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Wang J, Zheng Q, Wang Y, Wang C, Xu S, Ju Z, Pan L, Bai J, Liu Y, Qu B, Dai X. Dosimetric comparison of ZAP-X, Gamma Knife, and CyberKnife stereotactic radiosurgery for single brain metastasis. BMC Cancer 2024; 24:936. [PMID: 39090564 PMCID: PMC11295608 DOI: 10.1186/s12885-024-12710-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 07/26/2024] [Indexed: 08/04/2024] Open
Abstract
PURPOSE To evaluate the dosimetric characteristics of ZAP-X stereotactic radiosurgery (SRS) for single brain metastasis by comparing with two mature SRS platforms. METHODS Thirteen patients with single brain metastasis treated with CyberKnife (CK) G4 were selected retrospectively. The prescription dose for the planning target volume (PTV) was 18-24 Gy for 1-3 fractions. The PTV volume ranged from 0.44 to 11.52 cc.Treatment plans of thirteen patients were replanned using the ZAP-X plan system and the Gamma Knife (GK) ICON plan system with the same prescription dose and organs at risk (OARs) constraints. The prescription dose of PTV was normalized to 70% for both ZAP-X and CK, while it was 50% for GK. The dosimetric parameters of three groups included the plan characteristics (CI, GI, GSI, beams, MUs, treatment time), PTV (D2, D95, D98, Dmin, Dmean, Coverage), brain tissue (volume of 100%-10% prescription dose irradiation V100%-V10%, Dmean) and other OARs (Dmax, Dmean),all of these were compared and evaluated. All data were read and analyzed with MIM Maestro. One-way ANOVA or a multisample Friedman rank sum test was performed, where p < 0.05 indicated significant differences. RESULTS The CI of GK was significantly lower than that of ZAP-X and CK. Regarding the mean value, ZAP-X had a lower GI and higher GSI, but there was no significant difference among the three groups. The MUs of ZAP-X were significantly lower than those of CK, and the mean value of the treatment time of ZAP-X was significantly shorter than that of CK. For PTV, the D95, D98, and target coverage of CK were higher, while the mean of Dmin of GK was significantly lower than that of CK and ZAP-X. For brain tissue, ZAP-X showed a smaller volume from V100% to V20%; the statistical results of V60% and V50% showed a difference between ZAP-X and GK, while the V40% and V30% showed a significant difference between ZAP-X and the other two groups; V10% and Dmean indicated that GK was better. Excluding the Dmax of the brainstem, right optic nerve and optic chiasm, the mean value of all other OARs was less than 1 Gy. For the brainstem, GK and ZAP-X had better protection, especially at the maximum dose. CONCLUSION For the SRS treating single brain metastasis, all three treatment devices, ZAP-X system, CyberKnife G4 system, and GammaKnife system, could meet clinical treatment requirements. The newly platform ZAP-X could provide a high-quality plan equivalent to or even better than CyberKnife and Gamma Knife, with ZAP-X presenting a certain dose advantage, especially with a more conformal dose distribution and better protection for brain tissue. As the ZAP-X systems get continuous improvements and upgrades, they may become a new SRS platform for the treatment of brain metastasis.
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Affiliation(s)
- Jinyuan Wang
- Department of Radiation Oncology, The First Medical Center of PLA General Hospital, Beijing, 100853, China
| | - Qingzeng Zheng
- Department of Radiotherapy, Beijing Geriatric Hospital, Beijing, 100095, China
| | - Yanping Wang
- Department of Radiation Oncology, Hebei Yizhou Cancer Hospital, Zhuozhou, 072750, China
| | - Chengcheng Wang
- Department of Radiation Oncology, The First Medical Center of PLA General Hospital, Beijing, 100853, China
| | - Shouping Xu
- National Cancer Center, National Clincal Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Zhongjian Ju
- Department of Radiation Oncology, The First Medical Center of PLA General Hospital, Beijing, 100853, China
| | - Longsheng Pan
- Department of Neurosurgery, the First Medical Center of PLA General Hospital, Beijing, 100853, China
| | - Jingmin Bai
- Department of Radiation Oncology, The First Medical Center of PLA General Hospital, Beijing, 100853, China
| | - Yunmo Liu
- Department of Neurosurgery, the First Medical Center of PLA General Hospital, Beijing, 100853, China
| | - Baolin Qu
- Department of Radiation Oncology, The First Medical Center of PLA General Hospital, Beijing, 100853, China.
| | - Xiangkun Dai
- Department of Radiation Oncology, The First Medical Center of PLA General Hospital, Beijing, 100853, China.
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Kanakarajan H, De Baene W, Gehring K, Eekers DBP, Hanssens P, Sitskoorn M. Factors associated with the local control of brain metastases: a systematic search and machine learning application. BMC Med Inform Decis Mak 2024; 24:177. [PMID: 38907265 PMCID: PMC11191176 DOI: 10.1186/s12911-024-02579-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/17/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Enhancing Local Control (LC) of brain metastases is pivotal for improving overall survival, which makes the prediction of local treatment failure a crucial aspect of treatment planning. Understanding the factors that influence LC of brain metastases is imperative for optimizing treatment strategies and subsequently extending overall survival. Machine learning algorithms may help to identify factors that predict outcomes. METHODS This paper systematically reviews these factors associated with LC to select candidate predictor features for a practical application of predictive modeling. A systematic literature search was conducted to identify studies in which the LC of brain metastases is assessed for adult patients. EMBASE, PubMed, Web-of-Science, and the Cochrane Database were searched up to December 24, 2020. All studies investigating the LC of brain metastases as one of the endpoints were included, regardless of primary tumor type or treatment type. We first grouped studies based on primary tumor types resulting in lung, breast, and melanoma groups. Studies that did not focus on a specific primary cancer type were grouped based on treatment types resulting in surgery, SRT, and whole-brain radiotherapy groups. For each group, significant factors associated with LC were identified and discussed. As a second project, we assessed the practical importance of selected features in predicting LC after Stereotactic Radiotherapy (SRT) with a Random Forest machine learning model. Accuracy and Area Under the Curve (AUC) of the Random Forest model, trained with the list of factors that were found to be associated with LC for the SRT treatment group, were reported. RESULTS The systematic literature search identified 6270 unique records. After screening titles and abstracts, 410 full texts were considered, and ultimately 159 studies were included for review. Most of the studies focused on the LC of the brain metastases for a specific primary tumor type or after a specific treatment type. Higher SRT radiation dose was found to be associated with better LC in lung cancer, breast cancer, and melanoma groups. Also, a higher dose was associated with better LC in the SRT group, while higher tumor volume was associated with worse LC in this group. The Random Forest model predicted the LC of brain metastases with an accuracy of 80% and an AUC of 0.84. CONCLUSION This paper thoroughly examines factors associated with LC in brain metastases and highlights the translational value of our findings for selecting variables to predict LC in a sample of patients who underwent SRT. The prediction model holds great promise for clinicians, offering a valuable tool to predict personalized treatment outcomes and foresee the impact of changes in treatment characteristics such as radiation dose.
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Affiliation(s)
- Hemalatha Kanakarajan
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands.
| | - Wouter De Baene
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
| | - Karin Gehring
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Daniëlle B P Eekers
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Patrick Hanssens
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Margriet Sitskoorn
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands.
