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Jiani SL, Karlsson B, Vellayappan B, Ang Y, Wu P, Yeo TT, Nga V. Is Gamma Knife surgery, omitting adjunct whole brain radiation treatment, feasible for patients with 20 or more brain metastases? Neurooncol Adv 2024; 6:vdae047. [PMID: 38873531 PMCID: PMC11170483 DOI: 10.1093/noajnl/vdae047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024] Open
Abstract
Background The importance of the number of brain metastases (BM) when deciding between whole brain radiation treatment (WBRT) and radiosurgery is controversial. We hypothesized that the number of BM is of limited importance when deciding radiation strategy, and offered Gamma Knife surgery (GKS) also for selected patients with 20 or more BM. Methods The outcome following single session GKS for 75 consecutive patients harboring 20 or more (20+) BM was analyzed. Data was collected both retro- and prospectively. Results The median survival time was 9 months. Two grade 3 complications occurred, 1 resolved and 1 did not. Sex and clinical condition at the time of GKS (ECOG value) were the only parameters significantly related to survival time. Eighteen patients developed leptomeningeal dissemination with or without distant recurrences (DR), and another 32 patients developed DR a total of 73 times. DR was managed with GKS 24 times, with WBRT 3 times and with systemic treatment or best supportive care 46 times. The median time to developing DR was unrelated to the number of BM, but significantly longer for patients older than 65 years, as well as for patients with NSCLC. Conclusions GKS is a reasonable treatment option for selected patients with 20 or more BM. It is better to decide the optimal management of post-GKS intracranial disease progression once it occurs rather than trying to prevent it by using adjunct WBRT.
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Affiliation(s)
- Sherry Liu Jiani
- Department of Surgery, Division of Neurosurgery, National University Hospital, Singapore, Singapore
| | - Bengt Karlsson
- Department of Surgery, Division of Neurosurgery, National University Hospital, Singapore, Singapore
| | | | - Yvonne Ang
- Department of Medical Oncology, National University Hospital, Singapore, Singapore
| | - Peng Wu
- Department of Radiology, National University Hospital, Singapore, Singapore
| | - Tseng Tsai Yeo
- Department of Surgery, Division of Neurosurgery, National University Hospital, Singapore, Singapore
| | - Vincent Nga
- Department of Surgery, Division of Neurosurgery, National University Hospital, Singapore, Singapore
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2
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Liu CW, Yang HC, Chiang CL, Shen CI, Wu HM, Luo YH, Hu YS, Lin CJ, Chung WY, Shiau CY, Guo WY, Pan DHC, Lee CC. Leukoencephalopathy in patients with brain metastases who received radiosurgery with or without whole brain radiotherapy. J Neurooncol 2023; 161:85-95. [PMID: 36544061 DOI: 10.1007/s11060-022-04210-5] [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: 08/21/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Whole brain radiation therapy (WBRT) for brain metastases (BMs) is a common cause of radiation-induced leukoencephalopathy; however the safety of alternative stereotactic radiosurgery (SRS) remains unclear. This study examined the incidence of leukoencephalopathy in patients treated with SRS alone versus WBRT plus SRS for BMs with a focus on the relationship between prognostic factors and leukoencephalopathy. METHODS Analysis was performed between 2002 and 2021. The total enrollment was 993 patients with the distribution: WBRT plus SRS (n = 291) and SRS only (n = 702). Leukoencephalopathy was graded from 0 to 3 for changes in white matter indicated by the MRI after WBRT or SRS. Patient characteristics and SRS dosimetric parameters were reviewed to identify factors that contributed to the incidence of leukoencephalopathy or overall survival. RESULTS The incidence of leukoencephalopathy was consistently higher in WBRT plus SRS group than in SRS alone group (p < 0.001). Leukoencephalopathy was also associated with a larger total tumor volume (≧28cm3; p = 0.028) and age (> 77 years; p = 0.025). Nonetheless, the SRS integral dose to skull in the subgroup of WBRT plus SRS treatment was not demonstrated significance in development of leukoencephalopathy (p = 0.986 for integral dose 1-2 J, p = 0.776 for integral dose > 2 J). CONCLUSIONS This study revealed that SRS is safe for oligo-BMs in terms of leukoencephalopathy development. Patient age and total tumor volume were identified as important factors in assessing the development of leukoencephalopathy. The additional of SRS (even at an integral dose > 2 J) did not increase the incidence of leukoencephalopathy.
