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Kahl KH, Krauss PE, Neu M, Maurer CJ, Schill-Reiner S, Roushan Z, Laukmanis E, Dobner C, Janzen T, Balagiannis N, Sommer B, Stüben G, Shiban E. Intraoperative radiotherapy after neurosurgical resection of brain metastases as institutional standard treatment- update of the oncological outcome form a single center cohort after 117 procedures. J Neurooncol 2024; 169:187-193. [PMID: 38963657 PMCID: PMC11269407 DOI: 10.1007/s11060-024-04691-6] [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: 03/03/2024] [Accepted: 04/18/2024] [Indexed: 07/05/2024]
Abstract
PURPOSE Stereotactic radiotherapy (SRT) is the predominant method for the irradiation of resection cavities after resection of brain metastases (BM). Intraoperative radiotherapy (IORT) with 50 kV x-rays is an alternative way to irradiate the resection cavity focally. We have already reported the outcome of our first 40 IORT patients treated until 2020. Since then, IORT has become the predominant cavity treatment in our center due to patients´ choice. METHODS We retrospectively analyzed the outcomes of all patients who underwent resection of BM and IORT between 2013 and August 2023 at Augsburg University Medical Center (UKA). RESULTS We identified 105 patients with 117 resected BM treated with 50 kV x-ray IORT. Median diameter of the resected metastases was 3.1 cm (range 1.3 - 7.0 cm). Median applied dose was 20 Gy. All patients received standardized follow-up (FU) including three-monthly MRI of the brain. Mean FU was 14 months, with a median MRI FU for patients alive of nine months. Median overall survival (OS) of all treated patients was 18.2 months (estimated 1-year OS 57.7%). The observed local control (LC) rate of the resection cavity was 90.5% (estimated 1-year LC 84.2%). Distant brain control (DC) was 61.9% (estimated 1-year DC 47.9%). Only 16.2% of all patients needed WBI in the further course of disease. The observed radio necrosis rate was 2.6%. CONCLUSION After 117 procedures IORT still appears to be a safe and appealing way to perform cavity RT after neurosurgical resection of BM with low toxicity and excellent LC.
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Affiliation(s)
- Klaus-Henning Kahl
- Department of Radiotherapy and Radio- Oncology, University Medical Center Augsburg, Augsburg, Germany.
| | - Philipp E Krauss
- Department of Neurosurgery, University Medical Center Augsburg, Augsburg, Germany
| | - Maria Neu
- Department of Radiotherapy and Radio- Oncology, University Medical Center Augsburg, Augsburg, Germany
| | - Christoph J Maurer
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Medical Center Augsburg, Augsburg, Germany
| | - Sabine Schill-Reiner
- Department of Medical Physics and Radiation Protection, University Medical Center Augsburg, Augsburg, Germany
| | - Zoha Roushan
- Department of Medical Physics and Radiation Protection, University Medical Center Augsburg, Augsburg, Germany
| | - Eva Laukmanis
- Department of Medical Physics and Radiation Protection, University Medical Center Augsburg, Augsburg, Germany
| | - Christian Dobner
- Department of Medical Physics and Radiation Protection, University Medical Center Augsburg, Augsburg, Germany
| | - Tilman Janzen
- Department of Medical Physics and Radiation Protection, University Medical Center Augsburg, Augsburg, Germany
| | - Nikolaos Balagiannis
- Department of Radiotherapy and Radio- Oncology, University Medical Center Augsburg, Augsburg, Germany
| | - Björn Sommer
- Department of Neurosurgery, University Medical Center Augsburg, Augsburg, Germany
| | - Georg Stüben
- Department of Radiotherapy and Radio- Oncology, University Medical Center Augsburg, Augsburg, Germany
| | - Ehab Shiban
- Department of Neurosurgery, University Medical Center Augsburg, Augsburg, Germany
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Krauss P, Wolfert CL, Sommer B, Stemmer B, Stueben G, Kahl KH, Shiban E. Intraoperative radiotherapy combined with spinal stabilization surgery-a novel treatment strategy for spinal metastases based on a first single-center experiences. J Neurooncol 2024; 168:445-455. [PMID: 38652400 PMCID: PMC11186943 DOI: 10.1007/s11060-024-04688-1] [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: 01/05/2024] [Accepted: 04/17/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Current treatment of spinal metastases (SM) aims on preserving spinal stability, neurological status, and functional status as well as achieving local control. It consists of spinal surgery followed by radiotherapy and/or systemic treatment. Adjuvant therapy usually starts with a delay of a few weeks to prevent wound healing issues. Intraoperative radiotherapy (IORT) has previously been successfully applied during brain tumor, breast and colorectal carcinoma surgery but not in SM, including unstable one, to date. In our case series, we describe the feasibility, morbidity and mortality of a novel treatment protocol for SM combining stabilization surgery with IORT. METHODS Single center case series on patients with SM. Single session stabilization by navigated open or percutaneous procedure using a carbon screw-rod system followed by concurrent 50 kV photon-IORT (ZEISS Intrabeam). The IORT probe is placed via a guide canula using navigation, positioning is controlled by IOCT or 3D-fluroscopy enabling RT isodose planning in the OR. RESULTS 15 (8 female) patients (71 ± 10y) received this treatment between 07/22 and 09/23. Median Spinal Neoplastic Instability Score was 8 [7-10] IQR. Most metastasis were located in the thoracic (n = 11, 73.3%) and the rest in the lumbar (n = 4, 26.7%) spine. 9 (60%) patients received open, 5 (33%) percutaneous stabilization and 1 (7%) decompression only. Mean length of surgery was 157 ± 45 min. Eleven patients had 8 and 3 had 4 screws placed. In 2 patients radiotherapy was not completed due to bending of the guide canula with consecutive abortion of IORT. All other patients received 8 Gy isodoses at mdn. 1.5 cm [1.1-1.9, IQR] depth during 2-6 min. The patients had Epidural Spinal Cord Compression score 1a-3. Seven patients (46.7%) experienced adverse events including 2 surgical site infection (one 65 days after surgery). CONCLUSION 50 kV photon IORT for SM and consecutive unstable spine needing surgical intervention is safe and feasible and can be a promising technique in selected cases.
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Affiliation(s)
- P Krauss
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany.
| | - C L Wolfert
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - B Sommer
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - B Stemmer
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - G Stueben
- Department of Radio Oncology, University Hospital Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - K H Kahl
- Department of Radio Oncology, University Hospital Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - E Shiban
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
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Schneider M, Wispel C, Potthoff AL, Heimann M, Borger V, Schaub C, Herrlinger U, Vatter H, Schuss P, Schäfer N. Patients with Leptomeningeal Carcinomatosis and Hydrocephalus-Feasibility of Combined Ventriculoperitoneal Shunt and Reservoir Insertion for Intrathecal Chemotherapy. Curr Oncol 2024; 31:2410-2419. [PMID: 38785461 PMCID: PMC11120415 DOI: 10.3390/curroncol31050180] [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: 02/17/2024] [Revised: 04/08/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
Therapeutic management of patients with leptomeningeal carcinomatosis (LC) may require treatment of concomitant hydrocephalus (HC) in addition to intrathecal chemotherapy (ITC). Ventriculoperitoneal shunts (VPS) equipped with a valve for manual deactivation of shunt function and a concomitant reservoir for application of ITC pose an elegant solution to both problems. The present study evaluates indication, feasibility, and safety of such a modified shunt/reservoir design (mS/R). All patients with LC aged ≥ 18 years who had undergone mS/R implantation between 2013 and 2020 at the authors' institution were further analyzed. ITC was indicated following the recommendation of the neuro-oncological tumor board and performed according to a standardized protocol. Sixteen patients with LC underwent mS/R implantation for subsequent ITC and concomitant treatment of HC. Regarding HC-related clinical symptoms, 69% of patients preoperatively exhibited lethargy, 38% cognitive impairment, and 38% (additional) visual disturbances. Postoperatively, 86% of patients achieved subjective improvement of HC-related symptoms. Overall, postoperative complications occurred in three patients (19%). No patient encountered cancer treatment-related complications. The present study describes a combination procedure consisting of a standard VPS-system and a standard reservoir for patients suffering from LC and HC. No cancer treatment-related complications occurred, indicating straightforward handling and thus safety.
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Affiliation(s)
- Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (C.W.); (A.-L.P.); (M.H.); (V.B.); (H.V.)
| | - Christian Wispel
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (C.W.); (A.-L.P.); (M.H.); (V.B.); (H.V.)
| | - Anna-Laura Potthoff
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (C.W.); (A.-L.P.); (M.H.); (V.B.); (H.V.)
| | - Muriel Heimann
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (C.W.); (A.-L.P.); (M.H.); (V.B.); (H.V.)
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (C.W.); (A.-L.P.); (M.H.); (V.B.); (H.V.)
| | - Christina Schaub
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany; (C.S.); (U.H.); (N.S.)
| | - Ulrich Herrlinger
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany; (C.S.); (U.H.); (N.S.)
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (C.W.); (A.-L.P.); (M.H.); (V.B.); (H.V.)
| | - Patrick Schuss
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (C.W.); (A.-L.P.); (M.H.); (V.B.); (H.V.)
| | - Niklas Schäfer
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany; (C.S.); (U.H.); (N.S.)
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Layer JP, Shiban E, Brehmer S, Diehl CD, de Castro DG, Hamed M, Dejonckheere CS, Cifarelli DT, Friker LL, Herrlinger U, Hölzel M, Vatter H, Schneider M, Combs SE, Schmeel LC, Cifarelli CP, Giordano FA, Sarria GR, Kahl KH. Multicentric Assessment of Safety and Efficacy of Combinatorial Adjuvant Brain Metastasis Treatment by Intraoperative Radiation Therapy and Immunotherapy. Int J Radiat Oncol Biol Phys 2024; 118:1552-1562. [PMID: 38199383 DOI: 10.1016/j.ijrobp.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 01/01/2024] [Accepted: 01/03/2024] [Indexed: 01/12/2024]
Abstract
PURPOSE After surgical resection of brain metastases (BMs), intraoperative radiation therapy (IORT) provides a promising alternative to adjuvant external beam radiation therapy by enabling superior organ-at-risk preservation, reduction of in-hospital times, and timely admission to subsequent systemic treatments, which increasingly comprise novel targeted immunotherapeutic approaches. We sought to assess the safety and efficacy of IORT in combination with immune checkpoint inhibitors (ICIs) and other targeted therapies (TTs). METHODS AND MATERIALS In a multicentric approach incorporating individual patient data from 6 international IORT centers, all patients with BMs undergoing IORT were retrospectively assessed for combinatorial treatment with ICIs/TTs and evaluated for toxicity and cumulative rates, including wound dehiscence, radiation necrosis, leptomeningeal spread, local control, distant brain progression (DBP), and estimated overall survival. RESULTS In total, 103 lesions with a median diameter of 34 mm receiving IORT combined with immunomodulatory systemic treatment or other TTs were included. The median follow-up was 13.2 (range, 1.2-102.4) months, and the median IORT dose was 25 (range, 18-30) Gy prescribed to the applicator surface. There was 1 grade 3 adverse event related to IORT recorded (2.2%). A 4.9% cumulative radiation necrosis rate was observed. The 1-year local control rate was 98.0%, and the 1-year DBP-free survival rate was 60.0%. Median time to DBP was 5.5 (range, 1.0-18.5) months in the subgroup of patients experiencing DBP, and the cumulative leptomeningeal spread rate was 4.9%. The median estimated overall survival was 26 (range, 1.2 to not reached) months with a 1-year survival rate of 74.0%. Early initiation of immunotherapy/TTs was associated with a nonsignificant trend toward improved DBP rate and overall survival. CONCLUSIONS The combination of ICIs/TTs with IORT for resected BMs does not seem to increase toxicity and yields encouraging local control outcomes in the difficult-to-treat subgroup of larger BMs. Time gaps between surgery and systemic treatment could be shortened or avoided. The definitive role of IORT in local control after BM resection will be defined in a prospective trial.