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3
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Hahnemann L, Krämer A, Fink C, Jungk C, Thomas M, Christopoulos P, Lischalk J, Meis J, Hörner-Rieber J, Eichkorn T, Deng M, Lang K, Paul A, Meixner E, Weykamp F, Debus J, König L. Fractionated stereotactic radiotherapy of intracranial postoperative cavities after resection of brain metastases - Clinical outcome and prognostic factors. Clin Transl Radiat Oncol 2024; 46:100782. [PMID: 38694237 PMCID: PMC11061678 DOI: 10.1016/j.ctro.2024.100782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 04/17/2024] [Accepted: 04/20/2024] [Indexed: 05/04/2024] Open
Abstract
Background and Purpose After surgical resection of brain metastases (BM), radiotherapy (RT) is indicated. Postoperative stereotactic radiosurgery (SRS) reduces the risk of local progression and neurocognitive decline compared to whole brain radiotherapy (WBRT). Aside from the optimal dose and fractionation, little is known about the combination of systemic therapy and postoperative fractionated stereotactic radiotherapy (fSRT), especially regarding tumour control and toxicity. Methods In this study, 105 patients receiving postoperative fSRT with 35 Gy in 7 fractions performed with Cyberknife were retrospectively reviewed. Overall survival (OS), local control (LC) and total intracranial brain control (TIBC) were analysed via Kaplan-Meier method. Cox proportional hazards models were used to identify prognostic factors. Results Median follow-up was 20.8 months. One-year TIBC was 61.6% and one-year LC was 98.6%. Median OS was 28.7 (95%-CI: 16.9-40.5) months. In total, local progression (median time not reached) occurred in 2.0% and in 20.4% radiation-induced contrast enhancements (RICE) of the cavity (after median of 14.3 months) were diagnosed. Absence of extracranial metastases was identified as an independent prognostic factor for superior OS (p = <0.001) in multivariate analyses, while a higher Karnofsky performance score (KPS) was predictive for longer OS in univariate analysis (p = 0.041). Leptomeningeal disease (LMD) developed in 13% of patients. Conclusion FSRT after surgical resection of BM is an effective and safe treatment approach with excellent local control and acceptable toxicity. Further prospective randomized trials are needed to establish standardized therapeutic guidelines.
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Affiliation(s)
- L. Hahnemann
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - A. Krämer
- Department of Radiation Oncology, University Hospital of Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - C. Fink
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - C. Jungk
- Department of Neurosurgery, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - M. Thomas
- Department of Thoracic Oncology, Thoraxklinik and National Center for Tumor Diseases at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Germany
| | - P. Christopoulos
- Department of Thoracic Oncology, Thoraxklinik and National Center for Tumor Diseases at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Germany
| | - J.W. Lischalk
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Health at Long Island, New York, NY, USA
| | - J. Meis
- Institute of Medical Biometry, University of Heidelberg, Im Neuenheimer Feld 130, 69120 Heidelberg, Germany
| | - J. Hörner-Rieber
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - T. Eichkorn
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - M. Deng
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - K. Lang
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - A. Paul
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - E. Meixner
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - F. Weykamp
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - J. Debus
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology (E050), German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - L. König
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
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Fadrus P, Vybihal V, Roskova I, Selingerova I, Smrcka M, Jancalek R, Sana J, Slaby O, Pospisil P, Hynkova L, Garcic J, Belanova R, Kristek J, Sprlakova-Pukova A, Mackerle Z, Juran V, Sova M, Neuman E, Valekova H, Lakomy R, Holanek M, Hrstka R, Svajdova M, Polachova K, Kolouskova I, Slampa P, Kazda T. Adjuvant radiotherapy after brain metastasectomy: analysis of consecutive cohort of 118 patients from real world practice. Rep Pract Oncol Radiother 2024; 29:30-41. [PMID: 39165600 PMCID: PMC11333081 DOI: 10.5603/rpor.99362] [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: 09/23/2023] [Accepted: 01/26/2024] [Indexed: 08/22/2024] Open
Abstract
Background The aim of this retrospective study is to analyze a consecutive cohort of brain metastasis (BM) patients treated off clinical trials through combination of surgery and radiotherapy over the last 15 years in a tertiary neurooncology center. Materials and methods All BM patients operated between 2007-2019 received adjuvant linac-based radiotherapy categorized to whole brain radiotherapy (WBRT) and tumor bed stereotactic radiotherapy. Survival outcomes and local control was analyzed. Results In total, 118 patients were enrolled, those with stereotactic radiotherapy (41%) had better baseline characteristics mirrored in longer overall survival (OS) [18 vs. 7.1 months, p < 0.001; hazard ratio (HR) 0.47, p = 0.004] with median follow-up of 58 months. Cumulative incidence for local, distant, and extracranial control was not significantly different between groups, with 12-month cumulative control of 22% vs. 18%, 44% vs. 29%, and 35% vs. 32% for stereotactic and WBRT group, respectively. WBRT was an independent factor for better distal brain control. Conclusions Real world data demonstrating significantly better overall survival in patients treated with postoperative targeted radiotherapy compared with postoperative WBRT is presented, with no significant difference in cumulative incidence for local or distant brain control. The majority of patients with targeted radiotherapy had a fractionated dose schedule with outcomes comparable to single-dose radiation trials of postoperative targeted radiotherapy.
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Affiliation(s)
- Pavel Fadrus
- Department of Neurosurgery, University Hospital Brno, Czech Republic
- Department of Neurosurgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Vaclav Vybihal
- Department of Neurosurgery, University Hospital Brno, Czech Republic
- Department of Neurosurgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ivana Roskova
- Department of Neurosurgery, University Hospital Brno, Czech Republic
- Department of Neurosurgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Iveta Selingerova
- Research Center for Applied Molecular Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Martin Smrcka
- Department of Neurosurgery, University Hospital Brno, Czech Republic
- Department of Neurosurgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Radim Jancalek
- Department of Neurosurgery, St. Anne’s University Hospital Brno, Brno, Czech Republic
- Department of Neurosurgery, St. Anne’s University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jiri Sana
- Department of Biology, Faculty of Medicine, Central European Institute of Technology, Masaryk University, Brno, Czech Republic
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Ondrej Slaby
- Department of Biology, Faculty of Medicine, Central European Institute of Technology, Masaryk University, Brno, Czech Republic
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Petr Pospisil
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ludmila Hynkova
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jan Garcic
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Renata Belanova
- Department of Radiology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Jan Kristek
- Department of Radiology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Andrea Sprlakova-Pukova
- Department of Radiology and Nuclear Medicine, University Hospital Brno and Masaryk University, Brno, Czech Republic
| | - Zdenek Mackerle
- Department of Neurosurgery, St. Anne’s University Hospital Brno, Brno, Czech Republic
- Department of Neurosurgery, St. Anne’s University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Vilem Juran
- Department of Neurosurgery, University Hospital Brno, Czech Republic
- Department of Neurosurgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Marek Sova
- Department of Neurosurgery, University Hospital Brno, Czech Republic
- Department of Neurosurgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Eduard Neuman
- Department of Neurosurgery, University Hospital Brno, Czech Republic
- Department of Neurosurgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Hana Valekova
- Department of Neurosurgery, St. Anne’s University Hospital Brno, Brno, Czech Republic
- Department of Neurosurgery, St. Anne’s University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Radek Lakomy
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Comprehensive Cancer Care, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Milos Holanek
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Comprehensive Cancer Care, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Roman Hrstka
- Research Center for Applied Molecular Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Michaela Svajdova
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Radiation and Clinical Oncology, General Hospital Rimavska Sobota, Rimavska Sobota, Slovakia
| | - Katerina Polachova
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ivana Kolouskova
- Department of Comprehensive Cancer Care, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Pavel Slampa
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomas Kazda
