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Freret ME, Boire A. The anatomic basis of leptomeningeal metastasis. J Exp Med 2024; 221:e20212121. [PMID: 38451255 PMCID: PMC10919154 DOI: 10.1084/jem.20212121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 09/20/2022] [Accepted: 02/08/2024] [Indexed: 03/08/2024] Open
Abstract
Leptomeningeal metastasis (LM), or spread of cancer to the cerebrospinal fluid (CSF)-filled space surrounding the central nervous system, is a fatal complication of cancer. Entry into this space poses an anatomical challenge for cancer cells; movement of cells between the blood and CSF is tightly regulated by the blood-CSF barriers. Anatomical understanding of the leptomeninges provides a roadmap of corridors for cancer entry. This Review describes the anatomy of the leptomeninges and routes of cancer spread to the CSF. Granular understanding of LM by route of entry may inform strategies for novel diagnostic and preventive strategies as well as therapies.
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Affiliation(s)
- Morgan E. Freret
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Adrienne Boire
- Department of Neurology, Human Oncology and Pathogenesis Program, Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Morshed RA, Cummins DD, Nguyen MP, Saggi S, Vasudevan HN, Braunstein SE, Goldschmidt E, Chang EF, McDermott MW, Berger MS, Theodosopoulos PV, Daras M, Hervey-Jumper SL, Aghi MK. Genomic alterations associated with postoperative nodular leptomeningeal disease after resection of brain metastases. J Neurosurg 2024; 140:328-337. [PMID: 37548547 PMCID: PMC11175692 DOI: 10.3171/2023.5.jns23460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 05/30/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE The relationship between brain metastasis resection and risk of nodular leptomeningeal disease (nLMD) is unclear. This study examined genomic alterations found in brain metastases with the aim of identifying alterations associated with postoperative nLMD in the context of clinical and treatment factors. METHODS A retrospective, single-center study was conducted on patients who underwent resection of brain metastases between 2014 and 2022 and had clinical and genomic data available. Postoperative nLMD was the primary endpoint of interest. Targeted next-generation sequencing of > 500 oncogenes was performed in brain metastases. Cox proportional hazards analyses were performed to identify clinical features and genomic alterations associated with nLMD. RESULTS The cohort comprised 101 patients with tumors originating from multiple cancer types. There were 15 patients with nLMD (14.9% of the cohort) with a median time from surgery to nLMD diagnosis of 8.2 months. Two supervised machine learning algorithms consistently identified CDKN2A/B codeletion and ERBB2 amplification as the top predictors associated with postoperative nLMD across all cancer types. In a multivariate Cox proportional hazards analysis including clinical factors and genomic alterations observed in the cohort, tumor volume (× 10 cm3; HR 1.2, 95% CI 1.01-1.5; p = 0.04), CDKN2A/B codeletion (HR 5.3, 95% CI 1.7-16.9; p = 0.004), and ERBB2 amplification (HR 3.9, 95% CI 1.1-14.4; p = 0.04) were associated with a decreased time to postoperative nLMD. CONCLUSIONS In addition to increased resected tumor volume, ERBB2 amplification and CDKN2A/B deletion were independently associated with an increased risk of postoperative nLMD across multiple cancer types. Additional work is needed to determine if targeted therapy decreases this risk in the postoperative setting.
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Affiliation(s)
- Ramin A. Morshed
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Daniel D. Cummins
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Minh P. Nguyen
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Satvir Saggi
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Harish N. Vasudevan
- Department of Neurological Surgery, University of California, San Francisco, California
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Steve E. Braunstein
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Ezequiel Goldschmidt
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Edward F. Chang
- Department of Neurological Surgery, University of California, San Francisco, California
| | | | - Mitchel S. Berger
- Department of Neurological Surgery, University of California, San Francisco, California
| | | | - Mariza Daras
- Department of Neurological Surgery, University of California, San Francisco, California
| | | | - Manish K. Aghi
- Department of Neurological Surgery, University of California, San Francisco, California
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Abdulhaleem M, Hunting JC, Wang Y, Smith MR, Agostino RDJ, Lycan T, Farris MK, Ververs J, Lo HW, Watabe K, Topaloglu U, Li W, Whitlow C, Su J, Wang G, Chan MD, Xing F, Ruiz J. Use of comprehensive genomic profiling for biomarker discovery for the management of non-small cell lung cancer brain metastases. Front Oncol 2023; 13:1214126. [PMID: 38023147 PMCID: PMC10661935 DOI: 10.3389/fonc.2023.1214126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
Background Clinical biomarkers for brain metastases remain elusive. Increased availability of genomic profiling has brought discovery of these biomarkers to the forefront of research interests. Method In this single institution retrospective series, 130 patients presenting with brain metastasis secondary to Non-Small Cell Lung Cancer (NSCLC) underwent comprehensive genomic profiling conducted using next generation circulating tumor deoxyribonucleic acid (DNA) (Guardant Health, Redwood City, CA). A total of 77 genetic mutation identified and correlated with nine clinical outcomes using appropriate statistical tests (general linear models, Mantel-Haenzel Chi Square test, and Cox proportional hazard regression models). For each outcome, a genetic signature composite score was created by summing the total genes wherein genes predictive of a clinically unfavorable outcome assigned a positive score, and genes with favorable clinical outcome assigned negative score. Results Seventy-two genes appeared in at least one gene signature including: 14 genes had only unfavorable associations, 36 genes had only favorable associations, and 22 genes had mixed effects. Statistically significant associated signatures were found for the clinical endpoints of brain metastasis velocity, time to distant brain failure, lowest radiosurgery dose, extent of extracranial metastatic disease, concurrent diagnosis of brain metastasis and NSCLC, number of brain metastases at diagnosis as well as distant brain failure. Some genes were solely associated with multiple favorable or unfavorable outcomes. Conclusion Genetic signatures were derived that showed strong associations with different clinical outcomes in NSCLC brain metastases patients. While these data remain to be validated, they may have prognostic and/or therapeutic impact in the future. Statement of translation relevance Using Liquid biopsy in NSCLC brain metastases patients, the genetic signatures identified in this series are associated with multiple clinical outcomes particularly these ones that lead to early or more numerous metastases. These findings can be reverse-translated in laboratory studies to determine if they are part of the genetic pathway leading to brain metastasis formation.
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Affiliation(s)
- Mohammed Abdulhaleem
- Department of Internal Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - John C. Hunting
- Department of Internal Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Yuezhu Wang
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Margaret R. Smith
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Ralph D’ jr. Agostino
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Thomas Lycan
- Department of Internal Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Michael K. Farris
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - James Ververs
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Hui-Wen Lo
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Umit Topaloglu
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Wencheng Li
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Christopher Whitlow
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Jing Su
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ge Wang
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY, United States
| | - Michael D. Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Fei Xing
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Jimmy Ruiz
- Department of Internal Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC, United States
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Lee CK, Soon YY, Jeffree RL, Joshi R, Koh ES, Lam WS, Le H, Lwin Z, Pinkham MB, Siva S, Ng E, John T. Management Paradigm of Central Nervous System Metastases in NSCLC: An Australian Perspective. JTO Clin Res Rep 2023; 4:100553. [PMID: 37663675 PMCID: PMC10472312 DOI: 10.1016/j.jtocrr.2023.100553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 07/05/2023] [Accepted: 07/21/2023] [Indexed: 09/05/2023] Open
Abstract
Life-prolonging central nervous system active systemic therapies for metastatic NSCLC have increased the complexity of managing brain metastases (BMs). Australian medical oncologists, radiation oncologists, and neurosurgeons discussed the evidence guiding the diverse clinical approaches to the management of BM in NSCLC. The Australian context is broadly applicable to other jurisdictions; therefore, we have documented these discussions as principles with broader applications. Patient management was stratified according to clinical and radiologic factors under two broad classifications of newly diagnosed BMs: symptomatic and asymptomatic. Other important considerations include the number and location of metastases, tumor histotypes, molecular subtype, and treatment purpose. Careful consideration of the pace and burden of symptoms, risk of worsening neurologic function at a short interval, and extracranial disease burden should determine whether central nervous system active systemic therapies are used alone or in combination with local therapies (surgery with or without radiation therapy). Most clinical trial evidence currently focuses on historical treatment options or a single treatment modality rather than the optimal sequencing of multiple modern therapies; therefore, an individualized approach is key in a rapidly changing therapeutic landscape.
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Affiliation(s)
- Chee Khoon Lee
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Yu Yang Soon
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore
| | - Rosalind L. Jeffree
- Kenneth G Jamieson Department of Neurosurgery, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, St. Lucia, Queensland, Australia
| | - Rohit Joshi
- Medical Oncology, Lyell McEwin Hospital, University of Adelaide, Adelaide, South Australia, Australia
- Allied Health & Human Performance, University of South Australia, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Science, Adelaide, South Australia, Australia
| | - Eng-Siew Koh
- Liverpool and Macarthur Cancer Therapy Centres, Liverpool, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Wei-Sen Lam
- Department of Medical Oncology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Hien Le
- Department of Radiation Oncology, Royal Adelaide Hospital, South Australia, Australia
| | - Zarnie Lwin
- Faculty of Medicine, University of Queensland, St. Lucia, Queensland, Australia
- Department of Medical Oncology, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - Mark B. Pinkham
- Faculty of Medicine, University of Queensland, St. Lucia, Queensland, Australia
- The Radiation Oncology Centre, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Shankar Siva
- Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Victoria, Australia
| | - Evan Ng
- Department of Radiation Oncology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Thomas John
- Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Victoria, Australia
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Morshed RA, Saggi S, Cummins DD, Molinaro AM, Young JS, Viner JA, Villanueva-Meyer JE, Goldschmidt E, Boreta L, Braunstein SE, Chang EF, McDermott MW, Berger MS, Theodosopoulos PV, Hervey-Jumper SL, Aghi MK, Daras M. Identification of risk factors associated with leptomeningeal disease after resection of brain metastases. J Neurosurg 2023; 139:402-413. [PMID: 36640095 PMCID: PMC11208084 DOI: 10.3171/2022.12.jns221490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 12/07/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Resection of brain metastases (BMs) may be associated with increased risk of leptomeningeal disease (LMD). This study examined rates and predictors of LMD, including imaging subtypes, in patients who underwent resection of a BM followed by postoperative radiation. METHODS A retrospective, single-center study was conducted examining overall LMD, classic LMD (cLMD), and nodular LMD (nLMD) risk. Logistic regression, Cox proportional hazards, and random forest analyses were performed to identify risk factors associated with LMD. RESULTS Of the 217 patients in the cohort, 47 (21.7%) developed postoperative LMD, with 19 cases (8.8%) of cLMD and 28 cases (12.9%) of nLMD. Six-, 12-, and 24-month LMD-free survival rates were 92.3%, 85.6%, and 71.4%, respectively. Patients with cLMD had worse survival outcomes from the date of LMD diagnosis compared with nLMD (median 2.4 vs 6.9 months, p = 0.02, log-rank test). Cox proportional hazards analysis identified cerebellar/insular/occipital location (hazard ratio [HR] 3.25, 95% confidence interval [CI] 1.73-6.11, p = 0.0003), absence of extracranial disease (HR 2.49, 95% CI 1.27-4.88, p = 0.008), and ventricle contact (HR 2.82, 95% CI 1.5-5.3, p = 0.001) to be associated with postoperative LMD. A predictive model using random forest analysis with an area under the receiver operating characteristic curve of 0.87 in a test cohort identified tumor location, systemic disease status, and tumor volume as the most important factors associated with LMD. CONCLUSIONS Tumor location, absence of extracranial disease at the time of surgery, ventricle contact, and increased tumor volume were associated with LMD. Further work is needed to determine whether escalating therapies in patients at risk of LMD prevents disease dissemination.