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Affiliation(s)
- Julian P Layer
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany; Institute of Experimental Oncology, University Hospital Bonn, Bonn, Germany
| | - Ehab Shiban
- Department of Neurosurgery, University Hospital Augsburg, Augsburg, Germany
| | - Stefanie Brehmer
- Department of Neurosurgery, University Medical Center Mannheim, Mannheim, Germany
| | - Christian D Diehl
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Cas S Dejonckheere
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Daniel T Cifarelli
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia
| | - Lea L Friker
- Institute of Experimental Oncology, University Hospital Bonn, Bonn, Germany; Institute of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - Ulrich Herrlinger
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Michael Hölzel
- Institute of Experimental Oncology, University Hospital Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | | | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | | | - Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, Mannheim, Germany; DKFZ-Hector Cancer Institute of the University Medical Center Mannheim, Mannheim, Germany; Mannheim Institute of Intelligent Systems in Medicine (MIISM), Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany.
| | - Klaus-Henning Kahl
- Department of Radiooncology, University Hospital Augsburg, Augsburg, Germany
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Bao H, Ai S, Wang G, Yi L, Lai J, Wang S, Lv Z, Li C, Liu Q, Zhao X, Wu C, Liu C, Mi S, Sun X, Hao C, Liang P. Intraoperative radiotherapy in recurrent IDH-wildtype glioblastoma with gross total resection: A single-center retrospective study. Clin Neurol Neurosurg 2024; 236:108103. [PMID: 38199118 DOI: 10.1016/j.clineuro.2023.108103] [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: 11/07/2023] [Revised: 12/08/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Isocitrate dehydrogenase-wildtype (IDHwt) glioblastoma (GBM) is one of the most aggressive primary brain tumors. The recurrence of GBM is almost inevitable. As an adjuvant option to surgery, intraoperative radiotherapy (IORT) is gaining increasing attention in the treatment of glioma. This study is aimed to evaluate the therapeutic efficacy of IORT on recurrent IDHwt GBM. METHODS In total, 34 recurrent IDHwt GBM patients who received a second surgery were included in the analysis (17 in the surgery group and 17 in the surgery + IORT group). RESULTS The progression-free survival and overall survival after the second surgery were defined as PFS2 and OS2, respectively. The median PFS2 was 7.3 months (95% CI: 6.3-10.5) and 10.6 months (95% CI: 9.3-14.6) for those patients who received surgery and surgery + IORT, respectively. Patients in the surgery + IORT group also had a longer OS2 (12.8 months, 95% CI: 11.4-17.2) than those in the surgery group (9.3 months, 95% CI: 8.9-12.9). The Kaplan-Meier survival curves, analyzed by log-rank test, revealed a statistically significant difference in PFS2 and OS2 between both groups, suggesting that IORT plays an active role in the observed benefits for PFS2 and OS2. The effects of IORT on PFS2 and OS2 were further confirmed by multivariate Cox hazards regression analysis. Two patients in the surgery group developed distant glioma metastases, and no radiation-related complications were observed in the IORT group. CONCLUSIONS This study suggests that low-dose IORT may improve the prognosis of recurrent IDHwt GBM patients. Future prospective large-scale studies are needed to validate the efficacy and safety of IORT.
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Affiliation(s)
- Hongbo Bao
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China; Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Siqi Ai
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China; Department of Neurosurgery, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Gang Wang
- Department of Radiotherapy, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Liye Yi
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Jiacheng Lai
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Shuai Wang
- Department of Imaging Center, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Zhonghua Lv
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Chenlong Li
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Qing Liu
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Xinyu Zhao
- Department of Radiotherapy, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Chou Wu
- Department of Radiotherapy, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Chang Liu
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Shan Mi
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Xiaoyang Sun
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Chuncheng Hao
- Department of Radiotherapy, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China.
| | - Peng Liang
- Department of Neurosurgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China.
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Krauss P, Kahl KH, Bonk MN, Wolfert C, Sommer B, Stueben G, Shiban E. Intraoperative radiotherapy after resection of brain metastases located in the posterior fossa. Analysis of postoperative morbidity and mortality in a single center cohort. J Clin Neurosci 2023; 118:1-6. [PMID: 37832264 DOI: 10.1016/j.jocn.2023.09.014] [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: 08/08/2023] [Revised: 09/14/2023] [Accepted: 09/16/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION In order to improve surgical outcome and accelerate the adjuvant oncologic therapy, intraoperative Radiotherapy (IORT) has become a treatment option in oncologic surgery for various diseases including glioma and brain metastasis (BM). BMs are often located in the cranial posterior fossa (PF) requiring specific surgical considerations due to its complex anatomy. Up until now, data on IORT for BMs is limited and detailed description in the use of IORT for lesions in the PF is lacking. Our aim is to provide more insight into this emerging treatment strategy. METHODS We performed a retrospective analysis of patients receiving surgery for BMs and undergoing IORT at our institution. Each patient was discussed at the interdisciplinary tumor board decision before the intervention. Patient characteristics, functional status (Karnofsky Performance Score, KPS) before and after surgery, disease (recursive partitioning analysis, lesion size) and operative parameters were analyzed. Adverse events (AE) were recorded up until 30 days after the intervention and rated according to the Clavien Dindo Rating scale. RESULTS Nine patients (5 female) were included. None underwent prior radiotherapy (RT). Mean age was 66 ± 11 years. Preoperative median KPS was 80%. Mean BM diameter was 3.2 ± 0.9 cm. There was no statistically significant deterioration of the functional status after the intervention. Two patients experienced AEs with both of them needing revision surgery. CONCLUSION Surgery for BMs with IORT in the PF seems safe and feasible. Further studies are needed to evaluate the influence of IORT on long-term outcome after BM surgery.
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Affiliation(s)
- Philipp Krauss
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany.
| | - Klaus Henning Kahl
- Department of Radiooncology, University Hospital Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany
| | - Maximilian Niklas Bonk
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany
| | - Christina Wolfert
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany
| | - Bjoern Sommer
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany
| | - Georg Stueben
- Department of Radiooncology, University Hospital Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany
| | - Ehab Shiban
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany
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Tejada Solís S, Iglesias Lozano I, Meana Carballo L, Mollejo Villanueva M, Díez Valle R, González Sánchez J, Fernández Coello A, Al Ghanem R, García Duque S, Olivares Granados G, Plans Ahicart G, Hostalot Panisello C, Garcia Romero JC, Narros Giménez JL. Brain metastasis treatment guidelines: consensus by the Spanish Society of Neurosurgery Tumor Section. NEUROCIRUGIA (ENGLISH EDITION) 2023; 34:308-320. [PMID: 37832786 DOI: 10.1016/j.neucie.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/10/2023] [Indexed: 10/15/2023]
Abstract
Brain metastases are tumors that arise from a tumor cell originated in another organ reaching the brain through the blood. In the brain this tumor cell is capable of growing and invading neighboring tissues, such as the meninges and bone. In most patients a known tumor is present when the brain lesion is diagnosed, although it is possible that the first diagnose is the brain tumor before there is evidence of cancer elsewhere in the body. For this reason, the neurosurgeon must know the management that has shown the greatest benefit for brain metastasis patients, so treatments can be streamlined and optimized. Specifically, in this document, the following topics will be developed: selection of the cancer patient candidate for surgical resection and the role of the neurosurgeon in the multidisciplinary team, the importance of immunohistological and molecular diagnosis, surgical techniques, radiotherapy techniques, treatment updates of chemotherapy and immunotherapy and management algorithms in brain metastases. With this consensus manuscript, the tumor group of the Spanish Society of Neurosurgery (GT-SENEC) exposes the most relevant neurosurgical issues and the fundamental aspects to harmonize multidisciplinary treatment, especially with the medical specialties that are treating or will treat these patients.
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Affiliation(s)
- Sonia Tejada Solís
- Departamento de Neurocirugía, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain.
| | | | | | | | - Ricardo Díez Valle
- Departamento de Neurocirugía, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | | | | | - Rajab Al Ghanem
- Departamento de Neurocirugía, Hospital Universitario de Jaén, Spain
| | - Sara García Duque
- Departamento de Neurocirugía, Hospital Universitario HM Montepríncipe, Spain
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Dejonckheere CS, Layer JP, Hamed M, Layer K, Glasmacher A, Friker LL, Potthoff AL, Zeyen T, Scafa D, Koch D, Garbe S, Holz JA, Kugel F, Grimmer M, Schmeel FC, Gielen GH, Forstbauer H, Vatter H, Herrlinger U, Giordano FA, Schneider M, Schmeel LC, Sarria GR. Intraoperative or postoperative stereotactic radiotherapy for brain metastases: time to systemic treatment onset and other patient-relevant outcomes. J Neurooncol 2023; 164:683-691. [PMID: 37812290 PMCID: PMC10589145 DOI: 10.1007/s11060-023-04464-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/23/2023] [Indexed: 10/10/2023]
Abstract
PURPOSE Intraoperative radiotherapy (IORT) has become a viable treatment option for resectable brain metastases (BMs). As data on local control and radiation necrosis rates are maturing, we focus on meaningful secondary endpoints such as time to next treatment (TTNT), duration of postoperative corticosteroid treatment, and in-hospital time. METHODS Patients prospectively recruited within an IORT study registry between November 2020 and June 2023 were compared with consecutive patients receiving adjuvant stereotactic radiotherapy (SRT) of the resection cavity within the same time frame. TTNT was defined as the number of days between BM resection and start of the next extracranial oncological therapy (systemic treatment, surgery, or radiotherapy) for each of the groups. RESULTS Of 95 BM patients screened, IORT was feasible in 84 cases (88%) and ultimately performed in 64 (67%). The control collective consisted of 53 SRT patients. There were no relevant differences in clinical baseline features. Mean TTNT (range) was 36 (9 - 94) days for IORT patients versus 52 (11 - 126) days for SRT patients (p = 0.01). Mean duration of postoperative corticosteroid treatment was similar (8 days; p = 0.83), as was mean postoperative in-hospital time (11 versus 12 days; p = 0.97). Mean total in-hospital time for BM treatment (in- and out-patient days) was 11 days for IORT versus 19 days for SRT patients (p < 0.001). CONCLUSION IORT for BMs results in faster completion of interdisciplinary treatment when compared to adjuvant SRT, without increasing corticosteroid intake or prolonging in-hospital times. A randomised phase III trial will determine the clinical effects of shorter TTNT.