- Research Center for Applied Molecular Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Waltenberger M, Bernhardt D, Diehl C, Gempt J, Meyer B, Straube C, Wiestler B, Wilkens JJ, Zimmer C, Combs SE. Hypofractionated stereotactic radiotherapy (HFSRT) versus single fraction stereotactic radiosurgery (SRS) to the resection cavity of brain metastases after surgical resection (SATURNUS): study protocol for a randomized phase III trial. BMC Cancer 2023; 23:709. [PMID: 37516835 PMCID: PMC10385881 DOI: 10.1186/s12885-023-11202-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 07/19/2023] [Indexed: 07/31/2023] Open
Abstract
BACKGROUND The brain is a common site for cancer metastases. In case of large and/or symptomatic brain metastases, neurosurgical resection is performed. Adjuvant radiotherapy is a standard procedure to minimize the risk of local recurrence and is increasingly performed as local stereotactic radiotherapy to the resection cavity. Both hypofractionated stereotactic radiotherapy (HFSRT) and single fraction stereotactic radiosurgery (SRS) can be applied in this case. Although adjuvant stereotactic radiotherapy to the resection cavity is widely used in clinical routine and recommended in international guidelines, the optimal fractionation scheme still remains unclear. The SATURNUS trial prospectively compares adjuvant HFSRT with SRS and seeks to detect the superiority of HFSRT over SRS in terms of local tumor control. METHODS In this single center two-armed randomized phase III trial, adjuvant radiotherapy to the resection cavity of brain metastases with HFSRT (6 - 7 × 5 Gy prescribed to the surrounding isodose) is compared to SRS (1 × 12-20 Gy prescribed to the surrounding isodose). Patients are randomized 1:1 into the two different treatment arms. The primary endpoint of the trial is local control at the resected site at 12 months. The trial is based on the hypothesis that HFSRT is superior to SRS in terms of local tumor control. DISCUSSION Although adjuvant stereotactic radiotherapy after resection of brain metastases is considered standard of care treatment, there is a need for further prospective research to determine the optimal fractionation scheme. To the best of our knowledge, the SATURNUS study is the only randomized phase III study comparing different regimes of postoperative stereotactic radiotherapy to the resection cavity adequately powered to detect the superiority of HFSRT regarding local control. TRIAL REGISTRATION The study was retrospectively registered with ClinicalTrials.gov, number NCT05160818, on December 16, 2021. The trial registry record is available on https://clinicaltrials.gov/study/NCT05160818 . The presented protocol refers to version V1.3 from March 21, 2021.
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Affiliation(s)
- Maria Waltenberger
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany.
| | - Denise Bernhardt
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Christian Diehl
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany
| | | | - Benedikt Wiestler
- Institute of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany
| | - Jan J Wilkens
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany
| | - Claus Zimmer
- Institute of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum, Ingolstädter Landstraße 1, 85764, Neuherberg, Germany
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6
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Diehl CD, Giordano FA, Grosu AL, Ille S, Kahl KH, Onken J, Rieken S, Sarria GR, Shiban E, Wagner A, Beck J, Brehmer S, Ganslandt O, Hamed M, Meyer B, Münter M, Raabe A, Rohde V, Schaller K, Schilling D, Schneider M, Sperk E, Thomé C, Vajkoczy P, Vatter H, Combs SE. Opportunities and Alternatives of Modern Radiation Oncology and Surgery for the Management of Resectable Brain Metastases. Cancers (Basel) 2023; 15:3670. [PMID: 37509330 PMCID: PMC10377800 DOI: 10.3390/cancers15143670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Postsurgical radiotherapy (RT) has been early proven to prevent local tumor recurrence, initially performed with whole brain RT (WBRT). Subsequent to disadvantageous cognitive sequalae for the patient and the broad distribution of modern linear accelerators, focal irradiation of the tumor has omitted WBRT in most cases. In many studies, the effectiveness of local RT of the resection cavity, either as single-fraction stereotactic radiosurgery (SRS) or hypo-fractionated stereotactic RT (hFSRT), has been demonstrated to be effective and safe. However, whereas prospective high-level incidence is still lacking on which dose and fractionation scheme is the best choice for the patient, further ablative techniques have come into play. Neoadjuvant SRS (N-SRS) prior to resection combines straightforward target delineation with an accelerated post-surgical phase, allowing an earlier start of systemic treatment or rehabilitation as indicated. In addition, low-energy intraoperative RT (IORT) on the surgical bed has been introduced as another alternative to external beam RT, offering sterilization of the cavity surface with steep dose gradients towards the healthy brain. This consensus paper summarizes current local treatment strategies for resectable brain metastases regarding available data and patient-centered decision-making.
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Affiliation(s)
- Christian D Diehl
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 80336 München, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Anca-L Grosu
- Department of Radiation Oncology, University Medical Center, Medical Faculty, 79106 Freiburg, Germany
| | - Sebastian Ille
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Klaus-Henning Kahl
- Department of Radiation Oncology, University Medical Center Augsburg, 86156 Augsburg, Germany
| | - Julia Onken
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
- Berlin Institute of Health, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- German Cancer Consortium (DKTK), Partner Site Berlin, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, 37075 Göttingen, Germany
- Comprehensive Cancer Center Niedersachsen (CCC-N), 37075 Göttingen, Germany
| | - Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Ehab Shiban
- Department of Neurosurgery, University Medical Center Augsburg, 86156 Augsburg, Germany
| | - Arthur Wagner
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Jürgen Beck
- Department of Neurosurgery, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Stefanie Brehmer
- Department of Neurosurgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Oliver Ganslandt
- Neurosurgical Clinic, Klinikum Stuttgart, 70174 Stuttgart, Germany
| | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Marc Münter
- Department of Radiation Oncology, Klinikum Stuttgart Katharinenhospital, 70174 Stuttgart, Germany
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Veit Rohde
- Department of Neurosurgery, Universitätsmedizin Göttingen, 37075 Göttingen, Germany
| | - Karl Schaller
- Department of Neurosurgery, University of Geneva Medical Center & Faculty of Medicine, 1211 Geneva, Switzerland
| | - Daniela Schilling
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Elena Sperk
- Mannheim Cancer Center, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 80336 München, Germany
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7
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Bettag C, Hussein A, Schatlo B, Barrantes-Freer A, Abboud T, Rohde V, Mielke D. Endoscope-assisted visualization of 5-aminolevulinic acid fluorescence in surgery for brain metastases. J Neurosurg 2022; 137:1650-1655. [PMID: 35535845 DOI: 10.3171/2022.3.jns212301] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 03/08/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Fluorescence-guided resection of cerebral metastases has been proposed as an approach to visualize residual tumor tissue and maximize the extent of resection. Critics have argued that tumor cells at the resection margins might be overlooked under microscopic visualization because of technical limitations. Therefore, an endoscope, which is capable of inducing fluorescence, has been applied with the aim of improving exposure of fluorescent tumor tissue. In this retrospective analysis, authors assessed the utility of endoscope assistance in 5-aminolevulinic acid (5-ALA) fluorescence-guided resection of brain metastases. METHODS Between June 2013 and December 2016, a standard 20-mg/kg dose of 5-ALA was administered 4 hours prior to surgery in 26 patients with suspected single brain metastases. After standard neuronavigated microsurgical tumor resection, a microscope capable of inducing fluorescence was used to examine tumor margins. The authors classified the remaining fluorescence into 3 grades (0 = none, 1 = weak, and 2 = strong). Endoscopic assistance was employed if no or only weak fluorescence was visualized at the resection margins under the microscope. Endoscopically identified fluorescent tissue at the margins was resected and evaluated separately via histological examination to prove or disprove tumor infiltration. RESULTS Under the microscope, weakly fluorescent tissue was seen at the margins of the resection cavity in 15/26 (57.7%) patients. In contrast, endoscopic inspection revealed strongly fluorescent tissue in 22/26 (84.6%) metastases. In 11/26 (42.3%) metastases no fluorescence at the tumor margins was detected by the microscope; however, strong fluorescence was visualized under the endoscope in 7 (63.6%) of these 11 metastases. In the 15 metastases with microscopically weak fluorescence, strong fluorescence was seen when using the endoscope. Neither microscopic nor endoscopic fluorescence was found in 4/26 (15.4%) cases. In the 26 patients, 96 histological specimens were obtained from the margins of the resection cavity. Findings from these specimens were in conjunction with the histopathological findings, allowing identification of metastatic infiltration with a sensitivity of 95.5% and a specificity of 75% using endoscope assistance. CONCLUSIONS Fluorescence-guided endoscope assistance may overcome the technical limitations of the conventional microscopic exposure of 5-ALA-fluorescent metastases and thereby increase visualization of fluorescent tumor tissue at the margins of the resection cavity with high sensitivity and acceptable specificity.