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Affiliation(s)
- Ramin A. Morshed
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Satvir Saggi
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Daniel D. Cummins
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Annette M. Molinaro
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Jacob S. Young
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Jennifer A. Viner
- Department of Neurological Surgery, University of California, San Francisco, California
| | | | - Ezequiel Goldschmidt
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Lauren Boreta
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Steve E. Braunstein
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Edward F. Chang
- Department of Neurological Surgery, University of California, San Francisco, California
| | | | - Mitchel S. Berger
- Department of Neurological Surgery, University of California, San Francisco, California
| | | | | | - Manish K. Aghi
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Mariza Daras
- Department of Neurological Surgery, University of California, San Francisco, California
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Song Q, Ruiz J, Xing F, Lo HW, Craddock L, Pullikuth AK, Miller LD, Soike MH, O'Neill SS, Watabe K, Chan MD, Su J. Single-cell sequencing reveals the landscape of the human brain metastatic microenvironment. Commun Biol 2023; 6:760. [PMID: 37479733 PMCID: PMC10362065 DOI: 10.1038/s42003-023-05124-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 07/07/2023] [Indexed: 07/23/2023] Open
Abstract
Brain metastases is the most common intracranial tumor and account for approximately 20% of all systematic cancer cases. It is a leading cause of death in advanced-stage cancer, resulting in a five-year overall survival rate below 10%. Therefore, there is a critical need to identify effective biomarkers that can support frequent surveillance and promote efficient drug guidance in brain metastasis. Recently, the remarkable breakthroughs in single-cell RNA-sequencing (scRNA-seq) technology have advanced our insights into the tumor microenvironment (TME) at single-cell resolution, which offers the potential to unravel the metastasis-related cellular crosstalk and provides the potential for improving therapeutic effects mediated by multifaceted cellular interactions within TME. In this study, we have applied scRNA-seq and profiled 10,896 cells collected from five brain tumor tissue samples originating from breast and lung cancers. Our analysis reveals the presence of various intratumoral components, including tumor cells, fibroblasts, myeloid cells, stromal cells expressing neural stem cell markers, as well as minor populations of oligodendrocytes and T cells. Interestingly, distinct cellular compositions are observed across different samples, indicating the influence of diverse cellular interactions on the infiltration patterns within the TME. Importantly, we identify tumor-associated fibroblasts in both our in-house dataset and external scRNA-seq datasets. These fibroblasts exhibit high expression of type I collagen genes, dominate cell-cell interactions within the TME via the type I collagen signaling axis, and facilitate the remodeling of the TME to a collagen-I-rich extracellular matrix similar to the original TME at primary sites. Additionally, we observe M1 activation in native microglial cells and infiltrated macrophages, which may contribute to a proinflammatory TME and the upregulation of collagen type I expression in fibroblasts. Furthermore, tumor cell-specific receptors exhibit a significant association with patient survival in both brain metastasis and native glioblastoma cases. Taken together, our comprehensive analyses identify type I collagen-secreting tumor-associated fibroblasts as key mediators in metastatic brain tumors and uncover tumor receptors that are potentially associated with patient survival. These discoveries provide potential biomarkers for effective therapeutic targets and intervention strategies.
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Affiliation(s)
- Qianqian Song
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Jimmy Ruiz
- Hematology & Oncology, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
- W.G. (Bill) Hefner Department of Veteran Affairs Medical Center, Salisbury, NC, USA.
| | - Fei Xing
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Hui-Wen Lo
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Lou Craddock
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Ashok K Pullikuth
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Lance D Miller
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Michael H Soike
- Hazlerig-Salter Department of Radiation Oncology, University of Alabama-Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Stacey S O'Neill
- Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Jing Su
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA.
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Acker G, Nachbar M, Soffried N, Bodnar B, Janas A, Krantchev K, Kalinauskaite G, Kluge A, Shultz D, Conti A, Kaul D, Zips D, Vajkoczy P, Senger C. What if: A retrospective reconstruction of resection cavity stereotactic radiosurgery to mimic neoadjuvant stereotactic radiosurgery. Front Oncol 2023; 13:1056330. [PMID: 37007157 PMCID: PMC10062706 DOI: 10.3389/fonc.2023.1056330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 02/20/2023] [Indexed: 03/18/2023] Open
Abstract
Introduction Neoadjuvant stereotactic radiosurgery (NaSRS) of brain metastases has gained importance, but it is not routinely performed. While awaiting the results of prospective studies, we aimed to analyze the changes in the volume of brain metastases irradiated pre- and postoperatively and the resulting dosimetric effects on normal brain tissue (NBT). Methods We identified patients treated with SRS at our institution to compare hypothetical preoperative gross tumor and planning target volumes (pre-GTV and pre-PTV) with original postoperative resection cavity volumes (post-GTV and post-PTV) as well as with a standardized-hypothetical PTV with 2.0 mm margin. We used Pearson correlation to assess the association between the GTV and PTV changes with the pre-GTV. A multiple linear regression analysis was established to predict the GTV change. Hypothetical planning for the selected cases was created to assess the volume effect on the NBT exposure. We performed a literature review on NaSRS and searched for ongoing prospective trials. Results We included 30 patients in the analysis. The pre-/post-GTV and pre-/post-PTV did not differ significantly. We observed a negative correlation between pre-GTV and GTV-change, which was also a predictor of volume change in the regression analysis, in terms of a larger volume change for a smaller pre-GTV. In total, 62.5% of cases with an enlargement greater than 5.0 cm3 were smaller tumors (pre-GTV < 15.0 cm3), whereas larger tumors greater than 25.0 cm3 showed only a decrease in post-GTV. Hypothetical planning for the selected cases to evaluate the volume effect resulted in a median NBT exposure of only 67.6% (range: 33.2-84.5%) relative to the dose received by the NBT in the postoperative SRS setting. Nine published studies and twenty ongoing studies are listed as an overview. Conclusion Patients with smaller brain metastases may have a higher risk of volume increase when irradiated postoperatively. Target volume delineation is of great importance because the PTV directly affects the exposure of NBT, but it is a challenge when contouring resection cavities. Further studies should identify patients at risk of relevant volume increase to be preferably treated with NaSRS in routine practice. Ongoing clinical trials will evaluate additional benefits of NaSRS.
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Affiliation(s)
- Gueliz Acker
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Academy, Clinician Scientist Program, Berlin, Germany
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Marcel Nachbar
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Nina Soffried
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Bohdan Bodnar
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Anastasia Janas
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Kiril Krantchev
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Goda Kalinauskaite
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Anne Kluge
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - David Shultz
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Alfredo Conti
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum - Università di Bologna, Bologna, Italy
| | - David Kaul
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
- German Cancer Consortium (DKTK), Partner Site Berlin, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Daniel Zips
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Carolin Senger
- Department of Radiation Oncology and Radiotherapy, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
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8
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Abdulhaleem M, Ruiz J, O’Neill S, Hughes RT, Qasem S, Strowd RE, Furdui C, Watabe K, Miller LD, Debinski W, Tatter S, Metheny-Barlow L, White JJ, Lee J, McTyre ER, Laxton A, Chan MD, Su J, Soike MH. Collagen deposition within brain metastases is associated with leptomeningeal failure after
cavity-directed radiosurgery. Neurooncol Adv 2023; 5:vdac186. [PMID: 36789023 PMCID: PMC9918843 DOI: 10.1093/noajnl/vdac186] [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] [Indexed: 01/09/2023] Open
Abstract
Background Leptomeningeal failure (LMF) represents a devastating progression of disease following resection of brain metastases (BrM). We sought to identify a biomarker at time of BrM resection that predicts for LMF using mass spectrometry-based proteomic analysis of resected BrM and to translate this finding with histochemical assays. Methods We retrospectively reviewed 39 patients with proteomic data available from resected BrM. We performed an unsupervised analysis with false discovery rate adjustment (FDR) to compare proteomic signature of BrM from patients that developed LMF versus those that did not. Based on proteomic analysis, we applied trichrome stain to a total of 55 patients who specifically underwent resection and adjuvant radiosurgery. We used competing risks regression to assess predictors of LMF. Results Of 39 patients with proteomic data, FDR revealed type I collagen-alpha-1 (COL1A1, P = .045) was associated with LMF. The degree of trichrome stain in each block correlated with COL1A1 expression (β = 1.849, P = .001). In a cohort of 55 patients, a higher degree of trichrome staining was associated with an increased hazard of LMF in resected BrM (Hazard Ratio 1.58, 95% CI 1.11-2.26, P = .01). Conclusion The degree of trichrome staining correlated with COL1A1 and portended a higher risk of LMF in patients with resected brain metastases treated with adjuvant radiosurgery. Collagen deposition and degree of fibrosis may be able to serve as a biomarker for LMF.
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Affiliation(s)
- Mohammed Abdulhaleem
- Corresponding Author: Mohammed Abdulhaleem, MD, Department of Medicine Wake Forest School of Medicine Medical Center Blvd Winston-Salem, NC, 27157 ()
| | | | - Stacey O’Neill
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ryan T Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Shadi Qasem
- Department of Pathology, Kentucky School of Medicine, Lexington, Kentucky
| | - Roy E Strowd
- Department of Medicine (Hematology and Oncology), Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Cristina Furdui
- Department of Molecular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Konousuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Lance D Miller
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Waldemar Debinski
- Department of Cancer Biology, Brain Tumor Center of Excellence, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Stephen Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Linda Metheny-Barlow
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jaclyn J White
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jingyun Lee
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Emory R McTyre
- Department of Radiation Oncology, Greenville Health System Cancer Institute, Greenville, South Carolina
| | - Adrian Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jing Su
- Department of Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael H Soike
- Department of Radiation Oncology, Hazelrig-Salter Radiation Oncology Center, University of Alabama at Birmingham, Birmingham, Alabama
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9
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Rogers SJ, Lomax N, Alonso S, Lazeroms T, Riesterer O. Radiosurgery for Five to Fifteen Brain Metastases: A Single Centre Experience and a Review of the Literature. Front Oncol 2022; 12:866542. [PMID: 35619914 PMCID: PMC9128547 DOI: 10.3389/fonc.2022.866542] [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: 01/31/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose Stereotactic radiosurgery (SRS) is now mainstream for patients with 1-4 brain metastases however the management of patients with 5 or more brain metastases remains controversial. Our aim was to evaluate the clinical outcomes of patients with 5 or more brain metastases and to compare with published series as a benchmarking exercise. Methods Patients with 5 or more brain metastases treated with a single isocentre dynamic conformal arc technique on a radiosurgery linac were identified from the institutional database. Endpoints were local control, distant brain failure, leptomeningeal disease and overall survival. Dosimetric data were extracted from the radiosurgery plans. Series reporting outcomes following SRS for multiple brain metastases were identified by a literature search. Results 36 patients, of whom 35 could be evaluated, received SRS for 5 or more brain metastases between February 2015 and October 2021. 25 patients had 5-9 brain metastases (group 1) and 10 patients had 10-15 brain metastases (group 2). The mean number of brain metastases in group 1 was 6.3 (5-9) and 12.3 (10-15) in group 2. The median cumulative irradiated volume was 4.6 cm3 (1.25-11.01) in group 1 and 7.2 cm3 (2.6-11.1) in group 2. Median follow-up was 12 months. At last follow-up, local control rates per BM were 100% and 99.8% as compared with a median of 87% at 1 year in published series. Distant brain failure was 36% and 50% at a median interval of 5.2 months and 7.4 months after SRS in groups 1 and 2 respectively and brain metastasis velocity at 1 year was similar in both groups (9.7 and 11). 8/25 patients received further SRS and 7/35 patients received whole brain radiotherapy. Median overall survival was 10 months in group 1 and 15.7 months in group 2, which compares well with the 7.5 months derived from the literature. There was one neurological death in group 2, leptomeningeal disease was rare (2/35) and there were no cases of radionecrosis. Conclusion With careful patient selection, overall survival following SRS for multiple brain metastases is determined by the course of the extracranial disease. SRS is an efficacious and safe modality that can achieve intracranial disease control and should be offered to patients with 5 or more brain metastases and a constellation of good prognostic factors.