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Affiliation(s)
- Cas S Dejonckheere
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Julian P Layer
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- Institute of Experimental Oncology, University Hospital Bonn, 53127, Bonn, Germany
| | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, 53127, Bonn, Germany
| | - Katharina Layer
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Andrea Glasmacher
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Lea L Friker
- Institute of Experimental Oncology, University Hospital Bonn, 53127, Bonn, Germany
- Institute of Neuropathology, University Hospital Bonn, 53127, Bonn, Germany
| | | | - Thomas Zeyen
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, 53127, Bonn, Germany
| | - Davide Scafa
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - David Koch
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Stephan Garbe
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Jasmin A Holz
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Fabian Kugel
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Molina Grimmer
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | | | - Gerrit H Gielen
- Institute of Neuropathology, University Hospital Bonn, 53127, Bonn, Germany
| | | | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, 53127, Bonn, Germany
| | - Ulrich Herrlinger
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, 53127, Bonn, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, 68167, Mannheim, Germany
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, 53127, Bonn, Germany
| | | | - Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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9
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Cifarelli CP, Vargo JA, Sener U, Cifarelli DT, Scoville D, Dabir A. Intracranial intraoperative radiotherapy (IORT): evaluation of electrocorticography and peri-operative seizure risk. J Neurooncol 2023; 164:423-430. [PMID: 37668944 DOI: 10.1007/s11060-023-04443-y] [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: 07/07/2023] [Accepted: 08/30/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Intra-operative radiotherapy (IORT) for brain metastases (BMs) and primary brain tumors has emerged as an adjuvant radiation modality that allows for consolidation of care into a single anesthetic episode with surgical resection. Yet, there is a paucity of data regarding the impact that IORT may have on peri-operative and long-term seizure risk. METHODS A retrospective analysis of patients receiving IORT during tumor resection was performed via registry including data regarding peri-operative anti-seizure medications and anesthetic agents. Intra-operative neuromonitoring was performed using electrocorticography (ECoG) captured before-, during-, and after-IORT then analyzed for evidence of seizure or significant baseline changes. Kaplan-Meir estimations were used for overall survival analysis relative to documented clinical seizure incidence post-IORT. RESULTS Of the 24 consecutive patients treated with IORT during tumor resection included, 18 (75%) patients were diagnosed with BMs while 6 (25%) had newly-diagnosed glioblastoma. Mean and median survival times were 487 and 372 days, respectively. Clinical seizures occurred in 3 patients post-IORT, 2 BMs patients within 9 months and 1 glioblastoma patient at 14 months. IORT time represented 9.5% of anesthetic time. ECoG recordings were available for 5 patients (4 BMs; 1 glioblastoma), with mean recording durations of 13% of the total anesthetic time and no evidence of high-frequency oscillations or seizure activity. CONCLUSIONS IORT is an option for delivery of definitive radiation in surgically resected brain tumors without increasing the peri-operative or long-term risk of seizure. ECoG data during the delivery of radiation fail to demonstrate any electrophysiological changes in response to ionizing radiation.
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Affiliation(s)
- Christopher P Cifarelli
- Department of Neurosurgery, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26506-9183, USA.
- Department of Radiation Oncology, West Virginia University, Morgantown, WV, USA.
| | - John A Vargo
- Department of Radiation Oncology, UPMC, Pittsburgh, PA, USA
| | - Ugur Sener
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Daniel T Cifarelli
- Department of Neurosurgery, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26506-9183, USA
| | - David Scoville
- Division of Surgical Services, WVU Medicine, Morgantown, WV, USA
| | - Aman Dabir
- Department of Neurology, West Virginia University, Morgantown, WV, USA
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10
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Layer JP, Hamed M, Potthoff AL, Dejonckheere CS, Layer K, Sarria GR, Scafa D, Koch D, Köksal M, Kugel F, Grimmer M, Holz JA, Zeyen T, Friker LL, Borger V, Schmeel FC, Weller J, Hölzel M, Schäfer N, Garbe S, Forstbauer H, Giordano FA, Herrlinger U, Vatter H, Schneider M, Schmeel LC. Outcome assessment of intraoperative radiotherapy for brain metastases: results of a prospective observational study with comparative matched-pair analysis. J Neurooncol 2023; 164:107-116. [PMID: 37477822 PMCID: PMC10462513 DOI: 10.1007/s11060-023-04380-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/20/2023] [Indexed: 07/22/2023]
Abstract
PURPOSE Intraoperative radiation therapy (IORT) is an emerging alternative to adjuvant stereotactic external beam radiation therapy (EBRT) following resection of brain metastases (BM). Advantages of IORT include an instant prevention of tumor regrowth, optimized dose-sparing of adjacent healthy brain tissue and immediate completion of BM treatment, allowing an earlier admission to subsequent systemic treatments. However, prospective outcome data are limited. We sought to assess long-term outcome of IORT in comparison to EBRT. METHODS A total of 35 consecutive patients, prospectively recruited within a study registry, who received IORT following BM resection at a single neuro-oncological center were evaluated for radiation necrosis (RN) incidence rates, local control rates (LCR), distant brain progression (DBP) and overall survival (OS) as long-term outcome parameters. The 1 year-estimated OS and survival rates were compared in a balanced comparative matched-pair analysis to those of our institutional database, encompassing 388 consecutive patients who underwent adjuvant EBRT after BM resection. RESULTS The median IORT dose was 30 Gy prescribed to the applicator surface. A 2.9% RN rate was observed. The estimated 1 year-LCR was 97.1% and the 1 year-DBP-free survival 73.5%. Median time to DBP was 6.4 (range 1.7-24) months in the subgroup of patients experiencing intracerebral progression. The median OS was 17.5 (0.5-not reached) months with a 1 year-survival rate of 61.3%, which did not not significantly differ from the comparative cohort (p = 0.55 and p = 0.82, respectively). CONCLUSION IORT is a safe and effective fast-track approach following BM resection, with comparable long-term outcomes as adjuvant EBRT.
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Affiliation(s)
- Julian P Layer
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
- Institute of Experimental Oncology, University Hospital Bonn, Bonn, Germany.
| | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | | | - Cas S Dejonckheere
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Katharina Layer
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Davide Scafa
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - David Koch
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Mümtaz Köksal
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Fabian Kugel
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Molina Grimmer
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Jasmin A Holz
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Thomas Zeyen
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Lea L Friker
- Institute of Experimental Oncology, University Hospital Bonn, Bonn, Germany
- Institute of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - F Carsten Schmeel
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Johannes Weller
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Michael Hölzel
- Institute of Experimental Oncology, University Hospital Bonn, Bonn, Germany
| | - Niklas Schäfer
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Stephan Garbe
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | | | - Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, Mannheim, Germany
- DKFZ-Hector Cancer Institute of the University Medical Center Mannheim, Mannheim, Germany
- Mannheim Institute of Intelligent Systems in Medicine (MIISM), Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ulrich Herrlinger
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | | | - L Christopher Schmeel
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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11
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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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12
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Carconi C, Cerreti M, Roberto M, Arrivi G, D'Ambrosio G, De Felice F, Di Civita MA, Iafrate F, Lucatelli P, Magliocca FM, Picchetto A, Picone V, Catalano C, Cortesi E, Tombolini V, Mazzuca F, Tomao S. The Management of Oligometastatic Disease in Colorectal Cancer: Present Strategies and Future Perspectives. Crit Rev Oncol Hematol 2023; 186:103990. [PMID: 37061075 DOI: 10.1016/j.critrevonc.2023.103990] [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: 10/13/2022] [Revised: 03/29/2023] [Accepted: 04/11/2023] [Indexed: 04/17/2023] Open
Abstract
Oligometastatic disease has been described as an intermediate clinical state between localized cancer and systemically metastasized disease. Recent clinical studies have shown prolonged survival when aggressive locoregional approaches are added to systemic therapies in patients with oligometastases. The aim of this review is to outline the newest options to treat oligometastatic colorectal cancer (CRC), also considering its molecular patterns. We present an overview of the available local treatment strategies, including surgical procedures, stereotactic body radiation therapy (SBRT), thermal ablation, as well as trans-arterial chemoembolization (TACE) and selective internal radiotherapy (SIRT). Moreover, since imaging methods provide crucial information for the early diagnosis and management of oligometastatic CRC, we discuss the role of modern radiologic techniques in selecting patients that are amenable to potentially curative locoregional treatments.
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Affiliation(s)
- Catia Carconi
- Sant'Andrea University Hospital, Faculty of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
| | - Micaela Cerreti
- Sant'Andrea University Hospital, Faculty of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
| | - Michela Roberto
- UOC Oncologia A, Department of radiological, Oncological and Anathomo-patological Science, Policlinico Umberto I, "Sapienza" University of Rome, 00161 Rome, Italy.
| | - Giulia Arrivi
- Oncology Unit, Sant' Andrea University Hospital, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Giancarlo D'Ambrosio
- Department of General Surgery, Surgical Specialties and Organ Transplantation, Policlinico Umberto I, "Sapienza" University of Rome, 00161 Rome, Italy
| | - Francesca De Felice
- Department of Radiotherapy, Policlinico Umberto I "Sapienza" University of Rome, Rome, Italy
| | - Mattia Alberto Di Civita
- UOC Oncologia A, Department of radiological, Oncological and Anathomo-patological Science, Policlinico Umberto I, "Sapienza" University of Rome, 00161 Rome, Italy
| | - Franco Iafrate
- Department of Radiological Sciences, Oncology and Pathology, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Pierleone Lucatelli
- Vascular and Interventional radiology Unit, Department of radiological, Oncological and Anathomo-patological Science, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Fabio Massimo Magliocca
- Vascular and Interventional radiology Unit, Department of radiological, Oncological and Anathomo-patological Science, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Andrea Picchetto
- Emergency Department, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Vincenzo Picone
- UOC Oncologia B, Department of radiological, Oncological and Anathomo-patological Science, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Carlo Catalano
- Vascular and Interventional radiology Unit, Department of radiological, Oncological and Anathomo-patological Science, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Enrico Cortesi
- UOC Oncologia B, Department of radiological, Oncological and Anathomo-patological Science, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Vincenzo Tombolini
- Department of Radiotherapy, Policlinico Umberto I "Sapienza" University of Rome, Rome, Italy
| | - Federica Mazzuca
- Oncology Unit, Sant' Andrea University Hospital, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Silverio Tomao
- Oncology Unit, Sant' Andrea University Hospital, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
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13
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Lozares-Cordero S, Ibáñez-Carreras R, García-Barrios A, Castro-Moreno R, González-Rodríguez A, Sánchez-Casi M, Campos-Boned A, Gandía-Martínez A, Antonio Font-Gómez J, Jiménez-Puertas S, Villa-Gazulla D, Díez-Chamarro J, Hernández-Hernández M, González-Pérez V, Cisneros-Gimeno AI. End-To-End Procedure For IORT in Brain Metastases and Film Dosimetry. J Med Phys 2023; 48:175-180. [PMID: 37576088 PMCID: PMC10419752 DOI: 10.4103/jmp.jmp_18_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/14/2023] [Accepted: 05/18/2023] [Indexed: 08/15/2023] Open
Abstract
Purpose The study is intended to perform an end-to-end test of the entire intraoperative process using cadaver heads. A simulation of tumor removal was performed, followed by irradiation of the bed and measurement of absorbed doses with radiochromic films. Materials and Methods Low-energy X-ray intraoperative radiotherapy (IORT) was used for irradiation. A computed tomography study was performed at each site and the absorbed doses calculated by the treatment planning system, as well as absorbed doses with radiochromic films, were studied. Results The absorbed doses in the organs at risk (OAR) were evaluated in each case, obtaining maximum doses within the tolerance limits. The absorbed doses in the target were verified and the deviations were <1%. Conclusions These tests demonstrated that this comprehensive procedure is a reproducible quality assurance tool which allows continuous assessment of the dosimetric and geometric accuracy of clinical brain IORT treatments. Furthermore, the absorbed doses measured in both target and OAR are optimal for these treatments.