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Affiliation(s)
| | | | | | - Alonso Barrantes-Freer
- 2Paul-Flechsig Institute of Neuropathology, University Medical Center Leipzig; and
- 3Institute of Neuropathology, University Medical Center Göttingen, Germany
| | - Tammam Abboud
- 1Department of Neurosurgery, University Hospital Göttingen
| | - Veit Rohde
- 1Department of Neurosurgery, University Hospital Göttingen
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8
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Deguchi S, Mitsuya K, Yasui K, Kimura K, Onoe T, Ogawa H, Asakura H, Harada H, Hayashi N. Neoadjuvant fractionated stereotactic radiotherapy followed by piecemeal resection of brain metastasis: a case series of 20 patients. Int J Clin Oncol 2022; 27:481-487. [PMID: 34796412 PMCID: PMC8882569 DOI: 10.1007/s10147-021-02083-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 11/10/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The safety and effectiveness of neoadjuvant fractionated stereotactic radiotherapy (FSRT) before piecemeal resection of brain metastasis (BM) remains unknown. METHODS We retrospectively reviewed 20 consecutive patients with BM who underwent neoadjuvant FSRT followed by piecemeal resection between July 2019 and March 2021. The prescribed dose regimens were as follows: 30 Gy (n = 11) or 35 Gy (n = 9) in five fractions. RESULTS The mean follow-up duration was 7.8 months (range 2.2-22.3). The median age was 67 years (range 51-79). Fourteen patients were male. All patients were symptomatic. All tumors were located in the supratentorial compartment. The median maximum diameter and volume were 3.7 cm (range 2.6-4.9) and 17.6 cm3 (range 5.6-49.7), respectively. The median time from the end of FSRT to resection was 4 days (range 1-7). Nausea (CTCAE Grade 2) occurred in one patient and simple partial seizures (Grade 2) in two patients during radiation therapy. Gross total removal was performed in seventeen patients and sub-total removal in three patients. Postoperative complications were deterioration of paresis in two patients. Local recurrence was found in one patient (5.0%) who underwent sub-total resection at 2 months after craniotomy. Distant recurrence was found in six patients (30.0%) at a median of 6.9 months. Leptomeningeal disease recurrence was found in one patient (5.0%) at 3 months. No radiation necrosis developed. CONCLUSIONS Neoadjuvant FSRT appears to be a safe and effective approach for patients with BM requiring piecemeal resection. A multi-institutional prospective trial is needed.
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Affiliation(s)
- Shoichi Deguchi
- Division of Neurosurgery, Shizuoka Cancer Center, 1007, Shimo-nagakubo, Naga-izumi, Shizuoka, 411-8777, Japan
| | - Koichi Mitsuya
- Division of Neurosurgery, Shizuoka Cancer Center, 1007, Shimo-nagakubo, Naga-izumi, Shizuoka, 411-8777, Japan.
| | - Kazuaki Yasui
- Radiation and Proton Therapy Center, Shizuoka Cancer Center, Shizuoka, Japan
| | - Keisuke Kimura
- Division of Neurosurgery, Shizuoka Cancer Center, 1007, Shimo-nagakubo, Naga-izumi, Shizuoka, 411-8777, Japan
| | - Tsuyoshi Onoe
- Radiation and Proton Therapy Center, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hirofumi Ogawa
- Radiation and Proton Therapy Center, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hirofumi Asakura
- Radiation and Proton Therapy Center, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hideyuki Harada
- Radiation and Proton Therapy Center, Shizuoka Cancer Center, Shizuoka, Japan
| | - Nakamasa Hayashi
- Division of Neurosurgery, Shizuoka Cancer Center, 1007, Shimo-nagakubo, Naga-izumi, Shizuoka, 411-8777, Japan
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9
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Gallo J, Garimall S, Shanker M, Castelli J, Watkins T, Olson S, Huo M, Foote MC, Pinkham MB. Outcomes Following Hypofractionated Stereotactic Radiotherapy to the Cavity After Surgery for Melanoma Brain Metastases. Clin Oncol (R Coll Radiol) 2021; 34:179-186. [PMID: 34642065 DOI: 10.1016/j.clon.2021.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 09/05/2021] [Accepted: 09/21/2021] [Indexed: 11/18/2022]
Abstract
AIMS Hypofractionated stereotactic radiotherapy (HSRT) to the cavity after surgical resection of brain metastases improves local control. Most reported cohorts include few patients with melanoma, a population known to have high rates of recurrence and neurological death. We aimed to assess outcomes in patients with melanoma brain metastases who received HSRT after surgery at two Australian institutions. MATERIALS AND METHODS A retrospective analysis was carried out including patients treated between January 2012 and May 2020. HSRT was recommended for patients with melanoma brain metastases at high risk of local recurrence after surgery. Treatment was delivered using appropriately commissioned linear accelerators. Routine follow-up included surveillance magnetic resonance imaging brain every 3 months for at least 2 years. Primary outcomes were overall survival, local control, incidence of radiological radionecrosis and symptomatic radionecrosis. RESULTS There were 63 cavities identified in 57 patients. The most common HSRT dose prescriptions were 24 Gy in three fractions and 27.5 Gy in five fractions. The median follow-up was 32 months in survivors. Local control was 90% at 1 year, 83% at 2 years and 76% at 3 years. Subtotal brain metastases resection (hazard ratio 12.5; 95% confidence interval 1.4-111; P = 0.0238) was associated with more local recurrence. Overall survival was 64% at 1 year, 45% at 2 years and 40% at 3 years. There were 10 radiological radionecrosis events (16% of cavities) during the study period, with 5% at 1 year and 8% at 2 years after HSRT. The median time to onset of radiological radionecrosis was 21 months (range 6-56). Of these events, three became symptomatic (5%) during the study period at a median time to onset of 26 months (range 21-32). CONCLUSION Cavity HSRT is associated with high rates of local control in patients with melanoma brain metastases. Subtotal resection strongly predicts for local recurrence after HSRT. Symptomatic radionecrosis occurred in 5% of cavities but increased to 8% of longer-term survivors.