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Affiliation(s)
- Susanne J Rogers
- Radiation Oncology Center KSA-KSB, Canton Hospital Aarau, Aarau, Switzerland
| | - Nicoletta Lomax
- Radiation Oncology Center KSA-KSB, Canton Hospital Aarau, Aarau, Switzerland
| | - Sara Alonso
- Radiation Oncology Center KSA-KSB, Canton Hospital Aarau, Aarau, Switzerland
| | - Tessa Lazeroms
- Radiation Oncology Center KSA-KSB, Canton Hospital Aarau, Aarau, Switzerland
| | - Oliver Riesterer
- Radiation Oncology Center KSA-KSB, Canton Hospital Aarau, Aarau, Switzerland
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10
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Dohm AE, Oliver DE, Michael Yu HH, Ahmed KA. Commentary: From Postoperative to Preoperative: A Case Series of Hypofractionated and Single-Fraction Neoadjuvant Stereotactic Radiosurgery for Brain Metastases. Oper Neurosurg (Hagerstown) 2022; 22:e283-e284. [DOI: 10.1227/ons.0000000000000187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 11/19/2022] Open
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11
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Lowe SR, Wang CP, Brisco A, Whiting J, Arrington J, Ahmed K, Yu M, Robinson T, Oliver D, Etame A, Tran N, Beer Furlan A, Sahebjam S, Mokhtari S, Piña Y, Macaulay R, Forsyth P, Vogelbaum MA, Liu JKC. Surgical and anatomic factors predict development of leptomeningeal disease in patients with melanoma brain metastases. Neuro Oncol 2022; 24:1307-1317. [PMID: 35092434 PMCID: PMC9340645 DOI: 10.1093/neuonc/noac023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Leptomeningeal disease (LMD) is a devastating complication of systemic malignancy, of which there is an unclear etiology. The aim of this study is to determine if surgical or anatomic factors can predict LMD in patients with metastatic melanoma. METHODS A retrospective chart review was performed of 1162 patients treated at single institution for melanoma brain metastases (MBM). Patients with fewer than 3 months follow-up or lacking appropriate imaging were excluded. Demographic information, surgical, and anatomic data were collected. RESULTS Eight hundred and twenty-seven patients were included in the final review. On multivariate analysis for the entire cohort, female gender, dural-based and intraventricular metastasis, and tumor bordering CSF spaces were associated with increased risk of LMD. Surgical resection was not significant for risk of LMD. On multivariate analysis of patients who have undergone surgical resection of a metastatic tumor, dural-based and intraventricular metastasis, ventricular entry during surgery, and metastasis in the infratentorial space were associated with increased risk of LMD. On multivariate analysis of patients who did not undergo surgery, chemotherapy after initial diagnosis and metastasis bordering CSF spaces were associated with increased risk of LMD. CONCLUSION In a single-institution cohort of MBM, we found that surgical resection alone did not result in an increased risk of LMD. Anatomical factors such as dural-based and intraventricular metastasis were significant for developing LMD, as well as entry into a CSF space during surgical resection. These data suggest a strong correlation between anatomic location and tumor cell seeding in relation to the development of LMD.
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Affiliation(s)
- Stephen R Lowe
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Christopher P Wang
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Amanda Brisco
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Junmin Whiting
- Department of Biostatistics & Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - John Arrington
- Department of Radiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Kamran Ahmed
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Michael Yu
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Timothy Robinson
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Daniel Oliver
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Arnold Etame
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Nam Tran
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Andre Beer Furlan
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Solmaz Sahebjam
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Sepideh Mokhtari
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Yolanda Piña
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Robert Macaulay
- Department of Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Peter Forsyth
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Michael A Vogelbaum
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - James K C Liu
- Corresponding Author: James K. C. Liu, MD, Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA ()
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12
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Ganz JC. Cerebral metastases. PROGRESS IN BRAIN RESEARCH 2022; 268:229-258. [PMID: 35074082 DOI: 10.1016/bs.pbr.2021.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Brain metastases are common and deadly. Over the last 25 years GKNS has been established as an invaluable treatment. It may be used as a primary treatment or after either surgery or WBRT. Patients are assessed using one of a number of available scales. GKNS may be repeated for new metastases and for unresponsive tumors. Prescription doses are usually between 18 and 20Gy. The use of advanced MR techniques to highlight sensitive structures like the hippocampi have extended the efficacy of the treatment. More recently GKNS has been used with different target therapies with improved results. More recently frameless treatments have become more popular in this group of very sick patients. GKNS controls tumors in between 80% and over 95% of cases and may even be used for brainstem tumors.
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Affiliation(s)
- Jeremy C Ganz
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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13
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Mitchell D, Kwon HJ, Kubica PA, Huff WX, O’Regan R, Dey M. Brain metastases: An update on the multi-disciplinary approach of clinical management. Neurochirurgie 2022; 68:69-85. [PMID: 33864773 PMCID: PMC8514593 DOI: 10.1016/j.neuchi.2021.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/16/2021] [Accepted: 04/03/2021] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Brain metastasis (BM) is the most common malignant intracranial neoplasm in adults with over 100,000 new cases annually in the United States and outnumbering primary brain tumors 10:1. OBSERVATIONS The incidence of BM in adult cancer patients ranges from 10-40%, and is increasing with improved surveillance, effective systemic therapy, and an aging population. The overall prognosis of cancer patients is largely dependent on the presence or absence of brain metastasis, and therefore, a timely and accurate diagnosis is crucial for improving long-term outcomes, especially in the current era of significantly improved systemic therapy for many common cancers. BM should be suspected in any cancer patient who develops new neurological deficits or behavioral abnormalities. Gadolinium enhanced MRI is the preferred imaging technique and BM must be distinguished from other pathologies. Large, symptomatic lesion(s) in patients with good functional status are best treated with surgery and stereotactic radiosurgery (SRS). Due to neurocognitive side effects and improved overall survival of cancer patients, whole brain radiotherapy (WBRT) is reserved as salvage therapy for patients with multiple lesions or as palliation. Newer approaches including multi-lesion stereotactic surgery, targeted therapy, and immunotherapy are also being investigated to improve outcomes while preserving quality of life. CONCLUSION With the significant advancements in the systemic treatment for cancer patients, addressing BM effectively is critical for overall survival. In addition to patient's performance status, therapeutic approach should be based on the type of primary tumor and associated molecular profile as well as the size, number, and location of metastatic lesion(s).
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Affiliation(s)
- D Mitchell
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - HJ Kwon
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - PA Kubica
- Department of Neurosurgery, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA
| | - WX Huff
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - R O’Regan
- Department of Medicine/Hematology Oncology, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA
| | - M Dey
- Department of Neurosurgery, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA,Correspondence Should Be Addressed To: Mahua Dey, MD, University of Wisconsin School of Medicine & Public Health, 600 Highland Ave, Madison, WI 53792; Tel: 317-274-2601;
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14
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Tewarie IA, Jessurun CAC, Hulsbergen AFC, Smith TR, Mekary RA, Broekman MLD. Leptomeningeal disease in neurosurgical brain metastases patients: A systematic review and meta-analysis. Neurooncol Adv 2021; 3:vdab162. [PMID: 34859226 PMCID: PMC8633671 DOI: 10.1093/noajnl/vdab162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Leptomeningeal disease (LMD) is a complication distinguished by progression of metastatic disease into the leptomeninges and subsequent spread via cerebrospinal fluid (CSF). Although treatments for LMD exist, it is considered fatal with a median survival of 2–4 months. A broader overview of the risk factors that increase the brain metastasis (BM) patient's risk of LMD is needed. This meta-analysis aimed to systematically review and quantitatively assess risk factors for LMD after surgical resection for BM. Methods A systematic literature search was performed on 7 May 2021. Pooled effect sizes were calculated using a random-effects model for variables reported by three or more studies. Results Among 503 studies, thirteen studies met the inclusion criteria with a total surgical sample size of 2105 patients, of which 386 patients developed LMD. The median incidence of LMD across included studies was 16.1%. Eighteen unique risk factors were reported as significantly associated with LMD occurrence, including but not limited to: larger tumor size, infratentorial BM location, proximity of BM to cerebrospinal fluid spaces, ventricle violation during surgery, subtotal or piecemeal resection, and postoperative stereotactic radiosurgery. Pooled results demonstrated that breast cancer as the primary tumor location (HR = 2.73, 95% CI: 2.12–3.52) and multiple BMs (HR = 1.37, 95% CI: 1.18–1.58) were significantly associated with a higher risk of LMD occurrence. Conclusion Breast cancer origin and multiple BMs increase the risk of LMD occurrence after neurosurgery. Several other risk factors which might play a role in LMD development were also identified.
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Affiliation(s)
- Ishaan Ashwini Tewarie
- Department of Neurosurgery, Computational Neuroscience Outcomes Center (CNOC), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Leiden University Medical Center, Leiden, Zuid-Holland, the Netherlands.,Department of Neurosurgery, Haaglanden Medical Center, The Hague, Zuid-Holland, the Netherlands
| | - Charissa A C Jessurun
- Department of Neurosurgery, Computational Neuroscience Outcomes Center (CNOC), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Leiden University Medical Center, Leiden, Zuid-Holland, the Netherlands.,Department of Neurosurgery, Haaglanden Medical Center, The Hague, Zuid-Holland, the Netherlands
| | - Alexander F C Hulsbergen
- Department of Neurosurgery, Computational Neuroscience Outcomes Center (CNOC), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Leiden University Medical Center, Leiden, Zuid-Holland, the Netherlands.,Department of Neurosurgery, Haaglanden Medical Center, The Hague, Zuid-Holland, the Netherlands
| | - Timothy R Smith
- Department of Neurosurgery, Computational Neuroscience Outcomes Center (CNOC), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rania A Mekary
- Department of Neurosurgery, Computational Neuroscience Outcomes Center (CNOC), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts, USA
| | - Marike L D Broekman
- Department of Neurosurgery, Computational Neuroscience Outcomes Center (CNOC), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Leiden University Medical Center, Leiden, Zuid-Holland, the Netherlands.,Department of Neurosurgery, Haaglanden Medical Center, The Hague, Zuid-Holland, the Netherlands.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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15
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Leptomeningeal Disease. Hematol Oncol Clin North Am 2021; 36:189-215. [PMID: 34756800 DOI: 10.1016/j.hoc.2021.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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16
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Mollica L, Leli C, Puglisi S, Sardi S, Sottotetti F. Leptomeningeal carcinomatosis and breast cancer: a systematic review of current evidence on diagnosis, treatment and prognosis. Drugs Context 2021; 10:dic-2021-6-6. [PMID: 34745272 PMCID: PMC8552906 DOI: 10.7573/dic.2021-6-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/14/2021] [Indexed: 02/02/2023] Open
Abstract
Leptomeningeal carcinomatosis (LC) is a rare but challenging manifestation of advanced breast cancer with a severe impact on morbidity and mortality. We performed a systematic review of the evidence published over the last two decades, focusing on recent advances in the diagnostic and therapeutic options of LC. Lobular histology and a triple-negative intrinsic subtype are well-known risk factors for LC. Clinical manifestations are diverse and often aspecific. There is no gold standard for LC diagnosis: MRI and cerebrospinal fluid cytology are the most frequently used modalities despite the low accuracy. Current standard of care involves a multimodal strategy including systemic and intrathecal chemotherapy in combination with brain radiotherapy. Intrathecal chemotherapy has been widely used through the years despite the lack of data from randomized controlled trials and conflicting evidence on patient outcomes. No specific chemotherapeutic agent has shown superiority over others for both intrathecal and systemic treatment. Although endocrine therapy was heuristically considered unable to exert significant control on central nervous system metastatic disease, retrospective data suggest a favourable toxicity profile and even a possible positive impact on survival. In recent years, encouraging data on the use of targeted agents has emerged but further research in this field is required. Palliative treatment in the form of whole brain or stereotactic radiotherapy is associated with improvement in clinical manifestations and quality of life, with no proven impact on survival. The most investigated prognostic factors include performance status, non-triple-negative disease and multimodal treatment. Validation of prognostic scores is necessary to aid clinicians in the identification of patient subgroups that are most likely to benefit from an intensive therapeutic approach.
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Affiliation(s)
| | - Claudia Leli
- Division of Medical Oncology, IRCCS-ICS Maugeri, Pavia, Italy
| | - Silvia Puglisi
- Division of Medical Oncology, Ospedale Policlinico San Martino, Genova, Italy
| | - Silvia Sardi
- Department of Anaesthesia and Intensive Care Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Federico Sottotetti
- Division of Medical Oncology, IRCCS-ICS Maugeri, Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
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17
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Lee SY, Lomax N, Berkmann S, Vollmer K, Riesterer O, Bodis S, Rogers S. Successful salvage of recurrent leptomeningeal disease in large cell neuroendocrine lung cancer with stereotactic radiotherapy. Strahlenther Onkol 2021; 197:1143-1147. [PMID: 34459938 DOI: 10.1007/s00066-021-01814-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 07/01/2021] [Indexed: 11/28/2022]
Abstract
A 70-year old male with stage I large cell neuroendocrine carcinoma (LCNEC) of the lung underwent resection of a metachronous 5 cm brain metastasis and received postoperative hypofractionated stereotactic radiotherapy (hfSRT). Five sequential nodular leptomeningeal metastases up to 5.3 cm in diameter were diagnosed on MRI within 10 months and were treated with SRT. Currently the patient has no evidence of intracranial disease 24 months after last irradiation without chemotherapy or whole brain radiotherapy. This is the first report of sustained complete remission of multiple large leptomeningeal metastases achieved with hfSRT, highlighting this brain-sparing approach in selected patients with LCNEC lung cancer.
