1.9 months. The overall local tumor control rate was 87.5%. There were no acute complications following stereotactic radiosurgery and no evidence of radiation necrosis noted on post-treatment MRI scans. CONCLUSION Stereotactic radiosurgery is an effective treatment for brainstem metastases and should be considered especially for patients with good performance status.
Collapse
Affiliation(s)
- Edward W Jung
- Department of Radiation Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, USA
| | | | | | | | | | | | | | | |
Collapse
|
25
|
A review of the clinical outcomes for patients diagnosed with brainstem metastasis and treated with stereotactic radiosurgery. ISRN SURGERY 2013; 2013:652895. [PMID: 23691365 PMCID: PMC3649612 DOI: 10.1155/2013/652895] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 03/19/2013] [Indexed: 11/17/2022]
Abstract
Only 3%-5% of all brain metastases are located in the brainstem. We present a comprehensive review of the clinical outcomes from modern studies that treated patients with brainstem metastasis using either a Gamma Knife or a linear accelerator-based stereotactic radiosurgery. The median survival time of patients was compared to better understand what clinical or treatment factors are predictive of improved survival. This information can then be utilized to optimize patient care. The data suggests that higher prescribed marginal dose and the associated greater local control of brainstem lesions are associated with longer patient survival. Further research is necessary to better describe the most effective dose for individual brainstem lesions and to tailor optimum therapy to specific patient subgroups.
Collapse
|
26
|
Treatment of brainstem metastases with gamma-knife radiosurgery. J Neurooncol 2013; 113:33-8. [PMID: 23443514 DOI: 10.1007/s11060-013-1086-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 02/17/2013] [Indexed: 12/25/2022]
Abstract
The aim was to investigate the efficacy and safety of gamma-knife stereotactic radiosurgery (SRS) for treating brainstem metastases. The cases of 44 patients who underwent SRS as treatment for 46 brainstem metastases were retrospectively evaluated. The median age was 57 years (range 42-82 years) and the median Karnofsky performance score (KPS) was 80 (range 60-90). The primary tumor was lung carcinoma in 28 cases, breast carcinoma in 7 cases, colon carcinoma in 3 cases, renal cell carcinoma in 3 cases, malignant melanoma in 1 case, and unknown origin in 2 cases. Of the 46 metastases, 30 were in the pons, 14 were in the mesencephalon, and 2 were in the medulla oblongata. The median volume of the 46 metastases was 0.6 cc (range 0.34-7.3 cc). The median marginal dose of radiation was 16 Gy (range 10-20 Gy). Twenty-three patients (52 %) received whole brain radiotherapy prior to SRS, and 6 (14 %) received this therapy after SRS. In the remaining 15 cases (34 %), SRS was applied as the only treatment. Recursive partitioning analysis, graded prognostic assessment, and basic score for brain metastases were used to predict survival time. Local control was achieved for all but two of the 46 metastases (96 %). The overall survival time after SRS was 8 months. Female gender, KPS >70, mesencephalon tumor location, and response to treatment were associated with longer survival. Basic score for brain metastases class I and recursive partitioning analysis classification were associated with better prognosis. Peri-tumoral changes were detected radiologically at 2 (4 %) of the metastatic lesion sites but neither of these patients exhibited symptoms. Gamma-knife radiosurgery is effective for treating brainstem metastases without a higher risk for radiation necrosis.