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Affiliation(s)
- J Gallo
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
| | - S Garimall
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - M Shanker
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Princess Alexandra Hospital Research Foundation, Woolloongabba, Queensland, Australia
| | - J Castelli
- Icon Cancer Centre, Greenslopes Private Hospital, Greenslopes, Queensland, Australia
| | - T Watkins
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - S Olson
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - M Huo
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - M C Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Icon Cancer Centre, Greenslopes Private Hospital, Greenslopes, Queensland, Australia
| | - M B Pinkham
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Icon Cancer Centre, Greenslopes Private Hospital, Greenslopes, Queensland, Australia
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10
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Weiss HK, Pacione DR, Galetta S, Kondziolka D. Prosopagnosia associated with brain metastasis near the inferior longitudinal fasciculus in the nondominant temporal lobe: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21313. [PMID: 35855187 PMCID: PMC9265230 DOI: 10.3171/case21313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/09/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Disruptions of the inferior longitudinal fasciculus (ILF) in the nondominant temporal lobe can lead to the rare but significant higher visual-processing disturbance of prosopagnosia. Here, the authors describe a 57-year-old right hand-dominant female with a large breast cancer brain metastasis in the right temporal lobe who underwent resection and subsequent Gamma Knife radiosurgery. She presented with difficulty with facial recognition, but following surgical intervention, the prosopagnosia became more profound. OBSERVATIONS Even in nondominant cortex, significant deficits can arise when operating near higher visual-processing centers, including the ILF. LESSONS This case highlights the utility of imaging-based tractography obtained from preoperative imaging for resective surgical planning even when operating in areas that do not involve what is traditionally considered elegant areas of the brain. To optimize neurological outcomes in metastatic tumor resection, awareness and diffusion tensor imaging of neighboring, displaced white matter tracts may prevent permanent deficits in higher visual processing.
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11
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Minniti G, Niyazi M, Andratschke N, Guckenberger M, Palmer JD, Shih HA, Lo SS, Soltys S, Russo I, Brown PD, Belka C. Current status and recent advances in resection cavity irradiation of brain metastases. Radiat Oncol 2021; 16:73. [PMID: 33858474 PMCID: PMC8051036 DOI: 10.1186/s13014-021-01802-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 04/07/2021] [Indexed: 12/04/2022] Open
Abstract
Despite complete surgical resection brain metastases are at significant risk of local recurrence without additional radiation therapy. Traditionally, the addition of postoperative whole brain radiotherapy (WBRT) has been considered the standard of care on the basis of randomized studies demonstrating its efficacy in reducing the risk of recurrence in the surgical bed as well as the incidence of new distant metastases. More recently, postoperative stereotactic radiosurgery (SRS) to the surgical bed has emerged as an effective and safe treatment option for resected brain metastases. Published randomized trials have demonstrated that postoperative SRS to the resection cavity provides superior local control compared to surgery alone, and significantly decreases the risk of neurocognitive decline compared to WBRT, without detrimental effects on survival. While studies support the use of postoperative SRS to the resection cavity as the standard of care after surgery, there are several issues that need to be investigated further with the aim of improving local control and reducing the risk of leptomeningeal disease and radiation necrosis, including the optimal dose prescription/fractionation, the timing of postoperative SRS treatment, and surgical cavity target delineation. We provide a clinical overview on current status and recent advances in resection cavity irradiation of brain metastases, focusing on relevant strategies that can improve local control and minimize the risk of radiation-induced toxicity.
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Affiliation(s)
- Giuseppe Minniti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Policlinico Le Scotte, 53100, Siena, Italy. .,IRCCS Neuromed, Pozzilli, IS, Italy.
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital of Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital of Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Joshua D Palmer
- Department of Radiation Oncology, Arthur G. James Cancer Hospital, The Ohio State University, Columbus, OH, USA
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Scott Soltys
- Department of Radiation Oncology, Stanford University, Stanford, CA, USA
| | - Ivana Russo
- Radiation Oncology Unit, University of Pittsburgh Medical Center Hillman Cancer Center, San Pietro Hospital FBF, Rome, and Villa Maria Hospital, Mirabella, AV, Italy
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
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12
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Srivastava SP, Jani SS, Pinnaduwage DS, Yan X, Rogers L, Barranco FD, Barani IJ, Sorensen S. Treatment planning system and beam data validation for the ZAP-X: A novel self-shielded stereotactic radiosurgery system. Med Phys 2021; 48:2494-2510. [PMID: 33506520 DOI: 10.1002/mp.14740] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 12/04/2020] [Accepted: 01/16/2021] [Indexed: 12/16/2022] Open
Abstract
PURPOSE To evaluate the treatment planning system (TPS) performance of the ZAP-X stereotactic radiosurgery (SRS) system through nondosimetric, dosimetric, and end-to-end (E2E) tests. METHODS A comprehensive set of TPS commissioning and validation tests was developed using published guidelines. Nondosimetric validation tests included information transfer, computed tomography-magnetic resonance (CT-MR) image registration, structure/contouring, geometry, dose tools, and CT density. Dosimetric validation included comparisons between TPS and water tank/Solid Water measurements for various geometries and beam arrangements and end-to-end (E2E) tests. Patient-specific quality assurance was performed with an ion chamber in the Lucy phantom and with Gafchromic EBT3 film in the CyberKnife head phantom. RadCalc was used for independent verification of monitor units. Additional E2E tests were performed using the RPC Gamma Knife thermoluminescent dosimeter (TLD) phantom, MD Anderson SRS head phantom, and PseudoPatient gel phantom for independent absolute dose verification. RESULTS CT-MR image registrations with known translational and rotational offsets were within tolerance (<0.5 × maximum voxel dimension). Slice thickness and distance accuracy were within 0.1 mm, and volume accuracy was within 0 to 0.11 cm3 . Treatment planning system volume measurement uncertainty was within 0.1 to 0.4 cm3 . Ion chamber point-dose measurements for a single beam in a water phantom agreed to TPS-calculated values within ±4% for collimator diameters 10 to 25 mm, and ±6% for 7.5 mm, for all measured depths (7, 50, 100, 150, and 200 mm). In homogeneous Solid Water, point-dose measurements agreed to within ±4% for cones sizes 7.5 to 25 mm. With 1-cm high/low density inserts, measurements were within ±4.2% for cone sizes 10 to 25 mm. Film-based E2E using 4/5-mm cones resulted in a gamma passing rate (%GP) of 99.8% (2%/1.5 mm). Point-dose measurements in a Lucy phantom with an ion chamber using 36 beams distributed along three noncoplanar arcs agreed to within ±4% for cone sizes 10 to 25 mm. The RPC Gamma Knife TLD phantom yielded passing results with a measured-to-expected TLD dose ratio of 1.02. The MD Anderson SRS head phantom yielded passing results, with 4% TLD agreement and %GP of 95%/93% (5%/3 mm) for coronal/sagittal film planes. The RTsafe gel phantom gave %GP of >95% (5%/2 mm) for all four targets. For our first 58 patients, film-based patient-specific quality assurance has resulted in an average %GP of 98.7% (range, 94-100%) at 2%/2 mm. CONCLUSIONS Core ZAP-X features were found to be functional. On the basis of our results, point-dose and planar measurements were in agreement with TPS calculations using multiple phantoms and setup geometries, validating the ZAP-X TPS beam model for clinical use.
