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Begley SL, Goenka A, Schulder M. Brainstem Metastases Treated with Stereotactic Radiosurgery: Masked versus Framed Immobilization. World Neurosurg 2023; 175:e1158-e1165. [PMID: 37116783 DOI: 10.1016/j.wneu.2023.04.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Patients with brainstem metastases (BSMs) have minimal surgical options due to high-risk anatomy. To review our efficacy treating BSM using Gamma Knife stereotactic radiosurgery (SRS), we compared results on the basis of the utilization of mask-fixation (MF) or frame-fixation (FF). METHODS Data were retrospectively collected for 32 patients. Follow-up data for 49 lesions were analyzed for local control rate (LCR) and objective response rate (ORR). RESULTS Primary cancers included lung, breast, and melanoma; most lesions were pontine. MF was used in 18 patients. Average tumor volume was 0.99 cm3 (0.005-13.3 cm3). Thirty-nine lesions were treated with single-fraction 16 Gy. Ten lesions were treated in 3-5 fractions with mean dose of 22.5 Gy. Mean follow-up was 14.2 months (1.2-48.2 months). One-year LCR was 94.7%. ORR at last follow-up did not differ between MF and FF (P = 0.81). Average reduction of lesion volume at 6 and 12 months did not differ between MF and FF (64% vs. 45%, P = 0.77; 70% vs. 77%, P = 0.78). Failure occurred in a pontine colorectal cancer metastasis mask-immobilized for treatment with 14 Gy. CONCLUSIONS SRS for BSM achieved high LCR despite variability in tumor size and histology with no significant difference between MF and FF. Although trials have historically excluded patients with BSM, our data support SRS as a safe and efficacious treatment. This is the first study showing that MF provides equivalent, successful outcomes when compared with FF for patients with BSM.
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Affiliation(s)
- Sabrina L Begley
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, USA.
| | - Anuj Goenka
- Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York, USA
| | - Michael Schulder
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, USA
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2
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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.
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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.
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3
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Magnetic Resonance-guided Laser Interstitial Thermal Therapy (MRgLITT) for Brainstem Pathologies. World Neurosurg 2022; 161:e80-e89. [PMID: 35033695 DOI: 10.1016/j.wneu.2022.01.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/09/2022] [Accepted: 01/09/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Magnetic Resonance-guided Laser interstitial thermal therapy (MRgLITT) is a minimally invasive and effective treatment option that can potentially treat deep-seated pathologies in cases where there are no safe open surgical corridors. In this report, we present our experience using MRgLITT for brainstem pathologies. METHODS A retrospective chart analysis was conducted of all patients who underwent MRgLITT for pathologies within or closely surrounding the brainstem between 2011 and 2020. The patients underwent stereotactic laser placement in the operating suite and were transported to the MRI suite for laser ablation with real-time monitoring. Demographics, operative parameters and complications were recorded. RESULTS A total of twelve patients underwent MRgLITT for brainstem pathologies. The average age of the patients was 47.6 years old, ranging from 4 to 75. Pathologies included both primary and metastatic intracranial tumors. The average pre-ablation volume of the targets was 2.4cm3 ±SEM=0.50. The average time of ablation was 324.3± 60.7 seconds and average post-ablation volume was 2.92±0.53 cm3. There was one perioperative mortality directly related to the procedure and seven cases of post-operative deficits. Two patients had recurrence after MRgLITT and opted to undergo additional alternative treatments. CONCLUSION The brainstem represents formidable territory even for minimally invasive procedures. The overall morbidity and mortality remains high, and the probability of achieving a meaningful outcome needs to be carefully assessed.
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Chatzikonstantinou G, Wolff R, Tselis N. Fractionated stereotactic radiotherapy as a primary or salvage treatment for large brainstem metastasis. J Cancer Res Ther 2022; 18:1604-1609. [DOI: 10.4103/jcrt.jcrt_426_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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5
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Azar M, Mohsenian Sisakht A, Kazemi Gazik F, Shahrokhi P, Rastegar K, Karamzade-Ziarati N. PET-guided gamma knife radiosurgery in brain tumors: a brief review. Clin Transl Imaging 2021. [DOI: 10.1007/s40336-021-00447-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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6
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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.
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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
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7
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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.
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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
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8
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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]
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9
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Winograd E, Rivers CI, Fenstermaker R, Fabiano A, Plunkett R, Prasad D. The case for radiosurgery for brainstem metastases. J Neurooncol 2019; 143:585-595. [DOI: 10.1007/s11060-019-03195-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/11/2019] [Accepted: 05/16/2019] [Indexed: 11/30/2022]
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10
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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.
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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.
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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.
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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
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12
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Marta GN, Baraldi HE, Moraes FYD. Guidelines for the treatment of central nervous system metastases using radiosurgery. Rev Assoc Med Bras (1992) 2017; 63:559-563. [PMID: 28977079 DOI: 10.1590/1806-9282.63.07.559] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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13
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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.