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Affiliation(s)
- Seok-Yun Lee
- Radio-Onkologie-Zentrum KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland.
| | - Nicoletta Lomax
- Radio-Onkologie-Zentrum KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - Sven Berkmann
- Klinik für Neurochirurgie, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - Kathrin Vollmer
- Klinik für Onkologie, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - Oliver Riesterer
- Radio-Onkologie-Zentrum KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - Stephan Bodis
- Radio-Onkologie-Zentrum KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - Susanne Rogers
- Radio-Onkologie-Zentrum KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
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18
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Ruiz J, Chan M, Strowd RE. Treatment of Leptomeningeal Metastases: New Hammer, the Same Nail. J Thorac Oncol 2021; 16:1244-1246. [PMID: 34304852 DOI: 10.1016/j.jtho.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 06/13/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Jimmy Ruiz
- Section of Hematology and Oncology, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina; Cancer Center, W.G. (Bill) Hefner Veteran Administration Medical Center, Salisbury, North Carolina; Comprehensive Cancer Center at Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.
| | - Michael Chan
- Comprehensive Cancer Center at Wake Forest Baptist Medical Center, Winston-Salem, North Carolina; Department of Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Roy E Strowd
- Comprehensive Cancer Center at Wake Forest Baptist Medical Center, Winston-Salem, North Carolina; Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
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19
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Redmond KJ, De Salles AAF, Fariselli L, Levivier M, Ma L, Paddick I, Pollock BE, Regis J, Sheehan J, Suh J, Yomo S, Sahgal A. Stereotactic Radiosurgery for Postoperative Metastatic Surgical Cavities: A Critical Review and International Stereotactic Radiosurgery Society (ISRS) Practice Guidelines. Int J Radiat Oncol Biol Phys 2021; 111:68-80. [PMID: 33891979 DOI: 10.1016/j.ijrobp.2021.04.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/31/2021] [Accepted: 04/14/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE The purpose of this critical review is to summarize the literature specific to single-fraction stereotactic radiosurgery (SRS) and multiple-fraction stereotactic radiation therapy (SRT) for postoperative brain metastases resection cavities and to present practice recommendations on behalf of the ISRS. METHODS AND MATERIALS The Medline and Embase databases were used to apply the Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach to search for manuscripts reporting SRS/SRT outcomes for postoperative brain metastases tumor bed resection cavities with a search end date of July 20, 2018. Prospective studies, consensus guidelines, and retrospective series that included exclusively postoperative brain metastases and had at minimum 100 patients were considered eligible. RESULTS The Embase search revealed 157 manuscripts, of which 77 were selected for full-text screening. PubMed yielded 55 manuscripts, of which 23 were selected for full text screening. We deemed 8 retrospective series, 1 phase 2 prospective study, 3 randomized controlled trials, and 1 consensus contouring paper appropriate for inclusion. The data suggest that SRS/SRT to surgical cavities with prescription doses of 30 to 50 Gy equivalent effective dose (EQD) 210, 50 to 70 Gy EQD25, and 70 to 90 EQD22 are associated with rates of local control ranging from 60.5% to 91% (median, 80.5%). Randomized data suggest improved local control with single-fraction SRS compared with observation and improved cognitive outcomes compared with whole-brain radiation therapy (WBRT). The toxicity of SRS/SRT in the postoperative setting was limited and is reviewed herein. CONCLUSIONS Although randomized data raise concern for poorer local control after resection cavity SRS than WBRT, these findings may be driven by factors such as conservative prescription doses used in the SRS arm. Retrospective studies suggest high rates of local control after single-fraction SRS and hypofractionated SRT for postoperative brain metastases. With a superior neurocognitive profile and no survival disadvantage to withholding WBRT, the ISRS recommends SRS as first-line treatment for eligible postoperative patients. Emerging data suggest that fractionated SRT may provide superior local control compared with single-fraction SRS, in particular, for large tumor cavity volumes/diameters and potentially for patients with a preoperative diameter greater than 2.5 cm.
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Affiliation(s)
- Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland.
| | | | - Laura Fariselli
- Department of Neurosurgery, Unit of Radiotherapy, Fondazione IRCCS Istituto Neurologico C Besta, Milano, Italy
| | - Marc Levivier
- Neurosurgery Service and Gamma Knife Center Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland; Faculty of Biology and Medicine (FBM), University of Lausanne, Lausanne, Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Ian Paddick
- Medical Physics Ltd, Queen Square Radiosurgery Centre, London, United Kingdom
| | - Bruce E Pollock
- Department of Radiation Oncology and Department of Neurologic Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Jean Regis
- Aix-Marseille University, INSERM, UMR 1106, Timone University Hospital, Functional Neurosurgery and Radiosurgery Department, Marseille, France
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - John Suh
- Department of Radiation Oncology, Taussing Cancer Institute Cleveland Clinic, Cleveland, Ohio
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Canada
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Nguyen TK, Sahgal A, Detsky J, Atenafu EG, Myrehaug S, Tseng CL, Husain Z, Heyn C, Maralani P, Ruschin M, Perry J, Soliman H. Predictors of leptomeningeal disease following hypofractionated stereotactic radiotherapy for intact and resected brain metastases. Neuro Oncol 2021; 22:84-93. [PMID: 31412120 DOI: 10.1093/neuonc/noz144] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The objective was to evaluate the risk and predictors of developing leptomeningeal disease (LMD) in patients with brain metastases treated with 5-fraction hypofractionated stereotactic radiotherapy (HSRT). METHODS Patients treated with HSRT for intact brain metastases and/or surgical cavities were reviewed from a prospectively maintained database. Radiographic patterns of LMD were classified as focal classical, diffuse classical, focal nodular, and diffuse nodular. RESULTS HSRT was delivered, most commonly 30 Gy in 5 fractions, to 320 intracranial lesions (57% intact and 43% surgical cavities) in 235 patients. The median follow-up was 13.4 months (range, 0.8 to 60 mo). LMD developed in 19% of patients with a 1-year LMD rate of 12%. From the diagnosis of LMD, the median overall survival (OS) was 3.8 months (range, 2-20.8 mo). The most common LMD pattern was diffuse nodular (44%). No difference in OS was observed between LMD patterns (P = 0.203). Multivariable analysis identified surgical cavities at significantly higher risk of LMD compared with intact lesions (odds ratio [OR] = 2.30, 95% CI: 1.24, 4.29, P = 0.008). For cavities, radiosensitive tumors (OR = 2.35, 95% CI: 1.04, 5.35, P = 0.041) predicted for LMD, while, for intact metastases, patients receiving treatment with targeted agents or immunotherapy (TA/I) were at lower risk (OR = 0.178, 95% CI: 0.04, 0.79, P = 0.023). CONCLUSIONS Patients who had a brain metastasis resected were at an increased risk of LMD. OS was poor despite treatment of LMD, and no differences in OS based on the pattern of LMD was observed. Treatment with TA/I was observed to be protective against LMD and requires further study.
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Affiliation(s)
- Timothy K Nguyen
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chris Heyn
- Department of Neuroradiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman Maralani
- Department of Neuroradiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - James Perry
- Department of Medicine, Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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21
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Kondoh T, Sonoda T. Treatment Options for Leptomeningeal Metastases of Solid Cancers: Literature Review and Personal Experience. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 128:71-84. [PMID: 34191063 DOI: 10.1007/978-3-030-69217-9_8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Leptomeningeal metastases (LM) may complicate the clinical course of any solid cancer or hematological malignancy. Diagnosis of such cases requires a multifaceted approach, including careful evaluation of the clinical history, detailed neurological examination, advanced imaging studies, and related laboratory data analysis. Therapeutic options for management of LM have not been standardized yet. Conventional intrathecal chemotherapy with or without involved-field fractionated radiotherapy has only modest efficacy, and the prognosis of most patients remains grim. Therefore, development of new, more aggressive multimodal treatment strategies is definitely needed. Immune checkpoint inhibitors-in particular, molecular targeted therapy-have demonstrated promising results in selected groups of patients. There may be an important role for stereotactic radiosurgery as well. Because organization of prospective randomized multi-institutional trials on treatment of LM of solid cancers may be problematic, practical guidelines for optimal therapeutic strategies in such cases should be established on the basis of integrated results of small-scale prospective and retrospective studies.
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Affiliation(s)
- Takeshi Kondoh
- Department of Neurosurgery, Shinsuma General Hospital, Kobe, Japan.
| | - Takashi Sonoda
- Department of Oncology, Meiwa Hospital, Nishinomiya, Japan
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22
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Gutschenritter T, Venur VA, Combs SE, Vellayappan B, Patel AP, Foote M, Redmond KJ, Wang TJC, Sahgal A, Chao ST, Suh JH, Chang EL, Ellenbogen RG, Lo SS. The Judicious Use of Stereotactic Radiosurgery and Hypofractionated Stereotactic Radiotherapy in the Management of Large Brain Metastases. Cancers (Basel) 2020; 13:cancers13010070. [PMID: 33383817 PMCID: PMC7795798 DOI: 10.3390/cancers13010070] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/11/2020] [Accepted: 12/18/2020] [Indexed: 12/31/2022] Open
Abstract
Simple Summary Brain metastases are the most common cause of cancerous brain tumors in adults. Large brain metastases are an especially difficult clinical scenario as patients often have debilitating symptoms from these tumors, and large tumors are more difficult to control with traditional single treatment radiation regimens alone or after surgery. Hypofractionated stereotactic radiotherapy is a novel way to deliver the higher doses of radiation to control large tumors either after surgery (most common), alone (common), or potentially before surgery (uncommon). Herein, we describe how delivering high doses over three or five treatments may improve tumor control and decrease complication rates compared to more traditional single treatment regimens for brain metastases larger than 2 cm in maximum dimension. Abstract Brain metastases are the most common intracranial malignant tumor in adults and are a cause of significant morbidity and mortality for cancer patients. Large brain metastases, defined as tumors with a maximum dimension >2 cm, present a unique clinical challenge for the delivery of stereotactic radiosurgery (SRS) as patients often present with neurologic symptoms that require expeditious treatment that must also be balanced against the potential consequences of surgery and radiation therapy—namely, leptomeningeal disease (LMD) and radionecrosis (RN). Hypofractionated stereotactic radiotherapy (HSRT) and pre-operative SRS have emerged as novel treatment techniques to help improve local control rates and reduce rates of RN and LMD for this patient population commonly managed with post-operative SRS. Recent literature suggests that pre-operative SRS can potentially half the risk of LMD compared to post-operative SRS and that HSRT can improve risk of RN to less than 10% while improving local control when meeting the appropriate goals for biologically effective dose (BED) and dose-volume constraints. We recommend a 3- or 5-fraction regimen in lieu of SRS delivering 15 Gy or less for large metastases or resection cavities. We provide a table comparing the BED of commonly used SRS and HSRT regimens, and provide an algorithm to help guide the management of these challenging clinical scenarios.
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Affiliation(s)
- Tyler Gutschenritter
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA 98195, USA;
| | - Vyshak A. Venur
- Division of Medical Oncology, University of Washington School of Medicine, Seattle, WA 98195, USA;
| | - Stephanie E. Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany;
- Institute for Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
| | - Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute, Singapore 119074, Singapore;
| | - Anoop P. Patel
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA 98195, USA; (A.P.P.); (R.G.E.)
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, University of Queensland, ICON Cancer Care, Brisbane 4072, Australia;
| | - Kristin J. Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, MD 21093, USA;
| | - Tony J. C. Wang
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY 10032, USA;
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Toronto, ON M4N 3M5, Canada;
| | - Samuel T. Chao
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA; (S.T.C.); (J.H.S.)
| | - John H. Suh
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA; (S.T.C.); (J.H.S.)
| | - Eric L. Chang
- Department of Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA;
| | - Richard G. Ellenbogen
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA 98195, USA; (A.P.P.); (R.G.E.)
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA 98195, USA;
- Correspondence: ; Tel.: +1-206-598-4100
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23
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Perlow HK, Dibs K, Liu K, Jiang W, Rajappa P, Blakaj DM, Palmer J, Raval RR. Whole-Brain Radiation Therapy Versus Stereotactic Radiosurgery for Cerebral Metastases. Neurosurg Clin N Am 2020; 31:565-573. [PMID: 32921352 DOI: 10.1016/j.nec.2020.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Whole-brain radiation therapy (WBRT) was frequently used to treat brain metastases in the past. Stereotactic radiosurgery (SRS) is now generally preferred to WBRT for patients with limited brain metastases. SRS can also be used to treat extensive brain metastases (>10-15 metastases), and clinical trials are currently comparing WBRT with SRS for extensive disease. SRS may allow for an increased risk of radiation necrosis or leptomeningeal disease dissemination after treatment. Preoperative SRS and multifraction radiotherapy decrease the risk of these side effects and may soon become standard of care. Combining SRS with immune checkpoint inhibitors may improve patient outcomes.