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Affiliation(s)
- Sergio Lozares-Cordero
- Department of Physics and Radiation Protection, Miguel Servet University Hospital, Zaragoza, Spain
| | - Reyes Ibáñez-Carreras
- Department of Radiation Oncology, Miguel Servet University Hospital, Zaragoza, Spain
| | - Alberto García-Barrios
- Department of Anatomy and Histology, School of Medicine, University of Zaragoza, Valencia, Spain
| | - Raquel Castro-Moreno
- Department of Physics and Radiation Protection, Miguel Servet University Hospital, Zaragoza, Spain
| | | | - Marta Sánchez-Casi
- Department of Physics and Radiation Protection, Miguel Servet University Hospital, Zaragoza, Spain
| | - Arantxa Campos-Boned
- Department of Radiation Oncology, Miguel Servet University Hospital, Zaragoza, Spain
| | - Almudena Gandía-Martínez
- Department of Physics and Radiation Protection, Miguel Servet University Hospital, Zaragoza, Spain
| | - José Antonio Font-Gómez
- Department of Physics and Radiation Protection, Miguel Servet University Hospital, Zaragoza, Spain
| | - Sara Jiménez-Puertas
- Department of Physics and Radiation Protection, Miguel Servet University Hospital, Zaragoza, Spain
| | - David Villa-Gazulla
- Department of Physics and Radiation Protection, Miguel Servet University Hospital, Zaragoza, Spain
| | - Javier Díez-Chamarro
- Department of Physics and Radiation Protection, Miguel Servet University Hospital, Zaragoza, Spain
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14
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Palmisciano P, Haider AS, Balasubramanian K, Boockvar JA, Schwartz TH, D'Amico RS, Gabriella Wernicke A. Cesium-131 brachytherapy for the treatment of brain metastases: Current status and future perspectives. J Clin Neurosci 2023; 109:57-63. [PMID: 36753799 DOI: 10.1016/j.jocn.2023.01.010] [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: 11/05/2022] [Revised: 01/15/2023] [Accepted: 01/19/2023] [Indexed: 02/09/2023]
Abstract
Adjuvant radiotherapy is often necessary following surgical resection of brain metastases to improve local tumor control and survival. Brachytherapy using cesium-131 offers a novel method for loco-regional radiotherapy. We reviewed the current literature reporting the use of cesium-131 brachytherapy for the treatment of brain metastases. Published studies and ongoing trials were reviewed to identify treatment protocols and clinical outcomes of cesium-131 brachytherapy for brain metastases. Cesium-131 brachytherapy was further compared to current outcomes for iodine-125 brachytherapy and stereotactic radiosurgery. Intraoperative brachytherapy allows patients to receive two treatment modalities in one setting while minimizing tumor cell repopulation. After initial interest, the use of iodine-125 brachytherapy has declined due to unfavorable rates of radiation necrosis without survival improvement. Recent data on intracavitary cesium-131 brachytherapy in brain metastases have demonstrated improved locoregional tumor control with low risks of radiation necrosis, with associated improvements in patients compliance and satisfaction. Cesium-131 isotope has a short half-life, delivers 90% of its dose within a month, shortens the time to initiation of systemic therapy compared to iodine-125 or external radiotherapy, and has an excellent radiation safety profile. Further analyses have demonstrated superior cost-effectiveness and quality-of-life improvement ratios of cesium-131 brachytherapy than adjuvant stereotactic radiosurgery. Cesium-131 brachytherapy is a safe and effective post-surgical treatment option for brain metastases with associated clinical and cost-effectiveness benefits in appropriately selected patients.
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Affiliation(s)
- Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ali S Haider
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | | | - John A Boockvar
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra, New York, NY, USA
| | - Theodore H Schwartz
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - Randy S D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra, New York, NY, USA
| | - Alla Gabriella Wernicke
- Department of Radiation Medicine, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra, New York, NY, USA.
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15
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de Castro DG, Sanematsu PI, Pellizzon ACA, Suzuki SH, Fogaroli RC, Dias JES, Gondim GRM, Estrada DA, Silva MLG, Rassi MS, Chen MJ, Giacomelli R, Ramos H, Neto ES, Abrahão CH, Coelho TM, Yu LS, de Queiroz Tannous C, Calsavara VF, Giordano FA, de Oliveira JG. Intraoperative radiotherapy for brain metastases: first-stage results of a single-arm, open-label, phase 2 trial. J Neurooncol 2023; 162:211-215. [PMID: 36826700 DOI: 10.1007/s11060-023-04266-x] [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: 01/09/2023] [Accepted: 02/10/2023] [Indexed: 02/25/2023]
Abstract
OBJECTIVE Focal stereotactic radiosurgery to the surgical cavity lowers local recurrence after resection of brain metastases (BM). To evaluate local control (LC) and brain disease control (BDC) after intraoperative radiotherapy (IORT) for resected BM. METHODS Adult patients with completely resected single supratentorial BM were recruited and underwent IORT to the cavity with a prescribed dose of 18 Gy to 1 mm-depth. Primary endpoints were actuarial LC and BDC. Local failure (LF) and distant brain failure (DBF), with death as a competing risk, were estimated. Secondary endpoints were overall survival (OS) and incidence of radiation necrosis (RN). Simon's two-stage design was used and estimated an accrual of 10 patients for the first-stage analysis and a LC higher than 63% to proceed to second stage. We report the final analysis of the first stage. RESULTS Between June 2019 to November 2020, 10 patients were accrued. Median clinical and imaging FU was 11.2 and 9.7 months, respectively. Median LC was not reached and median BDC was 5 months. The 6-month and 12-month LC was 87.5%. The 6-month and 12-month BDC was 39% and 13%, respectively. Incidence of LF at 6 and 12 months was 10% and of DBF at 6 and 12 months was 50% and 70%, respectively. Median OS was not reached. The 6-month and 12-month OS was 80%. One patient had asymptomatic RN. CONCLUSION IORT for completely resected BM is associated with a potential high local control and low risk of RN, reaching the pre-specified criteria to proceed to second stage and warranting further studies.
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Affiliation(s)
| | | | | | | | - Ricardo Cesar Fogaroli
- Department of Radiation Oncology, A.C. Camargo Cancer Center, 01509-001, São Paulo, Brazil
| | | | | | | | | | - Marcio Saquy Rassi
- Department of Neurosurgery, A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Michael Jenwei Chen
- Department of Radiation Oncology, A.C. Camargo Cancer Center, 01509-001, São Paulo, Brazil
| | - Richard Giacomelli
- Department of Neurosurgery, A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Henderson Ramos
- Department of Radiation Oncology, A.C. Camargo Cancer Center, 01509-001, São Paulo, Brazil
| | - Elson Santos Neto
- Department of Radiation Oncology, A.C. Camargo Cancer Center, 01509-001, São Paulo, Brazil
| | | | | | - Liao Shin Yu
- Department of Imaging, A.C. Camargo Cancer Center, São Paulo, Brazil
| | | | | | - Frank Anton Giordano
- Department of Radiation Oncology, DKFZ-Hector Cancer Institute, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Jean Gonçalves de Oliveira
- Division of Neurosurgery, Department of Surgery, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
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16
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Krauss P, Steininger K, Motov S, Sommer B, Bonk MN, Cortes A, Wolfert C, Stueben G, Shiban E, Kahl KH. Resection of supratentorial brain metastases with intraoperative radiotherapy. Is it safe? Analysis and experiences of a single center cohort. Front Surg 2022; 9:1071804. [PMID: 36632525 PMCID: PMC9826792 DOI: 10.3389/fsurg.2022.1071804] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 12/12/2022] [Indexed: 12/27/2022] Open
Abstract
Introduction Intraoperative Radiotherapy (ioRT) is an emerging treatment option in oncologic surgery for various diseases including intraaxial brain lesions to improve surgical outcome and accelerate the adjuvant oncologic therapy. Despite its use in glioma surgery, the application and data regarding ioRT in the treatment of brain metastases (BMs) is sparse. Here were report the largest series of supratentorial BMs treated with resection and ioRT according to functional outcome and adverse events. Methods We performed a retrospective chart review analysis of patients undergoing surgery for BMs following an interdisciplinary tumor board decision in every case with ioRT at our institution. Patient properties, functional status (Karnofsky Performance Score/KPS) before and after surgery as well as oncologic (disease, recursive partitioning analysis, lesion size) and operative parameters were analyzed until hospital discharge. Adverse events (AE) were recorded until 30 days after surgery and rated according to the Clavien Dindo Grading (CDG) scale. Results 70 patients (40 female) with various oncologic diseases were identified and analyzed. Six underwent prior RT. Mean age was 66 ± 11 years. Preoperative median KPS was 80% with a mean BM volume of 3.2 ± 1.2 cm3. Nine patients (13%) experienced in total 14 AEs, including 2 cases (3%) of postoperative death (CDG5) and 2 with new postoperative epilepsy necessitating additional pharmacotreatment (CDG2). Five patients suffered from new neurologic deficit (CDG1) not needing further surgical or medical treatment. After surgery, the neurological status in 7 patients (10%) deteriorated while it improved in 21 cases (30%). Patients experiencing AEs had longer hospitalization and poorer postoperative KPS mdn. 90 vs. 80%. There was no statistically significant deterioration of the functional status during the immediate postoperative course in the whole patient cohort. Conclusion Surgery for supratentorial BMs with ioRT seems safe and feasible. Further studies on the benefit regarding oncologic outcome need to be performed.
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Affiliation(s)
- Philipp Krauss
- Department of Neurosurgery, University Hospital Augsburg, Augsburg, Germany,Correspondence: Philipp Krauss
| | - Kathrin Steininger
- Department of Neurosurgery, University Hospital Augsburg, Augsburg, Germany
| | - Stefan Motov
- Department of Neurosurgery, University Hospital Augsburg, Augsburg, Germany
| | - Bjoern Sommer
- Department of Neurosurgery, University Hospital Augsburg, Augsburg, Germany
| | | | - Abraham Cortes
- Department of Neurosurgery, University Hospital Augsburg, Augsburg, Germany
| | - Christina Wolfert
- Department of Neurosurgery, University Hospital Augsburg, Augsburg, Germany
| | - Georg Stueben
- Department of Radiooncology, University Hospital Augsburg, Augsburg, Germany
| | - Ehab Shiban
- Department of Neurosurgery, University Hospital Augsburg, Augsburg, Germany
| | - Klaus Henning Kahl
- Department of Radiooncology, University Hospital Augsburg, Augsburg, Germany
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17
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Diehl CD, Pigorsch SU, Gempt J, Krieg SM, Reitz S, Waltenberger M, Barz M, Meyer HS, Wagner A, Wilkens J, Wiestler B, Zimmer C, Meyer B, Combs SE. Low-Energy X-Ray Intraoperative Radiation Therapy (Lex-IORT) for Resected Brain Metastases: A Single-Institution Experience. Cancers (Basel) 2022; 15:cancers15010014. [PMID: 36612015 PMCID: PMC9817795 DOI: 10.3390/cancers15010014] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Resection followed by local radiation therapy (RT) is the standard of care for symptomatic brain metastases. However, the optimal technique, fractionation scheme and dose are still being debated. Lately, low-energy X-ray intraoperative RT (lex-IORT) has been of increasing interest. METHOD Eighteen consecutive patients undergoing BM resection followed by immediate lex-IORT with 16-30 Gy applied to the spherical applicator were retrospectively analyzed. Demographic, RT-specific, radiographic and clinical data were reviewed to evaluate the effectiveness and safety of IORT for BM. Descriptive statistics and Kaplan-Meyer analysis were applied. RESULTS The mean follow-up time was 10.8 months (range, 0-39 months). The estimated local control (LC), distant brain control (DBC) and overall survival (OS) at 12 months post IORT were 92.9% (95%-CI 79.3-100%), 71.4% (95%-CI 50.2-92.6%) and 58.0% (95%-CI 34.1-81.9%), respectively. Two patients developed radiation necrosis (11.1%) and wound infection (CTCAE grade III); both had additional adjuvant treatment after IORT. For five patients (27.8%), the time to the start or continuation of systemic treatment was ≤15 days and hence shorter than wound healing and adjuvant RT would have required. CONCLUSION In accordance with previous series, this study demonstrates the effectiveness and safety of IORT in the management of brain metastases despite the small cohort and the retrospective characteristic of this analysis.