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Affiliation(s)
- Shiv P Srivastava
- Department of Radiation Oncology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Shyam S Jani
- Department of Radiation Oncology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Dilini S Pinnaduwage
- Department of Radiation Oncology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Xiangsheng Yan
- Department of Radiation Oncology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Leland Rogers
- Department of Radiation Oncology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - F David Barranco
- Department of Radiation Oncology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Igor J Barani
- Department of Radiation Oncology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Stephen Sorensen
- Department of Radiation Oncology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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13
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Teyateeti A, Brown PD, Mahajan A, Laack NN, Pollock BE. Outcome comparison of patients who develop leptomeningeal disease or distant brain recurrence after brain metastases resection cavity radiosurgery. Neurooncol Adv 2021; 3:vdab036. [PMID: 33860228 PMCID: PMC8034660 DOI: 10.1093/noajnl/vdab036] [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: 11/12/2022] Open
Abstract
Background To compare the outcomes between patients with leptomeningeal disease (LMD) and distant brain recurrence (DBR) after stereotactic radiosurgery (SRS) brain metastases (BM) resection cavity. Methods Twenty-nine patients having single-fraction SRS after BM resection who developed either LMD (n = 11) or DBR (n = 18) as their initial and only site of intracranial progression were retrospectively reviewed. Results Patients developing LMD more commonly had a metachronous presentation (91% vs 50%, P = .04) and recursive partitioning class 1 status (45% vs 6%, P = .02). There was no difference in the median time from SRS to the development of LMD or DBR (5.0 vs 3.8 months, P = .68). The majority of patients with LMD (10/11, 91%) developed the nodular variant (nLMD). Treatment for LMD was repeat SRS (n = 4), whole-brain radiation therapy (WBRT; n = 5), resection + WBRT (n = 1), and no treatment (n = 1). Treatment for DBR was repeat SRS (n = 9), WBRT (n = 3), resection + resection cavity SRS (n = 1), and no treatment (n = 5). Median overall survival (OS) from time of resection cavity SRS was 15.7 months in the LMD group and 12.7 months in the DBR group (P = .60), respectively. Median OS in salvage SRS and salvage WBRT were 25.4 and 5.0 months in the nLMD group (P = .004) while 18.7 and 16.2 months in the DBR group (P = .30), respectively. Conclusions Following BM resection cavity SRS, nLMD recurrence is much more frequent than classical LMD. Salvage SRS may be considered for selected patients with nLMD, reserving salvage WBRT for patients with extensive intracranial disease without compromising survival. Further study with larger numbers of patients is needed.
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Affiliation(s)
- Achiraya Teyateeti
- Department of Radiation Oncology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA.,Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Nadia N Laack
- Department of Radiation Oncology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Bruce E Pollock
- Department of Neurologic Surgery, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
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14
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Diamond BH, Jairam V, Zuberi S, Li JY, Marquis TJ, Rutter CE, Park HS. Linear accelerator-based single-fraction stereotactic radiosurgery versus hypofractionated stereotactic radiotherapy for intact and resected brain metastases up to 3 cm: A multi-institutional retrospective analysis. JOURNAL OF RADIOSURGERY AND SBRT 2021; 7:179-187. [PMID: 33898081 PMCID: PMC8055233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 11/24/2020] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Single-fraction stereotactic radiosurgery (SF-SRS) is typically used to provide local control of brain metastases. Recently, hypofractionated stereotactic radiotherapy (HF-SRT) has been utilized for large brain metastases. Data comparing these two modalities are limited for brain metastases ≤3 cm. METHODS Patients with brain metastases receiving linear accelerator-based SF-SRS or HF-SRT were identified at three institutions. Local progression-free survival (LPFS), intracranial progression-free survival (ICPFS), overall survival (OS), and radionecrosis-free survival (RNFS) were determined from time of treatment. RESULTS 108 patients (76 intact, 32 resected) with 184 brain metastases (142 intact, 42 resected) were included. There were no significant differences between SF-SRS and HF-SRT for intact metastases in 1-year LPFS (62.8% vs. 58.5%, p=0.631), ICPFS (56.9% vs. 55.3%, p=0.300), and OS (71.6% vs. 70.6%, p=0.096), or for resected metastases in 1-year LPFS (67.3% vs. 57.8%, p=0.288), ICPFS (64.8% vs. 57%, p=0.291), and OS (64.8% vs. 66.1%, p=0.603). There were also no significant differences in 1-year RNFS between SF-SRS and HF-SRT (92% vs. 92%, p=0.325). CONCLUSIONS There were no significant differences in LPFS, ICPFS, OS, and RNFS between SF-SRS and HF-SRT for brain metastases ≤3 cm suggesting SF-SRS may be preferred due to similar outcomes and reduced number of fractions.
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Affiliation(s)
- Brett H. Diamond
- Tufts University School of Medicine, Department of Radiation Oncology, Boston, MA 02111, USA
| | - Vikram Jairam
- Yale School of Medicine, Department of Therapeutic Radiology, New Haven, CT 06511, USA
| | - Shaharyar Zuberi
- University of Connecticut School of Medicine, Department of Radiation Oncology, Farmington, CT 06032, USA
| | - Jessie Y. Li
- Yale School of Medicine, Department of Therapeutic Radiology, New Haven, CT 06511, USA
| | - Timothy J. Marquis
- Yale School of Medicine, Department of Medicine, New Haven, CT 06511, USA
| | - Charles E. Rutter
- University of Connecticut School of Medicine, Department of Radiation Oncology, Farmington, CT 06032, USA
- Hartford HealthCare, Department of Radiation Oncology, Hartford, CT 06106, USA
| | - Henry S. Park
- Tufts University School of Medicine, Department of Radiation Oncology, Boston, MA 02111, USA
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15
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Eitz KA, Lo SS, Soliman H, Sahgal A, Theriault A, Pinkham MB, Foote MC, Song AJ, Shi W, Redmond KJ, Gui C, Kumar AMS, Machtay M, Meyer B, Combs SE. Multi-institutional Analysis of Prognostic Factors and Outcomes After Hypofractionated Stereotactic Radiotherapy to the Resection Cavity in Patients With Brain Metastases. JAMA Oncol 2020; 6:1901-1909. [PMID: 33057566 PMCID: PMC7563677 DOI: 10.1001/jamaoncol.2020.4630] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/20/2020] [Indexed: 11/14/2022]
Abstract
IMPORTANCE For brain metastases, the combination of neurosurgical resection and postoperative hypofractionated stereotactic radiotherapy (HSRT) is an emerging therapeutic approach preferred to the prior practice of postoperative whole-brain radiotherapy. However, mature large-scale outcome data are lacking. OBJECTIVE To evaluate outcomes and prognostic factors after HSRT to the resection cavity in patients with brain metastases. DESIGN, SETTING, AND PARTICIPANTS An international, multi-institutional cohort study was performed in 558 patients with resected brain metastases and postoperative HSRT treated between December 1, 2003, and October 31, 2019, in 1 of 6 participating centers. Exclusion criteria were prior cranial radiotherapy (including whole-brain radiotherapy) and early termination of treatment. EXPOSURES A median total dose of 30 Gy (range, 18-35 Gy) and a dose per fraction of 6 Gy (range, 5-10.7 Gy) were applied. MAIN OUTCOMES AND MEASURES The primary end points were overall survival, local control (LC), and the analysis of prognostic factors associated with overall survival and LC. Secondary end points included distant intracranial failure, distant progression, and the incidence of neurologic toxicity. RESULTS A total of 558 patients (mean [SD] age, 61 [0.50] years; 301 [53.9%] female) with 581 resected cavities were analyzed. The median follow-up was 12.3 months (interquartile range, 5.0-25.3 months). Overall survival was 65% at 1 year, 46% at 2 years, and 33% at 3 years, whereas LC was 84% at 1 year, 75% at 2 years, and 71% at 3 years. Radiation necrosis was present in 48 patients (8.6%) and leptomeningeal disease in 73 patients (13.1%). Neurologic toxic events according to the Common Terminology Criteria for Adverse Events grade 3 or higher occurred in 16 patients (2.8%) less than 6 months and 24 patients (4.1%) greater than 6 months after treatment. Multivariate analysis identified a Karnofsky Performance Status score of 80% or greater (hazard ratio [HR], 0.61; 95% CI, 0.46-0.82; P < .001), 22 to 33 days between resection and radiotherapy (HR, 1.50; 95% CI, 1.07-2.10; P = .02), and a controlled primary tumor (HR, 0.69; 95% CI, 0.52-0.90; P = .007) as prognostic factors associated with overall survival. For LC, a single brain metastasis (HR, 0.57; 95% CI, 0.35-0.93; P = .03) and a controlled primary tumor (HR, 0.59; 95% CI, 0.39-0.92; P = .02) were significant in the multivariate analysis. CONCLUSIONS AND RELEVANCE To date, this cohort study includes one of the largest series of patients with brain metastases and postoperative HSRT and appears to confirm an excellent risk-benefit profile of local HSRT to the resection cavity. Additional studies will help determine radiation dose-volume parameters and provide a better understanding of synergistic effects with systemic and immunotherapies.