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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
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Joshi R, Johnson MD, Maitz A, Marvin KS, Olson RE, Grills IS. Utility of graded prognostic assessment in evaluation of patients with brainstem metastases treated with radiosurgery. Clin Neurol Neurosurg 2016; 147:30-3. [DOI: 10.1016/j.clineuro.2016.05.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 05/03/2016] [Indexed: 11/15/2022]
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15
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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.
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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
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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.
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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.
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17
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Trifiletti DM, Lee CC, Shah N, Patel NV, Chen SC, Sheehan JP. How Does Brainstem Involvement Affect Prognosis in Patients with Limited Brain Metastases? Results of a Matched-Cohort Analysis. World Neurosurg 2015; 88:563-568. [PMID: 26555507 DOI: 10.1016/j.wneu.2015.10.089] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 10/22/2015] [Accepted: 10/24/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Although brainstem metastases are thought to portend an inferior prognosis compared to non-brainstem brain metastases, there is limited evidence to support this claim, particularly in the modern radiosurgical era. METHODS We collected the clinical data for 500 patients with brain metastases treated at our institution with stereotactic radiosurgery (SRS). All patients received SRS to at least one brain metastasis, and all brainstem metastases underwent SRS. After propensity score matching, clinical characteristics and overall survival were calculated and compared between groups. RESULTS Three hundred sixteen patients with brain metastases were analyzed after matching (143 with brainstem involvement and 173 without). Patients with brainstem metastases lived shorter after first SRS than patients without brainstem metastases did (median 4.4 and 6.5 months, respectively; P = 0.01), and they were more likely to have received whole brain irradiation (P = 0.003). Patients with a single metastasis did not survive longer than patients with multiple brain metastases if there was brainstem involvement (P = 0.45). The incidence of new extracranial disease and severe toxicity after SRS did not differ between groups. CONCLUSIONS The survival of patients with brain metastases is inferior after a metastatic lesion develops within the brainstem, despite favorable local control with brainstem SRS. The brainstem location should be considered a negative prognostic factor for survival after SRS, and it could result from the eloquence of this location. Future research could identify the clinically life-limiting component of brainstem metastases.
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Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA.
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Neil Shah
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA
| | - Nirav V Patel
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA
| | - Shao-Ching Chen
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
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18
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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.
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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
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19
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Patel AJ, Suki D, Hatiboglu MA, Rao VY, Fox BD, Sawaya R. Impact of surgical methodology on the complication rate and functional outcome of patients with a single brain metastasis. J Neurosurg 2015; 122:1132-43. [PMID: 25794344 DOI: 10.3171/2014.9.jns13939] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Brain metastases are the most common intracranial neoplasms and are on the increase. As radiation side effects are increasingly better understood, more patients are being treated with surgery alone with varying outcomes. The authors previously reported that en bloc resection of a single brain metastasis was associated with decreased incidences of leptomeningeal disease and local recurrence compared with piecemeal resection. However, en bloc resection is often feared to cause an increased incidence of postoperative complications. This study aimed to answer this question. METHODS The authors reviewed data from patients with a previously untreated single brain metastasis, who were treated with resection at The University of Texas M.D. Anderson Cancer Center (1993-2012). Data related to the patient, tumor, and methods of resection were obtained. Discharge Karnofsky Performance Scale (KPS) scores and 30-day postoperative complications were noted. Complications were considered major when they persisted for longer than 30 days, resulted in hospitalization or prolongation of hospital stay, required aggressive treatment, and/or were life threatening. RESULTS During the study period, 1033 eligible patients were identified. The median age was 58 years, 83% had a KPS score greater than 70, and 81% were symptomatic at surgery. Sixty-two percent of the patients underwent en bloc resection of their tumor, and 38% underwent piecemeal resection. There were significant differences between the 2 groups in terms of preoperative tumor volume, tumor functional grade, and symptoms at presentation, among others. The overall complication rates were 13% for patients undergoing en bloc resection and 19% for patients undergoing piecemeal resection (p = 0.007). The incidences of major complications and neurological complications were also significantly different. There was a trend in the same direction for major neurological complications, although it was not significant. Among patients undergoing piecemeal resection of tumors in eloquent cortex, 24% had complications (13% had major, 18% had neurological, 9% had major neurological, and 13% had select neurological complications; 4% died within 1 month of surgery). Among those undergoing en bloc resection of such tumors, 11% had complications (6% had major, 8% had neurological, 4% had major neurological, and 4% had select neurological; 2% died within 1 month of surgery). The differences in overall, major, neurological, and select neurological complications were statistically significant, but 1-month mortality and major neurological complications were not. In addition, within subcategories of tumor volume, the incidence of various complications was generally higher for patients undergoing piecemeal resection than for those undergoing en bloc resection. CONCLUSIONS The authors' results indicate that postoperative complication rates are not increased by en bloc resection, including for lesions in eloquent brain regions or for large tumors. This gives credence to the idea that en bloc resection of brain metastases, when feasible, is at least as safe as piecemeal resection.