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Affiliation(s)
- Haley K Perlow
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA
| | - Khaled Dibs
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA
| | - Kevin Liu
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA
| | - William Jiang
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA
| | - Prajwal Rajappa
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA; Department of Neurological Surgery, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Dukagjin M Blakaj
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA
| | - Joshua Palmer
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA
| | - Raju R Raval
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA.
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24
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El Shafie RA, Dresel T, Weber D, Schmitt D, Lang K, König L, Höne S, Forster T, von Nettelbladt B, Eichkorn T, Adeberg S, Debus J, Rieken S, Bernhardt D. Stereotactic Cavity Irradiation or Whole-Brain Radiotherapy Following Brain Metastases Resection-Outcome, Prognostic Factors, and Recurrence Patterns. Front Oncol 2020; 10:693. [PMID: 32477942 PMCID: PMC7232539 DOI: 10.3389/fonc.2020.00693] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 04/14/2020] [Indexed: 12/27/2022] Open
Abstract
Introduction: Following the resection of brain metastases (BM), whole-brain radiotherapy (WBRT) is a long-established standard of care. Its position was recently challenged by the less toxic single-session radiosurgery (SRS) or fractionated stereotactic radiotherapy (FSRT) of the resection cavity, reducing dose exposure of the healthy brain. Patients and Methods: We analyzed 101 patients treated with either SRS/FSRT (n = 50) or WBRT (n = 51) following BM resection over a 5-year period. Propensity score adjustment was done for age, total number of BM, timepoint of BM diagnosis, controlled primary and extracranial metastases. A Cox Proportional Hazards model with univariate and multivariate analysis was fitted for overall survival (OS), local control (LC) and distant brain control (DBC). Results: Median patient age was 61 (interquartile range, IQR: 56-67) years and the most common histology was non-small cell lung cancer, followed by breast cancer. 38% of the patients had additional unresected BM. Twenty-four patients received SRS, 26 patients received FSRT and 51 patients received WBRT. Median OS in the SRS/FSRT subgroup was not reached (IQR NA-16.7 months) vs. 12.6 months (IQR 21.3-4.4) in the WBRT subgroup (hazard ratio, HR 3.3, 95%-CI: [1.5; 7.2] p < 0.002). Twelve-months LC-probability was 94.9% (95%-CI: [88.3; 100.0]) in the SRS subgroup vs. 81.7% (95%-CI: [66.6; 100.0]) in the WBRT subgroup (HR 0.2, 95%-CI: [0.01; 0.9] p = 0.037). Twelve-months DBC-probabilities were 65.0% (95%-CI: [50.8; 83.0]) and 58.8% (95%-CI: [42.9; 80.7]), respectively (HR 1.4, 95%-CI: [0.7; 2.7] p = 0.401). In propensity score-adjusted multivariate analysis, incomplete resection negatively impacted OS (HR 3.9, 95%-CI: [2.0;7.4], p < 0.001) and LC (HR 5.4, 95%-CI: [1.3; 21.9], p = 0.018). Excellent clinical performance (HR 0.4, 95%-CI: [0.2; 0.9], p = 0.030) and better graded prognostic assessment (GPA) score (HR 0.4, 95%-CI: [0.2; 1.0], p = 0.040) were prognostic of superior OS. A higher number of BM was associated with a greater risk of developing new distant BM (HR 5.6, 95%-CI: [1.0; 30.4], p = 0.048). In subgroup analysis, larger cavity volume (HR 1.1, 95%-CI: [1.0; 1.3], p = 0.033) and incomplete resection (HR 12.0, 95%-CI: [1.2; 118.3], p = 0.033) were associated with inferior LC following SRS/FSRT. Conclusion: This is the first propensity score-adjusted direct comparison of SRS/FSRT and WBRT following the resection of BM. Patients receiving SRS/FSRT showed longer OS and LC compared to WBRT. Future analyses will address the optimal choice of safety margin, dose and fractionation for postoperative stereotactic RT of the resection cavity.
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Affiliation(s)
- Rami A El Shafie
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Thorsten Dresel
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Dorothea Weber
- Institute of Medical Biometry and Informatics (IMBI), Heidelberg University Hospital, Heidelberg, Germany
| | - Daniela Schmitt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Kristin Lang
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Simon Höne
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Tobias Forster
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Bastian von Nettelbladt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Tanja Eichkorn
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Sebastian Adeberg
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology (E050), German Cancer Research Center (dkfz), Heidelberg, Germany.,Deutsches Konsortium Für Translationale Krebsforschung (DKTK), Partner Site Heidelberg, German Cancer Research Center (dkfz), Heidelberg, Germany.,Heidelberger Ionenstrahltherapie-Zentrum (HIT), Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Radiation Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
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25
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Brown DA, Lu VM, Himes BT, Burns TC, Quiñones-Hinojosa A, Chaichana KL, Parney IF. Breast brain metastases are associated with increased risk of leptomeningeal disease after stereotactic radiosurgery: a systematic review and meta-analysis. Clin Exp Metastasis 2020; 37:341-352. [DOI: 10.1007/s10585-020-10019-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 01/06/2020] [Indexed: 12/18/2022]
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26
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Turner BE, Prabhu RS, Burri SH, Brown PD, Pollom EL, Milano MT, Weiss SE, Iv M, Fischbein N, Soliman H, Lo SS, Chao ST, Cox BW, Murphy JD, Li G, Gephart MH, Nagpal S, Atalar B, Azoulay M, Thomas R, Tillman G, Durkee BY, Shah JL, Soltys SG. Nodular Leptomeningeal Disease-A Distinct Pattern of Recurrence After Postresection Stereotactic Radiosurgery for Brain Metastases: A Multi-institutional Study of Interobserver Reliability. Int J Radiat Oncol Biol Phys 2019; 106:579-586. [PMID: 31605786 DOI: 10.1016/j.ijrobp.2019.10.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 09/25/2019] [Accepted: 10/01/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE For brain metastases, surgical resection with postoperative stereotactic radiosurgery is an emerging standard of care. Postoperative cavity stereotactic radiosurgery is associated with a specific, underrecognized pattern of intracranial recurrence, herein termed nodular leptomeningeal disease (nLMD), which is distinct from classical leptomeningeal disease. We hypothesized that there is poor consensus regarding the definition of LMD, and that a formal, self-guided training module will improve interrater reliability (IRR) and validity in diagnosing LMD. METHODS AND MATERIALS Twenty-two physicians at 16 institutions, including 15 physicians with central nervous system expertise, completed a 2-phase survey that included magnetic resonance imaging and treatment information for 30 patients. In the "pretraining" phase, physicians labeled cases using 3 patterns of recurrence commonly reported in prospective studies: local recurrence (LR), distant parenchymal recurrence (DR), and LMD. After a self-directed training module, participating physicians completed the "posttraining" phase and relabeled the 30 cases using the 4 following labels: LR, DR, classical leptomeningeal disease, and nLMD. RESULTS IRR increased 34% after training (Fleiss' Kappa K = 0.41 to K = 0.55, P < .001). IRR increased most among non-central nervous system specialists (+58%, P < .001). Before training, IRR was lowest for LMD (K = 0.33). After training, IRR increased across all recurrence subgroups and increased most for LMD (+67%). After training, ≥27% of cases initially labeled LR or DR were later recognized as nLMD. CONCLUSIONS This study highlights the large degree of inconsistency among clinicians in recognizing nLMD. Our findings demonstrate that a brief self-guided training module distinguishing nLMD can significantly improve IRR across all patterns of recurrence, and particularly in nLMD. To optimize outcomes reporting, prospective trials in brain metastases should incorporate central imaging review and investigator training.
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Affiliation(s)
- Brandon E Turner
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California
| | - Roshan S Prabhu
- Southeast Radiation Oncology Group, Charlotte, North Carolina; Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Stuart H Burri
- Southeast Radiation Oncology Group, Charlotte, North Carolina; Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California
| | | | | | - Michael Iv
- Department of Neuroimaging and Neurointervention, Stanford University, Stanford, California
| | - Nancy Fischbein
- Department of Neuroimaging and Neurointervention, Stanford University, Stanford, California
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Samuel T Chao
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Brett W Cox
- Department of Radiation Medicine, Northwell Health, New York, New York
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California
| | - Gordon Li
- Department of Neurosurgery, Stanford School of Medicine, Stanford, California
| | | | - Seema Nagpal
- Department of Neurology, Stanford University, Stanford, California
| | - Banu Atalar
- Department of Radiation Oncology, Acibadem University School of Medicine, Istanbul, Turkey
| | - Melissa Azoulay
- Department of Radiation Oncology, McGill University Health Center, Montreal, Canada
| | - Reena Thomas
- Department of Neurology, Stanford University, Stanford, California
| | - Gayle Tillman
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ben Y Durkee
- Department of Radiation Oncology, SwedishAmerican, Rockford, Illinois
| | - Jennifer L Shah
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California.
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27
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Prabhu RS, Turner BE, Asher AL, Marcrom SR, Fiveash JB, Foreman PM, Press RH, Patel KR, Curran WJ, Breen WG, Brown PD, Jethwa KR, Grills IS, Arden JD, Foster LM, Manning MA, Stern JD, Soltys SG, Burri SH. A multi-institutional analysis of presentation and outcomes for leptomeningeal disease recurrence after surgical resection and radiosurgery for brain metastases. Neuro Oncol 2019; 21:1049-1059. [PMID: 30828727 PMCID: PMC6682204 DOI: 10.1093/neuonc/noz049] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Radiographic leptomeningeal disease (LMD) develops in up to 30% of patients following postoperative stereotactic radiosurgery (SRS) for brain metastases. However, the clinical relevancy of this finding and outcomes after various salvage treatments are not known. METHODS Patients with brain metastases, of which 1 was resected and treated with adjunctive SRS, and who subsequently developed LMD were combined from 7 tertiary care centers. LMD pattern was categorized as nodular (nLMD) or classical ("sugarcoating," cLMD). RESULTS The study cohort was 147 patients. Most patients (60%) were symptomatic at LMD presentation, with cLMD more likely to be symptomatic than nLMD (71% vs. 51%, P = 0.01). Salvage therapy was whole brain radiotherapy (WBRT) alone (47%), SRS (27%), craniospinal radiotherapy (RT) (10%), and other (16%), with 58% receiving a WBRT-containing regimen. WBRT was associated with lower second LMD recurrence compared with focal RT (40% vs 68%, P = 0.02). Patients with nLMD had longer median overall survival (OS) than those with cLMD (8.2 vs 3.3 mo, P < 0.001). On multivariable analysis for OS, pattern of initial LMD (nodular vs classical) was significant, but type of salvage RT (WBRT vs focal) was not. CONCLUSIONS Nodular LMD is a distinct pattern of LMD associated with postoperative SRS that is less likely to be symptomatic and has better OS outcomes than classical "sugarcoating" LMD. Although focal RT demonstrated increased second LMD recurrence compared with WBRT, there was no associated OS detriment. Focal cranial RT for nLMD recurrence after surgery and SRS for brain metastases may be a reasonable alternative to WBRT.