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Affiliation(s)
- Kerstin A. Eitz
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
- Institute for Radiation Medicine (IRM), Helmholtz Zentrum München, Neuherberg, Germany
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington, Seattle
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Aimee Theriault
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mark. B. Pinkham
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Department of Radiation Oncology, University of Queensland, Brisbane, Queensland, Australia
| | - Matthew C. Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Department of Radiation Oncology, University of Queensland, Brisbane, Queensland, Australia
| | - Andrew J. Song
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Wenyin Shi
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kristin J. Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chenchen Gui
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aryavarta M. S. Kumar
- Radiation Oncology Service, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio
| | - Mitchell Machtay
- Department of Radiation Oncology, University Hospital Cleveland Medical Center, Cleveland, Ohio
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University of Munich (TUM), Munich, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
- Institute for Radiation Medicine (IRM), Helmholtz Zentrum München, Neuherberg, Germany
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16
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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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17
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Carminucci A, Zeller S, Danish S. Radiographic Trends for Infield Recurrence After Radiosurgery for Cerebral Metastases. Cureus 2020; 12:e8680. [PMID: 32699680 PMCID: PMC7370660 DOI: 10.7759/cureus.8680] [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: 11/05/2022] Open
Abstract
Objective Recurrence following stereotactic radiosurgery (SRS) for the treatment of cerebral metastases is not uncommon. Recurrence can represent recurrent tumor and/or radiation necrosis. The radiographic response to Gamma Knife (GK) treatment is variable with some remaining stable, some decreasing in size, some increasing in size, while some may show a combination of all three. For tumors that demonstrate progression on MRI, the question to intervene with additional surgical or radiation therapy and the timing of such intervention remains debatable. In this study, we retrospectively reviewed surveillance MRIs of post-GK cerebral metastases to determine if radiographic trends are a predictor of infield progression. Methods A retrospective review of cerebral metastases treated with GK radiosurgery with at least two consecutive post-GK MRI scans was performed. Infield progression was defined by new enhancement increased by at least 25% in two out of three dimensions on two consecutive scans. Primary endpoints for infield recurrence were either continued observation, therapeutic intervention, or withdrawal of care. Results A total of 579 cerebral metastases were treated with GK radiosurgery. A total of 123 metastases demonstrated radiographic progression on one follow-up MRI scan. Of those, 75% demonstrated continued progression follow-up imaging, while 25% stabilized or regressed. For post-GK metastases demonstrating progression on two consecutive MRI scans, 85% of lesions continued to progress, whereas only 15% demonstrated stabilization or regression. A total of 91% of lesions either require intervention or demonstrate continued progression with observation at this timepoint. Cumulatively 100% of metastases with radiographic progression on ≥3 consecutive MRIs went on to need further intervention. Conclusion Approximately one-fourth of infield recurrence demonstrating progression on the first surveillance MRI will stabilize or regress. Those demonstrating infield progression on two consecutive MRI scans should be considered treatment failures. Early interventions before tumor volume increases in size or patients require high-dose steroids maybe beneficial.
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Affiliation(s)
- Arthur Carminucci
- Neurosurgery, Rutgers Robert Wood Johnson Medical School, Piscataway, USA
| | - Sabrina Zeller
- Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
| | - Shabbar Danish
- Neurosurgery, Rutgers Robert Wood Johnson Medical School, Piscataway, USA
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18
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Fadrus P, Kazda T, Dvoracek P, Pospisil P, Hynkova L, Zitterbartova J, Dymackova R, Kolouskova I, Belanova R, Prochazka T, Slampa P. Targeted Radiotherapy of the Tumor Cavity after Surgical Resection of Aggressive Recurrent Brain Metastasis: A Case Report. Case Rep Oncol 2020; 13:233-238. [PMID: 32308582 PMCID: PMC7154243 DOI: 10.1159/000506328] [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: 01/26/2020] [Accepted: 01/28/2020] [Indexed: 11/19/2022] Open
Abstract
Postoperative management of patients with brain metastases is controversial. Besides local control, cognitive function and quality of life are the most important outcomes of postoperative radiotherapy. In this case report, we introduce a patient with aggressive recurred solid metastasis treated with repeated surgery and an individual radiotherapy approach in order to highlight that close mutual collaboration leads to a clear benefit for our patients. The local targeted radiotherapy with 35 Gy in 10 fractions was performed with the volumetric modulated arc technique, leading to more than 2.5 years of local control and survival without any of the side effects usually attributed to whole brain radiotherapy.
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Affiliation(s)
- Pavel Fadrus
- Department of Neurosurgery, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Tomas Kazda
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czechia.,Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Petr Dvoracek
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czechia
| | - Petr Pospisil
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czechia.,Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Ludmila Hynkova
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czechia.,Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jana Zitterbartova
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czechia.,Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Radana Dymackova
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czechia.,Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | | | - Renata Belanova
- Faculty of Medicine, Masaryk University, Brno, Czechia.,Department of Radiology, Masaryk Memorial Cancer Institute, Brno, Czechia
| | - Tomas Prochazka
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czechia.,Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Pavel Slampa
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czechia.,Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czechia
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19
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Teyateeti A, Brown PD, Mahajan A, Laack NN, Pollock BE. Brain metastases resection cavity radio—surgery based on T2-weighted MRI: technique assessment. J Neurooncol 2020; 148:89-95. [DOI: 10.1007/s11060-020-03492-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/08/2020] [Indexed: 01/29/2023]
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20
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Abstract
Brain metastases are a very common manifestation of cancer that have historically been approached as a single disease entity given the uniform association with poor clinical outcomes. Fortunately, our understanding of the biology and molecular underpinnings of brain metastases has greatly improved, resulting in more sophisticated prognostic models and multiple patient-related and disease-specific treatment paradigms. In addition, the therapeutic armamentarium has expanded from whole-brain radiotherapy and surgery to include stereotactic radiosurgery, targeted therapies and immunotherapies, which are often used sequentially or in combination. Advances in neuroimaging have provided additional opportunities to accurately screen for intracranial disease at initial cancer diagnosis, target intracranial lesions with precision during treatment and help differentiate the effects of treatment from disease progression by incorporating functional imaging. Given the numerous available treatment options for patients with brain metastases, a multidisciplinary approach is strongly recommended to personalize the treatment of each patient in an effort to improve the therapeutic ratio. Given the ongoing controversies regarding the optimal sequencing of the available and expanding treatment options for patients with brain metastases, enrolment in clinical trials is essential to advance our understanding of this complex and common disease. In this Review, we describe the key features of diagnosis, risk stratification and modern paradigms in the treatment and management of patients with brain metastases and provide speculation on future research directions.