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Affiliation(s)
- Christian D. Diehl
- Department of Radiation Oncology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site, 81675 Munich, Germany
- Correspondence:
| | - Steffi U. Pigorsch
- Department of Radiation Oncology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site, 81675 Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Sandro M. Krieg
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- TUM-Neuroimaging Center, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Silvia Reitz
- Department of Radiation Oncology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Maria Waltenberger
- Department of Radiation Oncology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Melanie Barz
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Hanno S. Meyer
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Arthur Wagner
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Jan Wilkens
- Department of Radiation Oncology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Benedikt Wiestler
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), DKTK Partner Site, 81675 Munich, Germany
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18
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Lehrer EJ, Kowalchuk RO, Ruiz-Garcia H, Merrell KW, Brown PD, Palmer JD, Burri SH, Sheehan JP, Quninoes-Hinojosa A, Trifiletti DM. Preoperative stereotactic radiosurgery in the management of brain metastases and gliomas. Front Surg 2022; 9:972727. [PMID: 36353610 PMCID: PMC9637863 DOI: 10.3389/fsurg.2022.972727] [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: 06/18/2022] [Accepted: 10/04/2022] [Indexed: 01/24/2023] Open
Abstract
Stereotactic radiosurgery (SRS) is the delivery of a high dose ionizing radiation in a highly conformal manner, which allows for significant sparing of nearby healthy tissues. It is typically delivered in 1-5 sessions and has demonstrated safety and efficacy across multiple intracranial neoplasms and functional disorders. In the setting of brain metastases, postoperative and definitive SRS has demonstrated favorable rates of tumor control and improved cognitive preservation compared to conventional whole brain radiation therapy. However, the risk of local failure and treatment-related complications (e.g. radiation necrosis) markedly increases with larger postoperative treatment volumes. Additionally, the risk of leptomeningeal disease is significantly higher in patients treated with postoperative SRS. In the setting of high grade glioma, preclinical reports have suggested that preoperative SRS may enhance anti-tumor immunity as compared to postoperative radiotherapy. In addition to potentially permitting smaller target volumes, tissue analysis may permit characterization of DNA repair pathways and tumor microenvironment changes in response to SRS, which may be used to further tailor therapy and identify novel therapeutic targets. Building on the work from preoperative SRS for brain metastases and preclinical work for high grade gliomas, further exploration of this treatment paradigm in the latter is warranted. Presently, there are prospective early phase clinical trials underway investigating the role of preoperative SRS in the management of high grade gliomas. In the forthcoming sections, we review the biologic rationale for preoperative SRS, as well as pertinent preclinical and clinical data, including ongoing and planned prospective clinical trials.
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Affiliation(s)
- Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Roman O. Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Kenneth W. Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Paul D. Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Joshua D. Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Stuart H. Burri
- Department of Radiation Oncology, Atrium Health, Charlotte, NC, United States
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | | | - Daniel M. Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States,Correspondence: Daniel M. Trifiletti
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19
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Cantaloube M, Boucekine M, Balossier A, Muracciole X, Meyer M, Delsanti C, Carron R, Beltaifa YM, Figarella-Branger D, Regis J, Padovani L. Stereotactic radiosurgery for post operative brain metastasic surgical cavities: a single institution experience. Radiat Oncol 2022; 17:160. [PMID: 36163026 PMCID: PMC9513906 DOI: 10.1186/s13014-022-02118-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The standard therapy for brain metastasis was surgery combined with whole brain radiotherapy (WBRT). The latter is however, associated with important neurocognitive toxicity. To reduce this toxicity, postoperative stereotactic radiosurgery (SRS) is a promising technique. We assessed the efficacy and the tolerance to postoperative Gamma Knife radiosurgery (GK) on the tumor bed after resection of brain metastases. METHODS Between February 2011 and December 2016, following macroscopic complete surgical resection, 64 patients and 65 surgical cavities were treated by GK in our institution. The indication for adjuvant radiosurgery was a multidisciplinary decision. The main assessment criteria considered in this study were local control, intracranial metastasis-free survival (ICMFS), overall survival and toxicity. RESULTS Median follow-up: 11.1 months. Median time between surgery and radiosurgery: 35 days. Median dose was 20 Gy prescribed to the 50% isodose line, for a median treated volume of 5.6 cc. Four patients (7%) suffered from local recurrence. Local recurrence-free, intracranial recurrence-free and overall survival at 1 year were 97.5%, 57.6% and 62.4% respectively. In total, 23 patients (41%) suffered from intracranial recurrence outside the tumor bed. In univariate analysis: concomitant GK treatment of multiple lesions and the tumor bed was associated with a decrease in ICMFS (HR = 1.16 [1.005-1.34] p = 0.04). In multivariate analysis: a non-lung primary tumor was significantly associated with a decrease in ICMFS (HR = 8.04 [1.82-35.4] p = 0.006). An increase in performance status (PS) and in the initial number of cerebral metastases significantly reduced overall survival (HR = 5.4 [1.11-26.3] p = 0.037, HR = 2.7 [1.004-7.36] p = 0.049, respectively) and One radiation necrosis histologically proven. CONCLUSION Our study confirmed that postoperative GK after resection of cerebral metastases is an efficient and well-tolerated technique, to treat volumes of all sizes (0.8 to 40 cc). Iterative SRS or salvage WBRT can be performed in cases of intracranial relapse, postponing WBRT with its potential side effects.
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Affiliation(s)
- Marie Cantaloube
- Radiotherapy Department, Assistance Publique Des Hôpitaux de Marseille, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Mohamed Boucekine
- Unity of Research EA3279, Aix-Marseille Université, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Anne Balossier
- Department of Functional and Stereotactic Neurosurgery and Radiosurgery, Timone University Hospital, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Xavier Muracciole
- Radiotherapy Department, Assistance Publique Des Hôpitaux de Marseille, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Mickael Meyer
- Department of Neurosurgery, Hôpital de La Timone, Assistance Publique-Hôpitaux de Marseille, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Christine Delsanti
- Department of Functional and Stereotactic Neurosurgery and Radiosurgery, Timone University Hospital, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Romain Carron
- Department of Functional and Stereotactic Neurosurgery and Radiosurgery, Timone University Hospital, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Yassine Mohamed Beltaifa
- Department of Functional and Stereotactic Neurosurgery and Radiosurgery, Timone University Hospital, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Domnique Figarella-Branger
- Neuropathology Department, Assistance Publique Des Hôpitaux de Marseille, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Jean Regis
- Department of Functional and Stereotactic Neurosurgery and Radiosurgery, Timone University Hospital, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Laetitia Padovani
- Radiotherapy Department, Assistance Publique Des Hôpitaux de Marseille, Marseille, France. .,Neuropathology Department, Assistance Publique Des Hôpitaux de Marseille, Marseille, France. .,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France. .,Radiotherapy Department, Assistance Publique des Hôpitaux de Marseille, marseille, France.
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20
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Neoadjuvant Stereotactic Radiotherapy for Brain Metastases: Systematic Review and Meta-Analysis of the Literature and Ongoing Clinical Trials. Cancers (Basel) 2022; 14:cancers14174328. [PMID: 36077863 PMCID: PMC9455064 DOI: 10.3390/cancers14174328] [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: 08/11/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary The available treatment strategies for patients with brain metastases remain suboptimal, with current research focused on identifying therapies intended to improve patient outcomes while reducing the risk of treatment-related complications. Several studies have investigated the role of pre-operative neoadjuvant stereotactic radiotherapy, and have proposed it as a valid alternative to post-operative adjuvant stereotactic radiotherapy. The aim of our systematic review was to comprehensively analyze the current literature and ongoing clinical trials evaluating neoadjuvant stereotactic radiotherapy in patients with brain metastases, describing treatment protocols and related outcomes. Early evidence suggests that neoadjuvant stereotactic radiotherapy may offer rates of local control and overall survival comparable to those obtained with adjuvant postoperative SRS, but comparative studies are currently lacking. In addition, neoadjuvant stereotactic radiotherapy shows low rates of post-treatment radiation necrosis and leptomeningeal metastases. Ongoing clinical trials aim to evaluate long-term outcomes in large patient cohorts, with some focused on comparing neoadjuvant stereotactic radiotherapy to adjuvant stereotactic radiosurgery. Abstract Background: Brain metastases (BMs) carry a high morbidity and mortality burden. Neoadjuvant stereotactic radiotherapy (NaSRT) has shown promising results. We systematically reviewed the literature on NaSRT for BMs. Methods: PubMed, EMBASE, Scopus, Web-of-Science, Cochrane, and ClinicalTrial.gov were searched following the PRISMA guidelines to include studies and ongoing trials reporting NaSRT for BMs. Indications, protocols, and outcomes were analyzed using indirect random-effect meta-analyses. Results: We included 7 studies comprising 460 patients with 483 BMs, and 13 ongoing trials. Most BMs originated from non-small lung cell carcinoma (41.4%), breast cancer (18.7%) and melanoma (43.6%). Most patients had single-BM (69.8%) located supratentorial (77.8%). Patients were eligible if they had histologically-proven primary tumors and ≤4 synchronous BMs candidate for non-urgent surgery and radiation. Patients with primary tumors clinically responsive to radiotherapy, prior brain radiation, and leptomeningeal metastases were deemed non-eligible. Median planning target volume was 9.9 cm3 (range, 2.9–57.1), and NaSRT was delivered in 1-fraction (90.9%), 5-fraction (4.8%), or 3-fraction (4.3%), with a median biological effective dose of 39.6 Gy10 (range, 35.7–60). Most patients received piecemeal (76.3%) and gross-total (94%) resection after a median of 1-day (range, 1–10) post-NaSRT. Median follow-up was 19.2-months (range, 1–41.3). Actuarial post-treatment rates were 4% (95%CI: 2–6%) for symptomatic radiation necrosis, 15% (95%CI: 12–18%) and 47% (95%CI: 42–52%) for local and distant recurrences, 6% (95%CI: 3–8%) for leptomeningeal metastases, 81% (95%CI: 75–87%) and 59% (95%CI: 54–63%) for 1-year local tumor control and overall survival. Conclusion: NaSRT is effective and safe for BMs. Ongoing trials will provide high-level evidence on long-term post-treatment outcomes, further compared to adjuvant stereotactic radiotherapy.
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21
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Steininger K, Kahl KH, Konietzko I, Wolfert C, Motov S, Krauß PE, Bröcheler T, Hadrawa M, Sommer B, Stüben G, Shiban E. Intraoperative radiotherapy during awake craniotomies: preliminary results of a single-center case series. Neurosurg Rev 2022; 45:3657-3663. [PMID: 35881316 DOI: 10.1007/s10143-022-01838-9] [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: 05/26/2022] [Revised: 07/06/2022] [Accepted: 07/18/2022] [Indexed: 12/01/2022]
Abstract
Awake craniotomies are performed to avoid postoperative neurological deficits when resecting lesions in the eloquent cortex, especially the speech area. Intraoperative radiotherapy (IORT) has recently focused on optimizing the oncological treatment of primary malignant brain tumors and metastases. Herein, for the first time, we present preliminary results of IORT in the setting of awake craniotomies. From 2021 to 2022, all patients undergoing awake craniotomies for tumor resection combined with IORT were analyzed retrospectively. Demographical and clinical data, operative procedure, and treatment-related complications were evaluated. Five patients were identified (age (mean ± standard deviation (SD): 65 ± 13.5 years (y)). A solid left frontal metastasis was detected in the first patient (female, 49 y). The second patient (male, 72 y) presented with a solid metastasis on the left parietal lobe. The third patient (male, 52 y) was diagnosed with a left temporoparietal metastasis. Patient four (male, 74 y) was diagnosed with a high-grade glioma on the left frontal lobe. A metastasis on the left temporooccipital lobe was detected in the fifth patient (male, 78 y). After awake craniotomy and macroscopic complete tumor resection, intraoperative tumor bed irradiation was carried out with 50 kV x-rays and a total of 20 Gy for 16.7 ± 2.5 min. During a mean follow-up of 6.3 ± 2.6 months, none of the patients developed any surgery- or IORT-related complications or disabling permanent neurological deficits. Intraoperative radiotherapy in combination with awake craniotomy seems to be feasible and safe.