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Affiliation(s)
- Roshan S Prabhu
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
- Southeast Radiation Oncology Group, Charlotte, North Carolina
| | - Brandon E Turner
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Anthony L Asher
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | | | - John B Fiveash
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Paul M Foreman
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert H Press
- Winship Cancer Institute of Emory University, Atlanta, Georgia
| | | | - Walter J Curran
- Winship Cancer Institute of Emory University, Atlanta, Georgia
| | | | | | | | | | | | - Lauren M Foster
- Oakland University William Beaumont School of Medicine, Auburn Hills, Michigan
| | | | - Joseph D Stern
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
- Cone Health Cancer Center, Greensboro, North Carolina
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Stuart H Burri
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
- Southeast Radiation Oncology Group, Charlotte, North Carolina
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Pre-Operative Versus Post-Operative Radiosurgery of Brain Metastases-Volumetric and Dosimetric Impact of Treatment Sequence and Margin Concept. Cancers (Basel) 2019; 11:cancers11030294. [PMID: 30832257 PMCID: PMC6468393 DOI: 10.3390/cancers11030294] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/18/2019] [Accepted: 02/25/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Pre-operative radiosurgery (SRS) preceding the resection of brain metastases promises to circumvent limitations of post-operative cavity SRS. It minimizes uncertainties regarding delineation and safety margins and could reduce dose exposure of the healthy brain (HB). METHODS We performed a systematic treatment plan comparison on 24 patients who received post-operative radiosurgery of the resection cavity at our institution. Comparative treatment plans were calculated for hypofractionated stereotactic radiotherapy (7 × 5 Gray (Gy)) in a hypothetical pre-operative (pre-op) and two post-operative scenarios, either with (extended field, post-op-E) or without the surgical tract (involved field, post-op-I). Detailed volumetric comparison of the resulting target volumes was performed, as well as dosimetric comparison focusing on targets and the HB. RESULTS The resection cavity was significantly smaller and different in morphology from the pre-operative lesion, yielding a low Dice Similarity Coefficient (DSC) of 53% (p = 0.019). Post-op-I and post-op-E targets showed high similarity (DSC = 93%), and including the surgical tract moderately enlarged resulting median target size (18.58 ccm vs. 22.89 ccm, p < 0.001). Dosimetric analysis favored the pre-operative treatment setting since it significantly decreased relevant dose exposure of the HB (Median volume receiving 28 Gy: 6.79 vs. 10.79 for pre-op vs. post-op-E, p < 0.001). Dosimetrically, pre-operative SRS is a promising alternative to post-operative cavity irradiation that could furthermore offer practical benefits regarding delineation and treatment planning. Comparative trials are required to evaluate potential clinical advantages of this approach.
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Lanier CM, Hughes R, Ahmed T, LeCompte M, Masters AH, Petty WJ, Ruiz J, Triozzi P, Su J, O'Neill S, Watabe K, Cramer CK, Laxton AW, Tatter SB, Wang G, Whitlow C, Chan MD. Immunotherapy is associated with improved survival and decreased neurologic death after SRS for brain metastases from lung and melanoma primaries. Neurooncol Pract 2019; 6:402-409. [PMID: 31555455 DOI: 10.1093/nop/npz004] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background The effect of immunotherapy on brain metastasis patients remains incompletely understood. Our goal was to evaluate its effect on survival, neurologic death, and patterns of failure after stereotactic radiosurgery (SRS) without prior whole-brain radiation therapy (WBRT) in patients with lung and melanoma primaries metastatic to the brain. Methods We performed a retrospective analysis of 271 consecutive lung or melanoma patients treated with upfront SRS for brain metastases between 2013 and 2018. Of these patients, 101 (37%) received immunotherapy and 170 (63%) did not. Forty-three percent were treated with nivolumab. Thirty-seven percent were treated with pembrolizumab. Fifteen percent were treated with ipilimumab. One percent were treated with a combination of nivolumab and ipilimumab. One percent were treated with atezolizumab. Three percent were treated with another immunotherapy regimen. Survival was estimated by the Kaplan-Meier method and cumulative incidences of neurologic death, and local and distant brain failure were estimated using death as a competing risk. Results The median overall survival (OS) of patients treated with immunotherapy vs without was 15.9 (95% CI: 13.3 to 24.8) vs 6.1 (95% CI: 5.1 to 8.8) months (P < .01). The 1-year cumulative incidence of neurologic death was 9% in patients treated with immunotherapy vs 23% in those treated without (P = .01), while nonneurologic death was not significantly different (29% vs 41%, P = .51). Median brain metastasis velocity (BMV) did not differ between groups, and rates of salvage SRS and WBRT were similar. Conclusions The use of immunotherapy in patients with lung cancer or melanoma metastatic to the brain treated with SRS is associated with improved OS and decreased incidence of neurologic death.
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Affiliation(s)
- Claire M Lanier
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Ryan Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Tamjeed Ahmed
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC
| | - Michael LeCompte
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Adrianna H Masters
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| | - William J Petty
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC
| | - Jimmy Ruiz
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC.,W.G. (Bill) Hefner Veteran Administration Medical Center, Cancer Center, Salisbury, NC
| | - Pierre Triozzi
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC
| | - Jing Su
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Stacy O'Neill
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Kuonosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Christina K Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Ge Wang
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY
| | | | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
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Dohm AE, Hughes R, Wheless W, Lecompte M, Lanier C, Ruiz J, Watabe K, Xing F, Su J, Cramer C, Laxton A, Tatter S, Chan MD. Surgical resection and postoperative radiosurgery versus staged radiosurgery for large brain metastases. J Neurooncol 2018; 140:749-756. [PMID: 30367382 DOI: 10.1007/s11060-018-03008-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 09/20/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The purpose of this study was to retrospectively evaluate the new treatment paradigm of staged stereotactic radiosurgery (SRS) for the treatment of large brain metastases (BM) compared to the standard of surgical resection followed by SRS. METHODS We evaluated 78 patients with large BM treated 2012-2017 with surgical resection and postoperative SRS (surgery + SRS) or staged SRS separated by 1 month. Overall survival (OS) was estimated using the Kaplan Meier method and compared across groups using the log-rank test. Cumulative incidence of neurologic death and local and distant brain failure (LF, DBF) were estimated using competing risk methodology. RESULTS Forty patients were treated with surgery + SRS and 38 patients were treated with staged SRS. Median follow-up was 23.2 months (95% CI 20.5-39.3). Median OS was 13.2 months for staged SRS compared to surgery + SRS 9.7 months (p = 0.53). Cumulative incidence of neurologic death at 1 year was 23% after surgery + SRS, 27% after staged SRS (p = 0.69); cumulative incidence of LF at 1 year was 6% and 8% (p = 0.65) and 1-year DBF was 59% and 21% (p ≤ 0.01). Overall rates of leptomeningeal failure and radiation necrosis were similar between the groups (p = 0.63 and p = 1.0). CONCLUSIONS Though surgery and postoperative SRS is the standard, staged SRS represents an attractive treatment paradigm for treating large BM without sacrificing LC or survival, and potentially decreases DBF. Prospective studies are needed to validate these findings.
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Affiliation(s)
- Ammoren E Dohm
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - Ryan Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - William Wheless
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Michael Lecompte
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Claire Lanier
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Jimmy Ruiz
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Fei Xing
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jing Su
- Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Christina Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Adrian Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Stephen Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
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Prabhu RS, Patel KR, Press RH, Soltys SG, Brown PD, Mehta MP, Asher AL, Burri SH. Preoperative Vs Postoperative Radiosurgery For Resected Brain Metastases: A Review. Neurosurgery 2018; 84:19-29. [DOI: 10.1093/neuros/nyy146] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 03/25/2018] [Indexed: 01/27/2023] Open
Affiliation(s)
- Roshan S Prabhu
- Southeast Radiation Oncology Group, Charlotte, North Carolina
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Kirtesh R Patel
- Department of Radiation Oncology, Yale University, New Haven, Connecticut
| | - Robert H Press
- Department of Radiation Oncology, Emory University and Winship Cancer Institute, Atlanta, Georgia
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Anthony L Asher
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | - Stuart H Burri
- Southeast Radiation Oncology Group, Charlotte, North Carolina
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
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Foreman PM, Jackson BE, Singh KP, Romeo AK, Guthrie BL, Fisher WS, Riley KO, Markert JM, Willey CD, Bredel M, Fiveash JB. Postoperative radiosurgery for the treatment of metastatic brain tumor: Evaluation of local failure and leptomeningeal disease. J Clin Neurosci 2017; 49:48-55. [PMID: 29248376 DOI: 10.1016/j.jocn.2017.12.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 10/23/2017] [Accepted: 12/03/2017] [Indexed: 11/18/2022]
Abstract
In patients undergoing surgical resection of a metastatic brain tumor, whole brain radiation therapy reduces the risk of recurrence and neurologic death. Focal radiation has the potential to mitigate neurocognitive side effects. We present an institutional experience of postoperative radiosurgery for the treatment of brain metastases. A retrospective review of a prospectively maintained institutional radiosurgery database was performed for the years 2005-2015 identifying all adult patients treated with postoperative radiosurgery to the tumor bed. Primary endpoints include local recurrence and postoperative LMD. Kaplan-Meier curves and Cox regression were used to evaluate time to local recurrence and postoperative LMD. Ninety-one patients received adjuvant focal radiation for a brain metastasis. Median radiographic follow-up among patients who had not developed a local failure was 9 months. Of the 91 patients, 20 (22%) developed local recurrence and 32 (35%) experienced postoperative LMD. Freedom from local recurrence and LMD at 1 year was 84% and 69%, respectively. In multivariable models, predictors of local failure included the presence of more than one brain metastasis (HR = 2.65, p = .04) with a preoperative tumor diameter of >3 cm (HR = 4.16, p = .06) trending toward significance. There was a trend to a higher risk of LMD with >1 tumor (HR 2.07, p = .06) and breast cancer (HR 2.37, p = .07). More than one metastasis is an independent predictor of local and leptomeningeal failure following postoperative radiosurgery. The high rate of LMD was likely related to the liberal definition of LMD to include focal dural recurrences.
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Affiliation(s)
- Paul M Foreman
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Bradford E Jackson
- Division of Preventative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Karan P Singh
- Division of Preventative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Andrew K Romeo
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Barton L Guthrie
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Winfield S Fisher
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kristen O Riley
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - James M Markert
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Christopher D Willey
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Markus Bredel
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - John B Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
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Patel KR, Burri SH, Asher AL, Crocker IR, Fraser RW, Zhang C, Chen Z, Kandula S, Zhong J, Press RH, Olson JJ, Oyesiku NM, Wait SD, Curran WJ, Shu HKG, Prabhu RS. Comparing Preoperative With Postoperative Stereotactic Radiosurgery for Resectable Brain Metastases: A Multi-institutional Analysis. Neurosurgery 2017; 79:279-85. [PMID: 26528673 DOI: 10.1227/neu.0000000000001096] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is an increasingly common modality used with surgery for resectable brain metastases (BM). OBJECTIVE To present a multi-institutional retrospective comparison of outcomes and toxicities of preoperative SRS (Pre-SRS) and postoperative SRS (Post-SRS). METHODS We reviewed the records of patients who underwent resection of BM and either Pre-SRS or Post-SRS alone between 2005 and 2013 at 2 institutions. Pre-SRS used a dose-reduction strategy based on tumor size, with planned resection within 48 hours. Cumulative incidence with competing risks was used to determine estimated rates. RESULTS A total of 180 patients underwent surgical resection for 189 BM: 66 (36.7%) underwent Pre-SRS and 114 (63.3%) underwent Post-SRS. Baseline patient characteristics were balanced except for higher rates of performance status 0 (62.1% vs 28.9%, P < .001) and primary breast cancer (27.2% vs 10.5%, P = .010) for Pre-SRS. Pre-SRS had lower median planning target volume margin (0 mm vs 2 mm) and peripheral dose (14.5 Gy vs 18 Gy), but similar gross tumor volume (8.3 mL vs 9.2 mL, P = .85). The median imaging follow-up period was 24.6 months for alive patients. Multivariable analyses revealed no difference between groups for overall survival (P = .1), local recurrence (P = .24), and distant brain recurrence (P = .75). Post-SRS was associated with significantly higher rates of leptomeningeal disease (2 years: 16.6% vs 3.2%, P = .010) and symptomatic radiation necrosis (2 years: 16.4% vs 4.9%, P = .010). CONCLUSION Pre-SRS and Post-SRS for resected BM provide similarly favorable rates of local recurrence, distant brain recurrence, and overall survival, but with significantly lower rates of symptomatic radiation necrosis and leptomeningeal disease in the Pre-SRS cohort. A prospective clinical trial comparing these treatment approaches is warranted. ABBREVIATIONS BM, brain metastasesCI, confidence intervalCTV, clinical target volumeDBR, distant brain recurrenceGTV, gross tumor volumeLC, local controlLMD, leptomeningeal diseaseLR, local recurrenceMVA, multivariable analysisOS, overall survivalPost-SRS, postoperative stereotactic radiosurgeryPre-SRS, preoperative stereotactic radiosurgeryPTV, planning target volumeRN, radiation necrosisSRN, symptomatic radiation necrosisSRS, stereotactic radiosurgeryWBRT, whole-brain radiation therapy.