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21
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Evidence of dose-response following hypofractionated stereotactic radiotherapy to the cavity after surgery for brain metastases. J Neurooncol 2020; 146:357-362. [PMID: 31907796 DOI: 10.1007/s11060-019-03383-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 12/27/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND OBJECTIVE A retrospective review of consecutive patients between January 2012 and December 2018 receiving hypofractionated stereotactic radiotherapy (HSRT) to the cavity after resection for brain metastases was performed. METHODS Treatment was delivered using an appropriately commissioned linear accelerator. The primary outcome was time to radiological or histological confirmation of local recurrence following completion of HSRT. Dose-fractionation regimens were converted to biologically 2 Gy-equivalent doses assuming α/β = 10 (EQD2[10]). Multivariate Cox proportional hazards modelling was performed to determine hazard ratios (HR) with respective 95% confidence intervals (CI). The Log-rank test was used to determine p values taking statistical significance p < 0.05. RESULTS There were 134 patients and 144 cavities identified. The most common primary histologies were melanoma (n = 49) and lung (n = 32). 116 patients (87%) underwent a gross total resection. Median planning target volume (PTV) was 28 cm3 (range 2.4-149.2). Median EQD2[10] was 38.4 Gy (range 22.3-59.7) and 24 Gy in 3 fractions was the most common regimen. 12 (9%) patients demonstrated local recurrence at median interval 215 days (range 4-594). 7 (5%) patients experienced grade 3 or higher toxicities. In multivariate analysis, EQD2[10] was associated with local failure such that increased equivalent doses improved local control [HR = 0.79 and 95% CI 0.65-0.96, p = 0.0192]. There were no significant associations for primary histology, patient age, volume of residual disease, PTV volume or location. CONCLUSION This large series demonstrates that HSFRT to the surgical resection cavity for brain metastases has improved local control with increasing dose. Rates of grade 3 or higher toxicity were low overall.
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22
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Palmer JD, Trifiletti DM, Gondi V, Chan M, Minniti G, Rusthoven CG, Schild SE, Mishra MV, Bovi J, Williams N, Lustberg M, Brown PD, Rao G, Roberge D. Multidisciplinary patient-centered management of brain metastases and future directions. Neurooncol Adv 2020; 2:vdaa034. [PMID: 32793882 PMCID: PMC7415255 DOI: 10.1093/noajnl/vdaa034] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The incidence of brain metastasis is increasing as improvements in systemic therapy lead to increased survival. This provides new and challenging clinical decisions for patients who are trying to balance the risk of recurrence or progression with treatment-related side effects, and it requires appropriate management strategies from multidisciplinary teams. Improvements in prognostic assessment and systemic therapy with increasing activity in the brain allow for individualized care to better guide the use of local therapies and/or systemic therapy. Here, we review the current landscape of brain-directed therapy for the treatment of brain metastasis in the context of recent improved systemic treatment options. We also discuss emerging treatment strategies including targeted therapies for patients with actionable mutations, immunotherapy, modern whole-brain radiation therapy, radiosurgery, surgery, and clinical trials.
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Affiliation(s)
- Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Neurosurgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel M Trifiletti
- Departments of Radiation Oncology and Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Radiation Oncology Consultants LLC, Chicago, Illinois, USA
- Northwestern Medicine Chicago Proton Center Warrenville, Chicago, Illinois, USA
| | - Michael Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Giuseppe Minniti
- Radiation Oncology Unit, UPMC Hillman Cancer Center, San Pietro Hospital FBF, Rome, Italy
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic Scottsdale, Phoenix, Arizona, USA
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joseph Bovi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nicole Williams
- Department of Medical Oncology, The James Cancer Hospital and Solove Research Institute at The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Maryam Lustberg
- Department of Medical Oncology, The James Cancer Hospital and Solove Research Institute at The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ganesh Rao
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Roberge
- Department of Radiation Oncology, Centre Hospitalier de l’ Université de Montreal, Montreal, Quebec, Canada
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23
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Cifarelli CP, Brehmer S, Vargo JA, Hack JD, Kahl KH, Sarria-Vargas G, Giordano FA. Intraoperative radiotherapy (IORT) for surgically resected brain metastases: outcome analysis of an international cooperative study. J Neurooncol 2019; 145:391-397. [PMID: 31654248 DOI: 10.1007/s11060-019-03309-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 10/05/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVE The ideal delivery of radiation to the surgical cavity of brain metastases (BMs) remains the subject of debate. Risks of local failure (LF) and radiation necrosis (RN) have prompted a reappraisal of the timing and/or modality of this critical component of BM management. IORT delivered at the time of resection for BMs requiring surgery offers the potential for improved local control (LC) afforded by the elimination of delay in time to initiation of radiation following surgery, decreased uncertainty in target delineation, and the possibility of dose escalation beyond that seen in stereotactic radiosurgery (SRS). This study provides a retrospective analysis with identification of potential predictors of outcomes. METHODS Retrospective data was collected on patients treated with IORT immediately following surgical resection of BMs at three institutions according to the approval of individual IRBs. All patients were treated with 50kV portable linear accelerator using spherical applicators ranging from 1.5 to 4.0 cm. Statistical analyses were performed using IBM SPSS with endpoints of LC, DBC, incidence of RN, and overall survival (OS) and p < 0.05 considered significant. RESULTS 54 patients were treated with IORT with a median age of 64 years. The most common primary diagnosis was non-small cell lung cancer (40%) with the most common location in the frontal lobe (38%). Median follow-up was 7.2 months and 1-year LC, DBC, and OS were 88%, 58%, and 73%, respectively. LMD was identified in 2 patients (3%) and RN present in 4 patients (7%). The only predictor of LC was extent of resection with 1-year LC of 94% for GTR versus 62% for STR (p = 0.049). CONCLUSIONS IORT is a safe and effective means of delivering adjuvant radiation to the BM resection cavities with high rates of LC and low incidence of RN. Further studies are warranted directly comparing LC outcomes to SRS.
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Affiliation(s)
- Christopher P Cifarelli
- Department of Neurosurgery, West Virginia University, 1 Medical Center Drive, Suite 4300, Morgantown, WV, 26505, USA. .,Department of Radiation Oncology, West Virginia University, Morgantown, WV, USA.
| | - Stefanie Brehmer
- Department of Neurosurgery, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Joshua D Hack
- Department of Radiation Oncology, West Virginia University, Morgantown, WV, USA
| | - Klaus Henning Kahl
- Department of Radiation Oncology, University Medical Center Augsburg, Augsburg, Germany
| | - Gustavo Sarria-Vargas
- Department of Radiation Oncology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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