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Affiliation(s)
- K Steininger
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany.
| | - K H Kahl
- Department of Radiation Therapy, University Hospital Augsburg, Augsburg, Germany
| | - I Konietzko
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
| | - C Wolfert
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
| | - S Motov
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
| | - P E Krauß
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
| | - T Bröcheler
- Department of Anesthesia, University Hospital Augsburg, Augsburg, Germany
| | - M Hadrawa
- Department of Anesthesia, University Hospital Augsburg, Augsburg, Germany
| | - B Sommer
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
| | - G Stüben
- Department of Radiation Therapy, University Hospital Augsburg, Augsburg, Germany
| | - E Shiban
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
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22
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Palmisciano P, Haider AS, Balasubramanian K, D'Amico RS, Wernicke AG. The role of cesium-131 brachytherapy in brain tumors: a scoping review of the literature and ongoing clinical trials. J Neurooncol 2022; 159:117-133. [PMID: 35696019 DOI: 10.1007/s11060-022-04050-3] [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: 05/09/2022] [Accepted: 05/27/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Cesium-131 radioactive isotope has favored the resurgence of intracavitary brachytherapy in neuro-oncology, minimizing radiation-induced complications and maximizing logistical and clinical outcomes. We reviewed the literature on cesium-131 brachytherapy for brain tumors. METHODS PubMed, Web-of-Science, Scopus, Clinicaltrial.gov, and Cochrane were searched following the PRISMA extension for scoping reviews to include published studies and ongoing trials reporting cesium-131 brachytherapy for brain tumors. RESULTS We included 27 published studies comprising 279 patients with 293 lesions, and 3 ongoing trials. Most patients had brain metastases (63.1%), followed by high-grade gliomas (23.3%), of WHO Grade III (15.2%) and Grade IV (84.8%), and meningiomas (13.6%), mostly of WHO Grade II (62.8%) and Grade III (27.9%). Most brain metastases were newly diagnosed (72.3%), while most gliomas and meningiomas were recurrent (95.4% and 88.4%). Patients underwent gross-total (91.1%) or subtotal (8.9%) resection, with median postoperative cavity size of 3.5 cm (range 1-5.8 cm). A median of 20, 28, and 16 seeds were implanted in gliomas, meningiomas, and brain metastases, with median seed activity of 3.8 mCi (range 2.4-5 mCi). Median follow-up was 16.2 months (range 0.6-72 months). 1-year freedom from progression rates were local 94% (range 57-100%), regional 85.1% (range 55.6-93.8%), and distant 53.5% (range 26.3-67.4%). Post-treatment radiation necrosis, seizure, and surgical wound infection occurred in 3.4%, 4.7%, and 4.3% patients. CONCLUSION Initial data suggest that cesium-131 brachytherapy is safe and effective in primary or metastatic malignant brain tumors. Ongoing trials are evaluating long-term locoregional tumor control and future studies should analyze its role in multimodal systemic tumor management.
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Affiliation(s)
- Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ali S Haider
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | | | - Randy S D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra, New York, NY, USA
| | - Alla Gabriella Wernicke
- Department of Radiation Oncology, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra, New York, NY, USA. .,Department of Radiation Medicine, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra, 130 East 77th Street, New York, NY, 10075, USA.
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23
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Hamed M, Potthoff AL, Layer JP, Koch D, Borger V, Heimann M, Scafa D, Sarria GR, Holz JA, Schmeel FC, Radbruch A, Güresir E, Schäfer N, Schuss P, Garbe S, Giordano FA, Herrlinger U, Vatter H, Schmeel LC, Schneider M. Benchmarking Safety Indicators of Surgical Treatment of Brain Metastases Combined with Intraoperative Radiotherapy: Results of Prospective Observational Study with Comparative Matched-Pair Analysis. Cancers (Basel) 2022; 14:cancers14061515. [PMID: 35326666 PMCID: PMC8946541 DOI: 10.3390/cancers14061515] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/05/2022] [Accepted: 03/08/2022] [Indexed: 12/07/2022] Open
Abstract
Simple Summary Patients with brain metastasis (BM) are at advanced stages of metastatic cancer, and surgical resection is often required in order to avoid severe neurologic deficits. After surgery, patients are usually committed to postoperative radiotherapy. In recent years, intraoperative radiotherapy (IORT) has been proposed as an alternative to conventional postsurgical radiation approaches. This possibility has several advantages, e.g., as IORT is administered only once during the surgical procedure, patients do not have to attend several radiotherapy sessions afterward. However, the application of radiation therapy directly into the open brain during surgery might be accompanied by severe perioperative complications and, therefore, might negatively impact the overall benefit. In the present study, we show that patients who underwent surgery for BM combined with IORT do not suffer from elevated levels of perioperative complications compared to patients without IORT. Therefore, IORT constitutes a safe treatment strategy for cancer patients with BM. Abstract Intraoperative radiotherapy (IORT) of the operative cavity for surgically treated brain metastasis (BM) has gained increasing prominence with respect to improved local tumor control. However, IORT immediately performed at the time of surgery might be associated with increased levels of perioperative adverse events (PAEs). In the present study, we performed safety metric profiling in patients who had undergone surgery for BM with and without IORT in order to comparatively analyze feasibility of IORT as an adjuvant radiation approach. Between November 2020 and October 2021, 35 patients were surgically treated for BM with IORT at our neuro-oncological center. Perioperative complication profiles were collected in a prospective observational cohort study by means of patient safety indicators (PSIs), hospital-acquired conditions (HACs), and specific cranial-surgery-related complications (CSCs) as high-standard quality metric tools and compared to those of an institutional cohort of 388 patients with BM resection without IORT in a balanced comparative matched-pair analysis. Overall, 4 out of 35 patients (11%) with IORT in the course BM resection suffered from PAEs, accounting for 3 PSIs (9%) and 1 HAC (3%). Balanced matched-pair analysis did not reveal significant differences in the perioperative complication profiles between the cohorts of patients with and without IORT (p = 0.44). Thirty-day mortality rates were 6% for patients with IORT versus 8% for patients without IORT (p = 0.73). The present study demonstrates that IORT constitutes a safe and clinically feasible adjuvant treatment modality in patients undergoing surgical resection of BM.
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Affiliation(s)
- Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (V.B.); (M.H.); (E.G.); (P.S.); (H.V.)
| | - Anna-Laura Potthoff
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (V.B.); (M.H.); (E.G.); (P.S.); (H.V.)
- Correspondence: (A.-L.P.); (M.S.)
| | - Julian P. Layer
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany; (J.P.L.); (D.K.); (D.S.); (G.R.S.); (J.A.H.); (S.G.); (F.A.G.); (L.C.S.)
| | - David Koch
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany; (J.P.L.); (D.K.); (D.S.); (G.R.S.); (J.A.H.); (S.G.); (F.A.G.); (L.C.S.)
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (V.B.); (M.H.); (E.G.); (P.S.); (H.V.)
| | - Muriel Heimann
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (V.B.); (M.H.); (E.G.); (P.S.); (H.V.)
| | - Davide Scafa
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany; (J.P.L.); (D.K.); (D.S.); (G.R.S.); (J.A.H.); (S.G.); (F.A.G.); (L.C.S.)
| | - Gustavo R. Sarria
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany; (J.P.L.); (D.K.); (D.S.); (G.R.S.); (J.A.H.); (S.G.); (F.A.G.); (L.C.S.)
| | - Jasmin A. Holz
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany; (J.P.L.); (D.K.); (D.S.); (G.R.S.); (J.A.H.); (S.G.); (F.A.G.); (L.C.S.)
| | | | - Alexander Radbruch
- Department of Neuroradiology, University Hospital Bonn, 53127 Bonn, Germany; (F.C.S.); (A.R.)
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (V.B.); (M.H.); (E.G.); (P.S.); (H.V.)
| | - Niklas Schäfer
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany; (N.S.); (U.H.)
| | - Patrick Schuss
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (V.B.); (M.H.); (E.G.); (P.S.); (H.V.)
- Department of Neurosurgery, BG Klinikum Unfallkrankenhaus Berlin, 12683 Berlin, Germany
| | - Stephan Garbe
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany; (J.P.L.); (D.K.); (D.S.); (G.R.S.); (J.A.H.); (S.G.); (F.A.G.); (L.C.S.)
| | - Frank A. Giordano
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany; (J.P.L.); (D.K.); (D.S.); (G.R.S.); (J.A.H.); (S.G.); (F.A.G.); (L.C.S.)
| | - Ulrich Herrlinger
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany; (N.S.); (U.H.)
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (V.B.); (M.H.); (E.G.); (P.S.); (H.V.)
| | - Leonard Christopher Schmeel
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany; (J.P.L.); (D.K.); (D.S.); (G.R.S.); (J.A.H.); (S.G.); (F.A.G.); (L.C.S.)
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (V.B.); (M.H.); (E.G.); (P.S.); (H.V.)
- Correspondence: (A.-L.P.); (M.S.)
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Sarmey N, Kaisman-Elbaz T, Mohammadi AM. Management Strategies for Large Brain Metastases. Front Oncol 2022; 12:827304. [PMID: 35251995 PMCID: PMC8894177 DOI: 10.3389/fonc.2022.827304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Brain metastases represent the most common intracranial neoplasm and pose a significant disease burden on the individual and the healthcare system. Although whole brain radiation therapy was historically a first line approach, subsequent research and technological advancements have resulted in a larger armamentarium of strategies for treatment of these patients. While chemotherapeutic options remain limited, surgical resection and stereotactic radiosurgery, as well as their combination therapies, have shifted the paradigms for managing intracranial metastatic disease. Ultimately, no single treatment is shown to be consistently effective across patient groups in terms of overall survival, local and distant control, neurocognitive function, and performance status. However, close consideration of patient and tumor characteristics may help delineate more favorable treatment strategies for individual patients. Here the authors present a review of the recent literature surrounding surgery, whole brain radiation therapy, stereotactic radiosurgery, and combination approaches.