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Affiliation(s)
- Kirtesh R Patel
- *Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia; ‡Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina; §Carolina Neurosurgery and Spine Associates, Levine Cancer Institute, Charlotte, North Carolina; ¶Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, Georgia; ‖Department of Neurological Surgery, Emory University, Atlanta, Georgia
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Wang EC, Huang AJ, Huang KE, McTyre ER, Lo HW, Watabe K, Metheny-Barlow L, Laxton AW, Tatter SB, Strowd RE, Chan MD, Page BR. Leptomeningeal failure in patients with breast cancer receiving stereotactic radiosurgery for brain metastases. J Clin Neurosci 2017; 43:6-10. [PMID: 28511975 DOI: 10.1016/j.jocn.2017.04.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 04/22/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Prior studies suggest a high incidence of leptomeningeal failure (LMF) in breast cancer metastatic to brain. This study examines breast cancer-specific variables affecting development of LMF and survival after Gamma-Knife Radiosurgery (GKS). METHODS Between 2000-2010, 149 (breast) and 658 other-histology patients were treated with GKS. Hormone/HER2, age, local/distant brain failure, prior craniotomy, and prior whole-brain radiotherapy (WBRT) were assessed. Median follow-up was 54months (range, 0-106). Serial MRI determined local and distant-brain failure and LMF. Statistical analysis with categorical/continuous data comparisons were done with Fisher's-exact, Wilcoxon rank-sum, log-rank tests, and Cox-Proportional Hazard models. RESULTS Of 149 patients, 21 (14%) developed LMF (median time of 11.9months). None of the following predicted for LMF: Her2-status (HR=0.49, p=0.16), hormone-receptor status (HR=1.15, p=0.79), prior craniotomy (HR=1.58, p=0.42), prior WBRT (HR=1.36, p=0.55). Non-significant factors between patients that did (n=21) and did not (n=106) develop LMF included neurologic death (p=0.34) and median survival (8.6 vs 14.2months, respectively). Breast patients who had distant-failure after GKS (65/149; 43.6%) were more likely to later develop LMF (HR 4.2, p=0.005); including 15/65 (23%) patients who had distant-failure and developed LMF. Median time-to-death for patients experiencing LMF was 6.1months (IQR 3.4-7.8) from onset of LMF. Median survival from LMF to death was much longer in breast (6.1months) than in other (1.7months) histologies CONCLUSION: Breast cancer patients had a longer survival after diagnosis of LMF versus other histologies. Neither ER/PR/HER2 status, nor prior surgery or prior WBRT predicted for development of LMF in breast patients.
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Affiliation(s)
- Edina C Wang
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston Salem, NC 27157, USA
| | - Andrew J Huang
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston Salem, NC 27157, USA
| | - Karen E Huang
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston Salem, NC 27157, USA
| | - Emory R McTyre
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston Salem, NC 27157, USA
| | - Hui-Wen Lo
- Department of Cancer Biology, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston Salem, NC 27157, USA
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston Salem, NC 27157, USA
| | - Linda Metheny-Barlow
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston Salem, NC 27157, USA
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston Salem, NC 27157, USA
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston Salem, NC 27157, USA
| | - Roy E Strowd
- Department of Neurology, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston Salem, NC 27157, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston Salem, NC 27157, USA
| | - Brandi R Page
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston Salem, NC 27157, USA.
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Methods and results of local treatment of brain metastases in patients with breast cancer. Contemp Oncol (Pozn) 2017; 20:430-435. [PMID: 28239278 PMCID: PMC5320454 DOI: 10.5114/wo.2016.65601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 10/15/2015] [Indexed: 11/17/2022] Open
Abstract
This article presents methods and results of surgical treatment and radiation therapy of brain metastases in breast cancer patients (brain metastases from breast cancer BMF-BC). Based on the literature data, it was shown that patients with single BMF-BC, aged less than 65 years, with Karnofsky score (KPS) of 70 or more and with cured or controlled extracranial disease are the best candidates to surgical treatment. Irrespective of the extracranial disease control status, there are indications for surgery in patients with symptomatic mass effect (tumour diameter larger than 3 cm) and patients with obstructive hydrocephalus from their BMF-BC. Stereotactic radiosurgery (SRS) has some advantages over surgery, with similar effectiveness: it may be used in the treatment of lesions inaccessible to surgery, the number of lesion is not a limiting factor if each lesion is small (< 3) and adequate doses can be delivered, it is not contraindicated in patients with active extracranial disease, it does not interfere with ongoing systemic treatment, and it does not require general anaesthesia or hospitalisation. A disadvantage of SRS, as compared to whole brain radiotherapy (WBRT), in patients with BMF-BC is the possibility of subsequent development of new lesion in the non-irradiated field. Thus the majority of the BMF-BC patients are not good candidates to surgery or SRS; WBRT alone or combined with a systemic treatment still plays a major role in the treatment of these patients.
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36
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Page BR, Wang EC, White L, McTyre E, Peiffer A, Alistar A, Mu F, Loganathan A, Bourland JD, Laxton AW, Tatter SB, Chan MD. Gamma Knife radiosurgery for brain metastases from gastrointestinal primary. J Med Imaging Radiat Oncol 2017; 61:522-527. [PMID: 28139076 DOI: 10.1111/1754-9485.12584] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 12/11/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION In this study, we assessed clinical outcomes of patients with brain metastases from a gastrointestinal (GI) primary cancer and patterns of failure after stereotactic radiosurgery including failure within the radiosurgical volume, distant failure and leptomeningeal failure (LMF). We also assessed other factors associated with the patients' neurologic and extraneuraxial disease that may affect clinical outcomes. METHODS We reviewed our institutional series of 62 consecutive patients with brain metastases treated with stereotactic radiosurgery, which included 17 patients with oesophageal, 44 patients with colorectal and one patient with anal canal primary. The median marginal dose to the radiosurgery volume was 17 Gy (range 10-24 Gy). Thirteen patients were treated with whole-brain radiotherapy (WBRT) prior to GKS. RESULTS The median dose delivered to the margin of the tumour was 17 Gy (range: 10-24 Gy). The median largest tumour diameter was 2.7 cm (range: 0.60-6.1 cm). The median overall survival (OS) was 7.1 months with a median follow-up of 6.1 months and a range of 0-31.7 months. Freedom from local failure was 86.5% and 62.2% at 6 and 12 months respectively. Freedom from distant failure was 73.2% and 42.2% at 6 and 12 months, respectively, and 40% of patients died of neurologic death. LMF occurred in seven patients, all of whom had colorectal primaries. Multivariate analysis revealed that craniotomy for resection of brain metastasis (HR = 2.63, P < 0.02), an absence of extracranial disease (HR = 2.28, P < 0.03), and prolonged time to distant brain failure (HR = 2.85, P < 0.01) predicted for improved survival. CONCLUSIONS Colorectal cancer metastases tend to have a higher rate of leptomeningeal failure than other types of GI cancer metastases. Radiosurgical management of brain metastases from GI primary represents an acceptable management option. Neurologic death remains problematic.
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Affiliation(s)
- Brandi R Page
- Department of Radiation Oncology and Molecular Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Edina C Wang
- Department of Radiation Oncology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Lance White
- Department of Neurosurgery, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Emory McTyre
- Department of Radiation Oncology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Ann Peiffer
- Department of Radiation Oncology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA.,Brain Tumor Center of Excellence, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Angela Alistar
- Division of Hematology and Oncology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Frank Mu
- Department of Radiation Oncology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
| | | | - John Daniel Bourland
- Department of Radiation Oncology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA.,Brain Tumor Center of Excellence, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA.,Brain Tumor Center of Excellence, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA.,Brain Tumor Center of Excellence, Wake Forest University, Winston-Salem, North Carolina, USA
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37
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Patel KR, Burri SH, Boselli D, Symanowski JT, Asher AL, Sumrall A, Fraser RW, Press RH, Zhong J, Cassidy RJ, Olson JJ, Curran WJ, Shu HKG, Crocker IR, Prabhu RS. Comparing pre-operative stereotactic radiosurgery (SRS) to post-operative whole brain radiation therapy (WBRT) for resectable brain metastases: a multi-institutional analysis. J Neurooncol 2016; 131:611-618. [PMID: 28000105 DOI: 10.1007/s11060-016-2334-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 11/12/2016] [Indexed: 12/11/2022]
Abstract
Pre-operative stereotactic radiosurgery (pre-SRS) has been shown as a viable treatment option for resectable brain metastases (BM). The aim of this study is to compare oncologic outcomes and toxicities for pre-SRS and post-operative WBRT (post-WBRT) for resectable BM. We reviewed records of consecutive patients who underwent resection of BM and either pre-SRS or post-WBRT between 2005 and 2013 at two institutions. Overall survival (OS) was calculated using the Kaplan-Meier method. Cumulative incidence was used for intracranial outcomes. Multivariate analysis (MVA) was performed using the Cox and Fine and Gray models, respectively. Overall, 102 patients underwent surgical resection of BM; 66 patients with 71 lesions received pre-SRS while 36 patients with 42 cavities received post-WBRT. Baseline characteristics were similar except for the pre-SRS cohort having more single lesions (65.2% vs. 38.9%, p = 0.001) and smaller median lesion volume (8.3 cc vs. 15.3 cc, p = 0.006). 1-year OS was similar between cohorts (58% vs. 56%, respectively) (p = 0.43). Intracranial outcomes were also similar (2-year outcomes, pre-SRS vs. post-WBRT): local recurrence: 24.5% vs. 25% (p = 0.81), distant brain failure (DBF): 53.2% vs. 45% (p = 0.66), and leptomeningeal disease (LMD) recurrence: 3.5% vs. 9.0% (p = 0.66). On MVA, radiation cohort was not independently associated with OS or any intracranial outcome. Crude rates of symptomatic radiation necrosis were 5.6 and 0%, respectively. OS and intracranial outcomes were similar for patients treated with pre-SRS or post-WBRT for resected BM. Pre-SRS is a viable alternative to post-WBRT for resected BM. Further confirmatory studies with neuro-cognitive outcomes comparing these two treatment paradigms are needed.
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Affiliation(s)
- Kirtesh R Patel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA.
| | - Stuart H Burri
- Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - Danielle Boselli
- Department of Cancer Biostatistics, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - James T Symanowski
- Department of Cancer Biostatistics, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - Anthony L Asher
- Carolina Neurosurgery and Spine Associates, Levine Cancer Institute, Charlotte, NC, USA
| | - Ashley Sumrall
- Department of Oncology, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - Robert W Fraser
- Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - Robert H Press
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA
| | - Jim Zhong
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA
| | - Richard J Cassidy
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA
| | - Jeffrey J Olson
- Department of Neurosurgery and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Walter J Curran
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA
| | - Hui-Kuo G Shu
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA
| | - Ian R Crocker
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA
| | - Roshan S Prabhu
- Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
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Ha B, Chung SY, Kim YJ, Gwak HS, Chang JH, Lee SH, Park IH, Lee KS, Lee S, Kim TH, Kim DY, Kang SG, Suh CO. Effects of Postoperative Radiotherapy on Leptomeningeal Carcinomatosis or Dural Metastasis after Resection of Brain Metastases in Breast Cancer Patients. Cancer Res Treat 2016; 49:748-758. [PMID: 27809457 PMCID: PMC5512361 DOI: 10.4143/crt.2016.303] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/15/2016] [Indexed: 12/15/2022] Open
Abstract
Purpose In this retrospective study, we compared the incidence of leptomeningeal carcinomatosis or dural metastasis (LMCDM) in patients who received whole brain radiotherapy (WBRT), partial radiotherapy (PRT), or no radiotherapy (RT) following resection of brain metastases from breast cancer. Materials and Methods Fifty-one patients with breast cancer underwent surgical resection for newly diagnosed brain metastases in two institutions between March 2001 and March 2015. Among these, 34 received postoperative WBRT (n=24) or PRT (n=10) and 17 did not. Results With a median follow-up of 12.4 months (range, 2.3 to 83.6 months), 22/51 patients developed LMCDM at a median of 8.6 months (range, 4.8 to 51.2 months) after surgery. The 18-months LMCDM-free survival (LMCDM-FS) rates were 77.5%, 30.0%, and 13.6%, in the WBRT, PRT, and no RT groups, respectively (p=0.013). The presence of a tumor adjacent to cerebrospinal fluid flow and no systemic treatment after treatment for brain metastases were also associated with poor LMCDM-FS rate. Multivariate analysis showed that WBRT compared to PRT (p=0.009) and systemic treatment (p < 0.001) were independently associated with reduced incidence of LMCDM. Conclusion WBRT improved LMCDM-FS rate after resection of brain metastases compared to PRT in breast cancer patients.