Collapse
|
27
|
Ogura K, Mizowaki T, Ogura M, Sakanaka K, Arakawa Y, Miyamoto S, Hiraoka M. Outcomes of hypofractionated stereotactic radiotherapy for metastatic brain tumors with high risk factors. J Neurooncol 2012; 109:425-32. [DOI: 10.1007/s11060-012-0912-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Accepted: 06/04/2012] [Indexed: 10/28/2022]
|
28
|
Ohtakara K, Hayashi S, Tanaka H, Hoshi H. Consideration of optimal isodose surface selection for target coverage in micro-multileaf collimator-based stereotactic radiotherapy for large cystic brain metastases: comparison of 90%, 80% and 70% isodose surface-based planning. Br J Radiol 2012; 85:e640-6. [PMID: 22422384 DOI: 10.1259/bjr/21015703] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE This study aims to compare dynamic conformal arc (DCA) plans based on different-percentage isodose surfaces (IDSs), normalised to 100% at the isocentre, for target coverage (TC; dose prescription) in stereotactic radiotherapy for large cystic brain metastases. METHODS The DCA plans were generated for 15 targets (5 spherical models and 10 metastatic brain lesions) based on 90%, 80% and 70% IDSs for dose prescription to attain ≥99% TC values using the Novalis Tx platform. These plans were optimised mainly by leaf margin and/or collimator angle adjustment, while similar arc arrangements were used. RESULTS TC values were equivalent among the three plans. Conformity index values were similar between the 80% and 70% plans, while they were worse in the 90% plans. Mean doses (D(mean)) of the interior 3 mm rind structure were highest in the 70% plans, followed by the 80% plans and lowest in the 90% plans. D(mean) of the exterior 3 mm rind structure and the ratio of 50%/100% isodose volumes (Paddick's gradient index values) were highest in the 90% plans, followed by 80% and lowest in the 70% plans. CONCLUSIONS These results suggest that the 70% IDS plans might be beneficial for both tumour control and reducing toxicity to surrounding normal tissue if appropriate dose conformity and precise treatment set-up are ensured. The 90% IDS plans are unfavourable in view of inferior dose gradient outside the target and should be limited to cases in which the target dose homogeneity is given the highest priority.
Collapse
Affiliation(s)
- K Ohtakara
- Department of Radiology, Gifu University Graduate School of Medicine, Gifu, Japan.
| | | | | | | |
Collapse
|
29
|
Minniti G, Scaringi C, Clarke E, Valeriani M, Osti M, Enrici RM. Frameless linac-based stereotactic radiosurgery (SRS) for brain metastases: analysis of patient repositioning using a mask fixation system and clinical outcomes. Radiat Oncol 2011; 6:158. [PMID: 22085700 PMCID: PMC3253058 DOI: 10.1186/1748-717x-6-158] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2011] [Accepted: 11/16/2011] [Indexed: 11/21/2022] Open
Abstract
Purpose To assess the accuracy of patient repositioning and clinical outcomes of frameless stereotactic radiosurgery (SRS) for brain metastases using a stereotactic mask fixation system. Patients and Methods One hundred two patients treated consecutively with frameless SRS as primary treatment at University of Rome Sapienza Sant'Andrea Hospital between October 2008 and April 2010 and followed prospectively were involved in the study. A commercial stereotactic mask fixation system (BrainLab) was used for patient immobilization. A computerized tomography (CT) scan obtained immediately before SRS was used to evaluate the accuracy of patient repositioning in the mask by comparing the isocenter position to the isocenter position established in the planning CT. Deviations of isocenter coordinates in each direction and 3D displacement were calculated. Overall survival, brain control, and local control were estimated using the Kaplan-Meier method calculated from the time of SRS. Results The mean measured isocenter displacements were 0.12 mm (SD 0.35 mm) in the lateral direction, 0.2 mm (SD 0.4 mm) in the anteroposterior, and 0.4 mm (SD 0.6 mm) in craniocaudal direction. The maximum displacement of 2.1 mm was seen in craniocaudal direction. The mean 3D displacement was 0.5 mm (SD 0.7 mm), being maximum 2.9 mm. The median survival was 15.5 months, and 1-year and 2-year survival rates were 58% and 24%, respectively. Nine patients recurred locally after SRS, with 1-year and 2-year local control rates of 91% and 82%, respectively. Stable extracranial disease (P = 0.001) and KPS > 70 (P = 0.01) were independent predictors of survival. Conclusions Frameless SRS is an effective treatment in the management of patients with brain metastases. The presented non-invasive mask-based fixation stereotactic system is associated with a high degree of patient repositioning accuracy; however, a careful evaluation is essential since occasional errors up to 3 mm may occur.
Collapse
Affiliation(s)
- Giuseppe Minniti
- Department of Radiation Oncology, Sant' Andrea Hospital, University Sapienza, Rome, Italy.
| | | | | | | | | | | |
Collapse
|