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25
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Pinnaduwage DS, Srivastava SP, Yan X, Jani S, Brachman DG, Sorensen SP. Dosimetric Impacts of Source Migration, Radioisotope Type, and Decay with Permanent Implantable Collagen Tile Brachytherapy for Brain Tumors. Technol Cancer Res Treat 2022; 21:15330338221106852. [PMID: 35712977 PMCID: PMC9210077 DOI: 10.1177/15330338221106852] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/13/2022] [Accepted: 05/25/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: Brachytherapy using permanently implantable collagen tiles containing cesium-131 (Cs-131) is indicated for treatment of malignant intracranial neoplasms. We quantified Cs-131 source migration and modeled the resulting dosimetric impact for Cs-131, iodine-125 (I-125), and palladium-103 (Pd-103). Methods and Materials: This was a retrospective analysis of a subgroup of patients enrolled in a prospective, single-center, nonrandomized, clinical trial (NCT03088579) of Cs-131 collagen tile brachytherapy. Postimplant Cs-131 plans and hypothetical I-125 and Pd-103 calculations were compared for 20 glioblastoma patients for a set seed geometry. Dosimetric impact of decay and seed migration was calculated for 2 hypothetical scenarios: Scenario 1, assuming seed positions on a given image set were unchanged until acquisition of the subsequent set; Scenario 2, assuming any change in seed positions occurred the day following acquisition of the prior images. Seed migration over time was quantified for a subset of 7 patients who underwent subsequent image-guided radiotherapy. Results: Mean seed migration was 1.7 mm (range: 0.7-3.1); maximum seed migration was 4.3 mm. Mean dose to the 60 Gy volume differed by 0.4 Gy (0.6%, range 0.1-1.0) and 0.9 Gy (1.5%, range 0.2-1.7) for Cs-131, 1.2 Gy (2.0%, range 0.1-2.1) and 1.6 Gy (2.6%, range 1.2-2.6) for I-125, and 0.8 Gy (1.3%, range 0.2-1.5) and 1.4 Gy (2.3%, range 0.3-1.9) for Pd-103, for Scenarios 1 and 2, respectively, compared with the postimplant plan. For a set seed geometry mean implant dose was higher for Pd-103 (1.3 times) and I-125 (1.1 times) versus Cs-131. Dose fall-off was steepest for Pd-103: gradient index 1.88 versus 2.23 (I-125) and 2.40 (Cs-131). Conclusions: Dose differences due to source migration were relatively small, suggesting robust prevention of seed migration from Cs-131-containing collagen tiles. Intratarget heterogeneity was greater with Pd-103 and I-125 than Cs-131. Dose fall-off was fastest with Pd-103 followed by I-125 and then Cs-131.
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Affiliation(s)
- Dilini S. Pinnaduwage
- Department of Radiation Oncology, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Shiv P. Srivastava
- Department of Radiation Oncology, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Xiangsheng Yan
- Department of Radiation Oncology, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Shyam Jani
- Department of Radiation Oncology, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - David G. Brachman
- Department of Radiation Oncology, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
- GT Medical Technologies, Tempe, AZ, USA
| | - Stephen P. Sorensen
- Department of Radiation Oncology, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
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26
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Cifarelli CP, Jacobson GM. Intraoperative Radiotherapy in Brain Malignancies: Indications and Outcomes in Primary and Metastatic Brain Tumors. Front Oncol 2021; 11:768168. [PMID: 34858846 PMCID: PMC8631760 DOI: 10.3389/fonc.2021.768168] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/14/2021] [Indexed: 12/22/2022] Open
Abstract
Despite the continued controversy over defining an optimal delivery mechanism, the critical role of adjuvant radiation in the management of surgically resected primary and metastatic brain tumors remains one of the universally accepted standards in neuro-oncology. Local disease control still ranks as a significant predictor of survival in both high-grade glioma and treated intracranial metastases with radiation treatment being essential in maximizing tumor control. As with the emergence and eventual acceptance of cranial stereotactic radiosurgery (SRS) following an era dominated by traditional radiotherapy, evidence to support the use of intraoperative radiotherapy (IORT) in brain tumors requiring surgical intervention continues to accumulate. While the clinical trial strategies in treating glioblastoma with IORT involve delivery of a boost of cavitary radiation prior to the planned standard external beam radiation, the use of IORT in metastatic disease offers the potential for dose escalation to the level needed for definitive adjuvant radiation, eliminating the need for additional episodes of care while providing local control equal or superior to that achieved with SRS in a single fraction. In this review, we explore the contemporary clinical data on IORT in the treatment of brain tumors along with a discussion of the unique dosimetric and radiobiological factors inherent in IORT that could account for favorable outcome data beyond those seen in other techniques.
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Affiliation(s)
- Christopher P Cifarelli
- Department of Neurosurgery, West Virginia University, Morgantown, WV, United States.,Department of Radiation Oncology, West Virginia University, Morgantown, WV, United States
| | - Geraldine M Jacobson
- Department of Radiation Oncology, West Virginia University, Morgantown, WV, United States
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27
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Kahl KH, Balagiannis N, Höck M, Schill S, Roushan Z, Shiban E, Müller H, Grossert U, Konietzko I, Sommer B, Maurer CJ, Berlis A, Heidecke V, Janzen T, Stüben G. Intraoperative radiotherapy with low-energy x-rays after neurosurgical resection of brain metastases-an Augsburg University Medical Center experience. Strahlenther Onkol 2021; 197:1124-1130. [PMID: 34415358 PMCID: PMC8604815 DOI: 10.1007/s00066-021-01831-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/18/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE External-beam radiotherapy (EBRT) is the predominant method for localized brain radiotherapy (LBRT) after resection of brain metastases (BM). Intraoperative radiotherapy (IORT) with 50-kV x‑rays is an alternative way to focally irradiate the resection cavity after BM surgery, with the option of shortening the overall treatment time and limiting normal tissue irradiation. METHODS We retrospectively analyzed the outcomes of all patients who underwent neurosurgical resection of BM and 50-kV x‑ray IORT between 2013 and 2020 at Augsburg University Medical Center. RESULTS We identified 40 patients with 44 resected BM treated with 50-kV x‑ray IORT. Median diameter of the resected metastases was 2.8 cm (range 1.5-5.9 cm). Median applied dose was 20 Gy. All patients received standardized follow-up (FU) including 3‑monthly MRI of the brain. Mean FU was 14.4 months, with a median MRI FU for alive patients of 12.2 months. Median overall survival (OS) of all treated patients was 26.4 months (estimated 1‑year OS 61.6%). The observed local control (LC) rate of the resection cavity was 88.6% (estimated 1‑year LC 84.3%). Distant brain control (DC) was 47.5% (estimated 1‑year DC 33.5%). Only 25% of all patients needed WBI in the further course of disease. The observed radionecrosis rate was 2.5%. CONCLUSION IORT with 50-kV x‑rays is a safe and appealing way to apply LBRT after neurosurgical resection of BM, with low toxicity and excellent LC. Close MRI FU is paramount to detect distant brain failure (DBF) early.
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Affiliation(s)
- Klaus-Henning Kahl
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Augsburg, Stenglinstraße 2, 86156 Augsburg, Germany
| | - Nikolaos Balagiannis
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Augsburg, Stenglinstraße 2, 86156 Augsburg, Germany
| | - Michael Höck
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Augsburg, Stenglinstraße 2, 86156 Augsburg, Germany
| | - Sabine Schill
- Medizinische Physik und Strahlenschutz, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Zoha Roushan
- Medizinische Physik und Strahlenschutz, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Ehab Shiban
- Klinik für Neurochirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Heiko Müller
- Klinik für Neurochirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Ute Grossert
- Klinik für Neurochirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Ina Konietzko
- Klinik für Neurochirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Björn Sommer
- Klinik für Neurochirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Christoph J. Maurer
- Klinik für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Ansgar Berlis
- Klinik für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Volkmar Heidecke
- Klinik für Neurochirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Tilman Janzen
- Medizinische Physik und Strahlenschutz, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Georg Stüben
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Augsburg, Stenglinstraße 2, 86156 Augsburg, Germany
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28
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Elbanna M, Chowdhury NN, Rhome R, Fishel ML. Clinical and Preclinical Outcomes of Combining Targeted Therapy With Radiotherapy. Front Oncol 2021; 11:749496. [PMID: 34733787 PMCID: PMC8558533 DOI: 10.3389/fonc.2021.749496] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/30/2021] [Indexed: 12/12/2022] Open
Abstract
In the era of precision medicine, radiation medicine is currently focused on the precise delivery of highly conformal radiation treatments. However, the tremendous developments in targeted therapy are yet to fulfill their full promise and arguably have the potential to dramatically enhance the radiation therapeutic ratio. The increased ability to molecularly profile tumors both at diagnosis and at relapse and the co-incident progress in the field of radiogenomics could potentially pave the way for a more personalized approach to radiation treatment in contrast to the current ‘‘one size fits all’’ paradigm. Few clinical trials to date have shown an improved clinical outcome when combining targeted agents with radiation therapy, however, most have failed to show benefit, which is arguably due to limited preclinical data. Several key molecular pathways could theoretically enhance therapeutic effect of radiation when rationally targeted either by directly enhancing tumor cell kill or indirectly through the abscopal effect of radiation when combined with novel immunotherapies. The timing of combining molecular targeted therapy with radiation is also important to determine and could greatly affect the outcome depending on which pathway is being inhibited.
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Affiliation(s)
- May Elbanna
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN, United States.,Indiana University Simon Comprehensive Cancer Center, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Nayela N Chowdhury
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ryan Rhome
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN, United States.,Indiana University Simon Comprehensive Cancer Center, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Melissa L Fishel
- Indiana University Simon Comprehensive Cancer Center, Indiana University School of Medicine, Indianapolis, IN, United States.,Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN, United States.,Department of Pediatrics and Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, United States
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29
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Vaidya JS, Bulsara M, Baum M, Wenz F, Massarut S, Pigorsch S, Alvarado M, Douek M, Saunders C, Flyger H, Eiermann W, Brew-Graves C, Williams NR, Potyka I, Roberts N, Bernstein M, Brown D, Sperk E, Laws S, Sütterlin M, Corica T, Lundgren S, Holmes D, Vinante L, Bozza F, Pazos M, Blanc-Onfroy ML, Gruber G, Polkowski W, Dedes KJ, Niewald M, Blohmer J, McReady D, Hoefer R, Kelemen P, Petralia G, Falzon M, Joseph D, Tobias JS. New clinical and biological insights from the international TARGIT-A randomised trial of targeted intraoperative radiotherapy during lumpectomy for breast cancer. Br J Cancer 2021; 125:380-389. [PMID: 34035435 PMCID: PMC8329051 DOI: 10.1038/s41416-021-01440-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 04/26/2021] [Accepted: 05/13/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The TARGIT-A trial reported risk-adapted targeted intraoperative radiotherapy (TARGIT-IORT) during lumpectomy for breast cancer to be as effective as whole-breast external beam radiotherapy (EBRT). Here, we present further detailed analyses. METHODS In total, 2298 women (≥45 years, invasive ductal carcinoma ≤3.5 cm, cN0-N1) were randomised. We investigated the impact of tumour size, grade, ER, PgR, HER2 and lymph node status on local recurrence-free survival, and of local recurrence on distant relapse and mortality. We analysed the predictive factors for recommending supplemental EBRT after TARGIT-IORT as part of the risk-adapted approach, using regression modelling. Non-breast cancer mortality was compared between TARGIT-IORT plus EBRT vs. EBRT. RESULTS Local recurrence-free survival was no different between TARGIT-IORT and EBRT, in every tumour subgroup. Unlike in the EBRT arm, local recurrence in the TARGIT-IORT arm was not a predictor of a higher risk of distant relapse or death. Our new predictive tool for recommending supplemental EBRT after TARGIT-IORT is at https://targit.org.uk/addrt . Non-breast cancer mortality was significantly lower in the TARGIT-IORT arm, even when patients received supplemental EBRT, HR 0.38 (95% CI 0.17-0.88) P = 0.0091. CONCLUSION TARGIT-IORT is as effective as EBRT in all subgroups. Local recurrence after TARGIT-IORT, unlike after EBRT, has a good prognosis. TARGIT-IORT might have a beneficial abscopal effect. TRIAL REGISTRATION ISRCTN34086741 (21/7/2004), NCT00983684 (24/9/2009).