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Affiliation(s)
- Boram Ha
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Seung Yeun Chung
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Yeon-Joo Kim
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Ho-Shin Gwak
- Neuro-Oncology Clinic, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hyun Lee
- Department of Neurology, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - In Hae Park
- Center for Breast Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Keun Seok Lee
- Center for Breast Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Seeyoun Lee
- Center for Breast Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Tae Hyun Kim
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dae Yong Kim
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Seok-Gu Kang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Chang-Ok Suh
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
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Cohen-Inbar O, Melmer P, Lee CC, Xu Z, Schlesinger D, Sheehan JP. Leukoencephalopathy in long term brain metastases survivors treated with radiosurgery. J Neurooncol 2016; 126:289-98. [PMID: 26468138 DOI: 10.1007/s11060-015-1962-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/10/2015] [Indexed: 12/28/2022]
Abstract
Brain metastases (BM) develop in 10-30 % of patients. Stereotactic radiosurgery (SRS) was shown to improve local control, and performance status, in certain cohorts of brain metastasis patients. The cumulative neurocognitive effect of numerous SRS sessions remains unknown. Leukoencephalopathy is significant diffuse white matter changes and it usually implies a neurocognitive decline. We report patients with BM who survived >2 years after SRS. Clinical and treatment parameters were analyzed for development of leukoencephalopathy. Multiple parameters as well as leukoencephalopathy grade changes were recorded. The median clinical and radiological follow-up was 42 and 41 months (range 24–115 and 24–115) respectively. The cohort included 92 patients and 704 lesions. The most common malignancies were non-small cell lung carcinoma (44.5 % n = 41), breast adenocarcinoma (23.9 %, n = 22) and melanoma (16.3 %,n = 15). 27.6 % (n = 26) of patients underwent adjuvant WBRT. At last follow up, local tumor control was achieved in 76.3 % (n = 61) of patients and 71.8 % (n = 461) of lesions. Overall prevalence of leukoencephalopathy was 42, 60, 73 and 84 % at 1, 2, 3, and 4 years after SRS. Moderate-severe leukoencephalopathy development was related to an integral dose to skull >3 Joules (p = 0.012) at any radiosurgical treatment and prior WBRT (p<0.042). Leukoencephalopathy incidence was consistently higher in the WBRT + SRS group at each following year of survival from initial SRS. Long-term BM survivors treated with SRS are at progressive risk for developing leukoencephalopathy.Those with a higher BM burden, higher integral SRS dose to the skull, and treatment with WBRT are at increased risk of leukoencephalopathy.
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McKay WH, McTyre ER, Okoukoni C, Alphonse-Sullivan NK, Ruiz J, Munley MT, Qasem S, Lo HW, Xing F, Laxton AW, Tatter SB, Watabe K, Chan MD. Repeat stereotactic radiosurgery as salvage therapy for locally recurrent brain metastases previously treated with radiosurgery. J Neurosurg 2016; 127:148-156. [PMID: 27494815 DOI: 10.3171/2016.5.jns153051] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There are a variety of salvage options available for patients with brain metastases who experience local failure after stereotactic radiosurgery (SRS). These options include resection, whole-brain radiation therapy, laser thermoablation, and repeat SRS. There is little data on the safety and efficacy of repeat SRS following local failure of a prior radiosurgical procedure. This study evaluates the clinical outcomes and dosimetric characteristics of patients who experienced tumor recurrence and were subsequently treated with repeat SRS. METHODS Between 2002 and 2015, 32 patients were treated with repeat SRS for local recurrence of ≥ 1 brain metastasis following initial SRS treatment. The Kaplan-Meier method was used to estimate time-to-event outcomes including overall survival (OS), local failure, and radiation necrosis. Cox proportional hazards analysis was performed for predictor variables of interest for each outcome. Composite dose-volume histograms were constructed for each reirradiated lesion, and these were then used to develop a predictive dosimetric model for radiation necrosis. RESULTS Forty-six lesions in 32 patients were re-treated with a second course of SRS after local failure. A median dose of 20 Gy (range 14-22 Gy) was delivered to the tumor margin at the time of repeat SRS. Local control at 1 year was 79% (95% CI 67%-94%). Estimated 1-year OS was 70% (95% CI 55%-88%). Twelve patients had died at the most recent follow-up, with 8/12 patients experiencing neurological death (as described in Patchell et al.). Eleven of 46 (24%) lesions in 11 separate patients treated with repeat SRS were associated with symptomatic radiation necrosis. Freedom from radiation necrosis at 1 year was 71% (95% CI 57%-88%). Analysis of dosimetric data revealed that the volume of a lesion receiving 40 Gy (V40Gy) was the most predictive factor for the development of radiation necrosis (p = 0.003). The following V40Gy thresholds were associated with 10%, 20%, and 50% probabilities of radiation necrosis, respectively: 0.28 cm3 (95% CI 3%-28%), 0.76 cm3 (95% CI 9%-39%), 1.60 cm3 (95% CI 26%-74%). CONCLUSIONS Repeat SRS appears to be an effective salvage option for patients with brain metastases experiencing local failure following initial SRS treatment. This series demonstrates durable local control and, although rates of radiation necrosis are significant, repeat SRS may be indicated for select cases of local disease recurrence. Because the V40Gy is predictive of radiation necrosis, limiting this value during treatment planning may allow for a reduction in radiation necrosis rates.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Adrian W Laxton
- Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Stephen B Tatter
- Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
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41
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Ozdemir Y, Yildirim BA, Topkan E. Whole brain radiotherapy in management of non-small-cell lung carcinoma associated leptomeningeal carcinomatosis: evaluation of prognostic factors. J Neurooncol 2016; 129:329-35. [PMID: 27306442 DOI: 10.1007/s11060-016-2179-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 06/05/2016] [Indexed: 11/29/2022]
Abstract
To assess the efficacy of whole-brain radiotherapy (WBRT) and prognostic factors in leptomeningeal carcinomatosis (LMC) of non-small-cell lung cancer (NSCLC) patients. WBRT records of 51 LMC patients confined to brain were reviewed. Eligible patients had squamous-cell carcinoma (SCC) or adenocarcinoma, and Eastern Cooperative Oncology Group Performance Status (ECOG PS) 0-3. The WBRT was either 20 or 30 Gray. The primary and secondary objectives were to determine overall survival (OS) and prognostic factors for improved treatment response, respectively. Median age was 53 years (range 39-68), 58.8 % had SCC, 74.5 % had ECOG PS 1-2, and 70.6 % had LMC accompanied by parenchymal brain metastases (BM). The median follow-up was 4.1 months (range 0.7-14.4); all patients died due to disease progression. Median OS was 3.9 months (95 % CI 3.3-4.5) with 6 and 12 month estimates of 19.6 and 5.9 %, respectively. Evaluation of prognostic factors revealed that patients with ECOG 1, longer time to LMC (TT-LMC) from NSCLC diagnosis (>11.3 months), and absence of parenchymal BM had significantly superior OS than those patients with ECOG 2 (p = 0.01) or 3 (p < 0.001), TT-LMC < 11.3 months (p = 0.001), and parenchymal BM (p = 0.012). Median OS of 3.9 months after WBRT appeared to confirm the poor prognosis of LMC. WBRT might be most effective for patients with favorable PS, longer TT-LMC, and no accompanying BM. Therefore, we identified ECOG PS 1, TT-LMC > 11.3 months, and no BM as independent prognosticators for better response to WBRT in NSCLC patients with LMC.
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Affiliation(s)
- Yurday Ozdemir
- Department of Radiation Oncology, Baskent University Adana Medical Faculty, Adana, Turkey.
| | - Berna Akkus Yildirim
- Department of Radiation Oncology, Baskent University Adana Medical Faculty, Adana, Turkey
| | - Erkan Topkan
- Department of Radiation Oncology, Baskent University Adana Medical Faculty, Adana, Turkey
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Johnson MD, Avkshtol V, Baschnagel AM, Meyer K, Ye H, Grills IS, Chen PY, Maitz A, Olson RE, Pieper DR, Krauss DJ. Surgical Resection of Brain Metastases and the Risk of Leptomeningeal Recurrence in Patients Treated With Stereotactic Radiosurgery. Int J Radiat Oncol Biol Phys 2016; 94:537-43. [DOI: 10.1016/j.ijrobp.2015.11.022] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 08/19/2015] [Accepted: 11/13/2015] [Indexed: 11/29/2022]
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43
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Espenel S, Vallard A, Langrand-Escure J, Ben Mrad M, Méry B, Rivoirard R, Moriceau G, Guy JB, Trone JC, Moncharmont C, Wang G, Diao P, Bernichon É, Chanal É, Fournel P, Magné N. [Carcinomatous meningitis: The radiation therapist's point of view]. Cancer Radiother 2016; 20:54-9. [PMID: 26867467 DOI: 10.1016/j.canrad.2015.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 09/09/2015] [Accepted: 09/11/2015] [Indexed: 11/28/2022]
Abstract
Carcinomatous meningitis complicates 5 to 10% of cancers, essentially with breast cancers, lung cancers and melanomas. The incidence probably increased because of therapeutic advances in oncology. Treatment is based on external beam radiotherapy, systemic treatment, intrathecal chemotherapy and supportive care. The aim of this work was to review data on external radiation therapy and carcinomatous meningitis. There are few evidences on the subject, but it is a major topic of interest. A whole brain radiation therapy is indicated in case of brain metastases or clinical encephalitis. Focal radiation therapy is recommended on symptomatic, bulky or obstructive sites. The dose depends on performance status (20 to 40 Gy in five to 20 fractions), volume to treat and available techniques (classic fractionation or hypofractionation via stereotactic radiosurgery). The objective of radiation therapy is to improve quality of life. Association with systemic therapy improves overall survival. Administration of sequential intrathecal chemotherapy may also improve overall survival, but induces more toxicity. The use of new radiotherapy techniques and development of radiosensitizing molecules in patients with good performance status could improve survival in this frequent complication of cancer.
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Affiliation(s)
- S Espenel
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - A Vallard
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - J Langrand-Escure
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - M Ben Mrad
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - B Méry
- Département d'oncologie médicale, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - R Rivoirard
- Département d'oncologie médicale, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - G Moriceau
- Département d'oncologie médicale, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - J-B Guy
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - J-C Trone
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - C Moncharmont
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - G Wang
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - P Diao
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - É Bernichon
- Département d'oncologie médicale, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - É Chanal
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - P Fournel
- Département d'oncologie médicale, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France
| | - N Magné
- Département de radiothérapie, institut de cancérologie Lucien-Neuwirth, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest-en-Jarez cedex, France.
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Trifiletti DM, Romano KD, Xu Z, Reardon KA, Sheehan J. Leptomeningeal disease following stereotactic radiosurgery for brain metastases from breast cancer. J Neurooncol 2015; 124:421-7. [PMID: 26093620 DOI: 10.1007/s11060-015-1854-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 06/17/2015] [Indexed: 11/30/2022]
Abstract
Leptomeningeal disease (LMD) is a highly aggressive and usually rapidly fatal condition. The purpose of this study is to identify clinical factors that can serve to predict for LMD at the time of stereotactic radiosurgery (SRS) for brain metastases from breast carcinoma. We conducted a retrospective review of patients with brain metastases from breast cancer treated with SRS from 1995 to 2014 at our institution. Clinical, radiographic, and dosimetric data were collected. LMD was diagnosed by cerebrospinal fluid (CSF) cytology or MRI demonstrating CSF seeding. Comparative statistical analyses were conducted using Cox proportional hazards regression, binary logistic regression, and/or log-rank test. 126 patients met inclusion criteria. Eighteen patients (14 %) developed LMD following SRS. From the time of SRS, the actuarial rate of LMD at 12 months from diagnosis of brain metastasis was 9 % (11 patients). Active disease in the chest at the time of SRS was associated with development of LMD (p = 0.038). Factors including receptor status, tumor size, number of intra-axial tumors, cystic tumor morphology, prior WBRT, active bone metastases, and active liver metastases were not significantly associated with the development of LMD. In patients with brain metastasis from breast cancer that undergo SRS, there is a relatively low rate of LMD. We found that while tumor hormonal status, bone metastases, and hepatic metastases were not associated with the development of LMD, active lung metastases at SRS was associated with LMD. Further research may help to delineate a causative relationship between metastatic lung disease and LMD.
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Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia Health System, P.O. Box 800383, Charlottesville, VA, 22908, USA.
| | - Kara D Romano
- Department of Radiation Oncology, University of Virginia Health System, P.O. Box 800383, Charlottesville, VA, 22908, USA
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Kelli A Reardon
- Department of Radiation Oncology, University of Virginia Health System, P.O. Box 800383, Charlottesville, VA, 22908, USA
| | - Jason Sheehan
- Department of Radiation Oncology, University of Virginia Health System, P.O. Box 800383, Charlottesville, VA, 22908, USA.,Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
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