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Affiliation(s)
- Akash J Patel
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center; and
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20
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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.
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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.)
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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.
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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
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22
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Gamma knife treatment of brainstem metastases. Int J Mol Sci 2014; 15:9748-61. [PMID: 24886816 PMCID: PMC4100118 DOI: 10.3390/ijms15069748] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Revised: 05/01/2014] [Accepted: 05/05/2014] [Indexed: 11/16/2022] Open
Abstract
The management of brainstem metastases is challenging. Surgical treatment is usually not an option, and chemotherapy is of limited utility. Stereotactic radiosurgery has emerged as a promising palliative treatment modality in these cases. The goal of this study is to assess our single institution experience treating brainstem metastases with Gamma Knife radiosurgery (GKRS). This retrospective chart review studied 41 patients with brainstem metastases treated with GKRS. The most common primary tumors were lung, breast, renal cell carcinoma, and melanoma. Median age at initial treatment was 59 years. Nineteen (46%) of the patients received whole brain radiation therapy (WBRT) prior to or concurrent with GKRS treatment. Thirty (73%) of the patients had a single brainstem metastasis. The average GKRS dose was 17 Gy. Post-GKRS overall survival at six months was 42%, at 12 months was 22%, and at 24 months was 13%. Local tumor control was achieved in 91% of patients, and there was one patient who had a fatal brain hemorrhage after treatment. Karnofsky performance score (KPS) >80 and the absence of prior WBRT were predictors for improved survival on multivariate analysis (HR 0.60 (p = 0.02), and HR 0.28 (p = 0.02), respectively). GKRS was an effective treatment for brainstem metastases, with excellent local tumor control.
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23
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Frischer JM, Gatterbauer B, Holzer S, Stavrou I, Gruber A, Novak K, Wang WT, Reinprecht A, Mert A, Trattnig S, Mallouhi A, Kitz K, Knosp E. Microsurgery and radiosurgery for brainstem cavernomas: effective and complementary treatment options. World Neurosurg 2014; 81:520-8. [PMID: 24440458 DOI: 10.1016/j.wneu.2014.01.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Revised: 10/20/2013] [Accepted: 01/09/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate treatment options for brainstem cavernous malformations (BSCMs) using the results from a center with long-standing experience in microsurgical resection and Gamma Knife radiosurgery (GKRS) treatment of BSCMs. METHODS Study participants were 67 symptomatic patients with BSCMs who were treated either microsurgically (n = 29) or radiosurgically (n = 38). Patients were followed for a minimum of 2 years (median, 7.7 years). A recent follow-up was performed. RESULTS Patients receiving surgical treatment had mainly large, superficially seated lesions and experienced preoperative hemorrhages more often and presented with higher preoperative modified Rankin Scale scores. Patients receiving GKRS harbored smaller, deep-seated lesions, reflecting a selection bias. In both treatment groups, patients presented with significantly better modified Rankin Scale scores at follow-up than before intervention. Overall annual preoperative hemorrhage rates were 3.2% in microsurgery patients and 2.3% in radiosurgery patients. In the preoperative observation period, the rehemorrhage rate was 25.1% for microsurgery patients and 7.2% for radiosurgery patients. Hemorrhage rate after GKRS decreased significantly to 0.6% after 2 years. The postoperative hemorrhage rate was 8.8% but only for microsurgery patients with residual lesions. Advancements in microsurgical techniques improved surgical outcomes, resulting in a high total excision rate in the modern era. CONCLUSIONS In the treatment of BSCM, patient selection and timing of surgery are crucial. If applied in a multidisciplinary neurosurgical center, microsurgery and radiosurgery are complementary treatment options that both result in reduced bleeding rates and improvement of clinical outcome.
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Affiliation(s)
- Josa M Frischer
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria.
| | | | - Sabrina Holzer
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Ioannis Stavrou
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Klaus Novak
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Wei-Te Wang
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Andrea Reinprecht
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Ayguel Mert
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Siegfried Trattnig
- Department of Radiology, MR Centre of Excellence, Medical University Vienna, Vienna, Austria
| | - Ammar Mallouhi
- Department of Radiology, Medical University Vienna, Vienna, Austria
| | - Klaus Kitz
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
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Anaesthetic techniques for unique cancer surgery procedures. Best Pract Res Clin Anaesthesiol 2013; 27:513-26. [DOI: 10.1016/j.bpa.2013.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 09/26/2013] [Accepted: 09/30/2013] [Indexed: 11/19/2022]
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