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Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, UK.
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Steffi Pigorsch
- Department of Radiation Oncology, Red Cross Hospital, Technical University of Munich, Munich, Germany
| | - Michael Alvarado
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Michael Douek
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - Henrik Flyger
- Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark
| | - Wolfgang Eiermann
- Department of Gynecology and Obstetrics, Red Cross Hospital, Technical University of Munich, Munich, Germany
| | - Chris Brew-Graves
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Norman R Williams
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Ingrid Potyka
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Nicholas Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | | | - Douglas Brown
- Department of Surgery, Ninewells Hospital, Dundee, UK
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Siobhan Laws
- Department of Surgery, Royal Hampshire County Hospital, Winchester, UK
| | - Marc Sütterlin
- Department of Gynecology and Obstetrics, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Berlin, Germany
| | - Tammy Corica
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Steinar Lundgren
- Department of Oncology, St Olav's University Hospital, & Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Dennis Holmes
- John Wayne Cancer Institute & Helen Rey Breast Cancer Foundation, University of Southern California, Los Angeles, CA, USA
| | - Lorenzo Vinante
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Fernando Bozza
- Department of Surgery, Instituto Oncologico Veneto (IVO) IRCCS, Padoa, Italy
| | - Montserrat Pazos
- Department of Radiation Oncology, University Hospital, Ludwig Maximilians Universitat, Munich, Germany
| | | | | | - Wojciech Polkowski
- Department of Surgical Oncology, Medical University of Lublin, Lublin, Poland
| | | | | | - Jens Blohmer
- Sankt Gertrauden-Krankenhaus, and The Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | | | - Pond Kelemen
- Ashikari Breast Center, New York Medical College, New York, NY, USA
| | - Gloria Petralia
- Department of Surgery, University College London Hospitals, London, UK
| | - Mary Falzon
- Department of Pathology University College London Hospitals, London, UK
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, UK
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30
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Sarria GR, Cifarelli CP, Kahl H, Giordano FA. In regard to Minniti et al.: Current status and recent advances in resection cavity irradiation of brain metastases-roundup to cover all angles. Radiat Oncol 2021; 16:127. [PMID: 34246284 PMCID: PMC8272371 DOI: 10.1186/s13014-021-01854-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 07/04/2021] [Indexed: 11/10/2022] Open
Abstract
We read with great interest the recent review, entitled "Current status and recent advances in resection cavity irradiation of brain metastases". It is a comprehensive summary of currently available techniques for treatment of post-resection cavity in patients with this diagnosis. We would like to complement this manuscript by including intraoperative techniques as other viable approaches in the management of these patients.
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Affiliation(s)
- Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Venusberg Campus 1 Building 55, 53127, Bonn, Germany
| | - Christopher P Cifarelli
- Department of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown, WV, USA
| | - Henning Kahl
- Department of Radiation Oncology, University Hospital Augsburg, Augsburg, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Venusberg Campus 1 Building 55, 53127, Bonn, Germany.
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Liu B, Ge L, Wang J, Chen YQ, Ma SX, Ma PL, Zhang YQ, Yang KH, Cai H. Efficacy and safety of intraoperative radiotherapy in rectal cancer: A systematic review and meta-analysis. World J Gastrointest Oncol 2021; 13:69-86. [PMID: 33510850 PMCID: PMC7805273 DOI: 10.4251/wjgo.v13.i1.69] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/06/2020] [Accepted: 12/17/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In recent years, intraoperative radiotherapy (IORT) has been increasingly used for the treatment of rectal cancer. However, the efficacy and safety of IORT for the treatment of rectal cancer are still controversial.
AIM To evaluate the value of IORT for patients with rectal cancer.
METHODS We searched PubMed, Embase, Cochrane Library, Web of Science databases, and conference abstracts and included randomized controlled trials and observational studies on IORT vs non-IORT for rectal cancer. Dichotomous variables were evaluated by odds ratio (OR) and 95% confidence interval (CI), hazard ratio (HR) and 95%CI was used as a summary statistic of survival outcomes. Statistical analyses were performed using Stata V.15.0 and Review Manager 5.3 software.
RESULTS In this study, 3 randomized controlled studies and 12 observational studies were included with a total of 1460 patients, who are mainly residents of Europe, the United States, and Asia. Our results did not show significant differences in 5-year overall survival (HR = 0.80, 95%CI = 0.60-1.06; P = 0.126); 5-year disease-free survival (HR = 0.94, 95%CI = 0.73-1.22; P = 0.650); abscess (OR = 1.10, 95%CI = 0.67-1.80; P = 0.713), fistulae (OR = 0.79, 95%CI = 0.33-1.89; P = 0.600); wound complication (OR = 1.21, 95%CI = 0.62-2.36; P = 0.575); anastomotic leakage (OR = 1.09, 95%CI = 0.59-2.02; P = 0.775); and neurogenic bladder dysfunction (OR = 0.69, 95%CI = 0.31-1.55; P = 0.369). However, the meta-analysis of 5-year local control was significantly different (OR = 3.07, 95%CI = 1.66-5.66; P = 0.000).
CONCLUSION The advantage of IORT is mainly reflected in 5-year local control, but it is not statistically significant for 5-year overall survival, 5-year disease-free survival, and complications.
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Affiliation(s)
- Bin Liu
- Gansu Provincial Hospital, General Surgery Clinical Medical Center, Lanzhou 730000, Gansu Province, China
| | - Long Ge
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Jing Wang
- Gansu University of Chinese Medicine, Gansu University of Chinese Medicine, Lanzhou 730000, Gansu Province, China
| | - Ya-Qiong Chen
- Gansu Provincial Hospital, General Surgery Clinical Medical Center, Lanzhou 730000, Gansu Province, China
| | - Shi-Xun Ma
- Gansu Provincial Hospital, General Surgery Clinical Medical Center, Lanzhou 730000, Gansu Province, China
| | - Pei-Lan Ma
- Gansu Provincial Hospital, General Surgery Clinical Medical Center, Lanzhou 730000, Gansu Province, China
| | - Yun-Qiang Zhang
- Gansu Provincial Hospital, General Surgery Clinical Medical Center, Lanzhou 730000, Gansu Province, China
| | - Ke-Hu Yang
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Hui Cai
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou 730000, Gansu Province, China
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Dahshan BA, Weir JS, Bice RP, Renz P, Cifarelli DT, Poplawski L, Hack J, Vargo JA, Cifarelli CP. Dose homogeneity analysis of adjuvant radiation treatment in surgically resected brain metastases: Comparison of IORT, SRS, and IMRT indices. Brachytherapy 2021; 20:426-432. [PMID: 33454200 DOI: 10.1016/j.brachy.2020.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/10/2020] [Accepted: 11/10/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Although surgery remains a treatment option for symptomatic brain metastases, the need for adjuvant radiation after surgery is widely accepted as standard. Despite a multitude of randomized trials aimed at identifying the ideal radiation treatment plan for surgically resected metastases, the development of new delivery regiments necessitates a periodic re-evaluation of dosimetric performance/outcome. Here, we compare the homogeneity index (HI) across three platforms: single-session stereotactic radiosurgery (SRS), multisession stereotactic radiotherapy, and intraoperative radiotherapy (IORT). METHODS AND MATERIALS Patients treated with IORT after surgical resection of brain metastases were identified and dosimetric parameters collected from the dose-volume histograms based on the development of conformal plans for adjuvant radiation using Gamma Knife-SRS (GK-SRS), linear accelerator based intensity-modulated radiation therapy, and IORT. HIs were calculated using four established methods and compared across platforms within the patient cohort. Statistical analyses were performed using analysis of variance. RESULTS The mean maximal doses for the GK-SRS and IMRT plans were 30 Gy and 29 Gy with margin prescription doses of 16 Gy and 24 Gy, respectively. The IORT dose was 30 Gy to the applicator surface. HIs varied based on calculation methods, but maintained consistency when comparing across platforms with IORT having the lower mean HI value (0.56; 95% confidence interval (CI) 0.55-0.60) in single-fraction treatment, compared with GK-SRS (0.77; 95% CI 0.76-0.80). The mean multisession IMRT HI was lower than both single-fraction treatment modalities at 0.41 (95% CI 0.40-0.42). CONCLUSIONS When using the HI as the primary dosimetric parameter for adjuvant radiation plans after surgical resection of brain metastases IORT offers improved dose homogeneity compared with GK-SRS in single-fraction treatment, whereas fractionated LINAC-based IMRT was superior with respect to the HI in comparison among all three methods.
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Affiliation(s)
- Basem A Dahshan
- Department of Radiation Oncology, West Virginia University, Morgantown, WV
| | - Joshua S Weir
- Department of Radiation Oncology, West Virginia University, Morgantown, WV
| | - Robert P Bice
- Department of Radiation Oncology, West Virginia University, Morgantown, WV
| | - Paul Renz
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA
| | | | - Linda Poplawski
- Department of Radiation Oncology, West Virginia University, Morgantown, WV
| | - Joshua Hack
- Department of Radiation Oncology, West Virginia University, Morgantown, WV
| | - John A Vargo
- Department of Radiation Oncology, UPMC, Pittsburgh, PA
| | - Christopher P Cifarelli
- Department of Radiation Oncology, West Virginia University, Morgantown, WV; Department of Neurosurgery, West Virginia University, Morgantown, WV.
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Mooney MA, Bi WL, Cantalino JM, Wu KC, Harris TC, Possatti LL, Juvekar P, Hsu L, Dunn IF, Al-Mefty O, Devlin PM. Brachytherapy with surgical resection as salvage treatment for recurrent high-grade meningiomas: a matched cohort study. J Neurooncol 2019; 146:111-120. [PMID: 31745706 DOI: 10.1007/s11060-019-03342-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 11/12/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE To evaluate surgical resection with brachytherapy placement as a salvage treatment in patients with recurrent high-grade meningioma who exhausted prior external beam treatment options. METHODS Single-center retrospective review of our institutional experience of brachytherapy implantation from 2012 to 2018. The primary outcome of the study was progression free survival (PFS). Secondary outcomes included overall survival (OS) and complications. A matched cohort of patients not treated with brachytherapy over the same time period was evaluated as a control group. All patients had received prior radiation treatment and underwent planned gross total resection (GTR) surgery. RESULTS A total of 27 cases were evaluated. Compared with prior treatment, brachytherapy implantation demonstrated a statistically significant improvement in tumor control [HR 0.316 (0.101 - 0.991), p = 0.034]. PFS-6 and PFS-12 were 92.3% and 84.6%, respectively. Compared with the matched control cohort, brachytherapy treatment demonstrated improved PFS [HR 0.310 (0.103 - 0.933), p = 0.030]. Overall survival was not statistically significantly different between groups [HR 0.381 (0.073 - 1.982), p = 0.227]. Overall postoperative complications were comparable between groups, although there was a higher incidence of radiation necrosis in the brachytherapy cohort. CONCLUSION Brachytherapy with planned GTR improved PFS in recurrent high-grade meningioma patients who exhausted prior external beam radiation treatment options. Future improvement of brachytherapy dose delivery methods and techniques may continue to prolong control rates and improve outcomes for this challenging group of patients.
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Affiliation(s)
- Michael A Mooney
- Department of Neurosurgery, Barrow Neurological Institute, 350 W. Thomas Rd, Phoenix, AZ, USA. .,Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - Wenya Linda Bi
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Kyle C Wu
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Thomas C Harris
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, USA
| | - Lucas L Possatti
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Parikshit Juvekar
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Liangge Hsu
- Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Ian F Dunn
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Ossama Al-Mefty
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Phillip M Devlin
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, USA
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