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Affiliation(s)
- Chan-Wei Liu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chi-Lu Chiang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-I Shen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yung-Hung Luo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yong-Sin Hu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Ying Shiau
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan.,Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan. .,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan. .,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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3
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Molina-Romero OI, Segura-Hernandez A, Fonnegra-Caballero A, Diez-Palma JC, Cortés-Muñoz F, Fonnegra-Pardo JR. Gamma Knife radiosurgery - 12 years of experience in a high-complexity center of a middle-income country. Surg Neurol Int 2022; 13:582. [PMID: 36600776 PMCID: PMC9805623 DOI: 10.25259/sni_679_2022] [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: 07/28/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022] Open
Abstract
Background Gamma Knife radiosurgery (GKR) is a technique that consists of the release of a high dose of ionizing radiation onto a therapeutic target, which has been previously delimited. This technique was described by Lars Leksell and Borje Larsson in 1951. In Colombia, there is only one GKR unit functioning machine nowadays. The objective of this study is to describe the institutional experience of a single institution with Gamma Knife Perfexion over 12 years. Methods We conducted a retrospective observational study. A total of 1906 medical records, taken from the period between May 4, 2010, and May 4, 2022, were included in the study. Descriptive analysis was performed through STATA 17 as statistic tool. Measures of central tendency were calculated depending on the distribution of the continuous data and proportions were taken into account in the case of qualitative variables. Results A total of 1906 procedures were performed. Patients from 1 year to 99 years old were treated, with a median age of 51 years. The most frequent diagnoses were meningioma (20.8%), arteriovenous malformation (AVM) (17%), vestibular schwannoma (15.6%), metastases (9.81%), and trigeminal neuralgia (9.12%). At 3-year posttreatment, in meningiomas, tumor size stability was observed in 57.3%, size decrease in 36%, and disappearance in 1.3%. In AVM, complete obliteration of the lesion was described in 36.8% and a decrease in size in 52.6%. Intracranial hemorrhage occurred in 5.2% during the follow-up period and 3.5% of all treated patients required a new procedure due to residual malformation. In vestibular schwannomas, tumor size remained stable in 62.2% and decreased in 28.8%. No new cases of facial paralysis after the procedure were described. At 1-year posttreatment, in metastasis, the size of the lesions remained stable in 40% of the patients, decreased in 47.5%, and disappeared in 2.5%. In trigeminal neuralgia, 88.4% of patients had pain relief and recurrences occurred in 16.6%. Acute complications were generally uncommon, the main ones being headache, pain at frame fixation points, and nausea. Conclusion Our experience suggests that GKR is a noninvasive procedure with a broad spectrum of clinical applications, low frequency of complications, feasible, with good enough control size of tumor and vascular lesions in images, and good clinical results in the medium and long term.
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Affiliation(s)
- Oscar I. Molina-Romero
- Department of Neurosurgery, Fundación Clínica Shaio, Bogotá, Colombia.,Corresponding author: Oscar I. Molina-Romero, Department of Neurosurgery, Fundación Clínica Shaio, Bogotá, Colombia.
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Ahn SJ, Kwon H, Kim JW, Park G, Park M, Joo B, Suh SH, Chang YS, Lee JM. Hippocampal Metastasis Rate Based on Non-Small Lung Cancer TNM Stage and Molecular Markers. Front Oncol 2022; 12:781818. [PMID: 35619920 PMCID: PMC9127383 DOI: 10.3389/fonc.2022.781818] [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: 09/23/2021] [Accepted: 04/04/2022] [Indexed: 01/18/2023] Open
Abstract
Hippocampal-avoidance whole-brain radiation therapy (HA-WBRT) is justified because of low hippocampal brain metastases (BM) rate and its prevention of cognitive decline. However, we hypothesize that the risk of developing BM in the hippocampal-avoidance region (HAR) may differ depending on the lung-cancer stage and molecular status. We retrospectively reviewed 123 patients with non-small cell lung cancer (NSCLC) at the initial diagnosis of BM. The number of BMs within the HAR (5 mm expansion) was counted. The cohort was divided into patients with and without BMs in the HAR, and their clinical variables, TNM stage, and epidermal growth factor receptor (EGFR) status were compared. The most influential variable predicting BMs in the HAR was determined using multi-variable logistic regression, classification and regression tree (CART) analyses, and gradient boosting method (GBM). The feasibility of HAR expansion was tested using generalized estimating equation marginal model. Patients with BMs in the HAR were more frequently non-smokers, and more likely to have extra-cranial metastases and EGFR mutations (p<0.05). Multi-variable analysis revealed that extra-cranial metastases were independently associated with the presence of BM in the HAR (odds ratio=8.75, p=0.04). CART analysis and GBM revealed that the existence of extra-cranial metastasis was the most influential variable predicting BM occurrence in the HAR (variable importance: 23% and relative influence: 37.38). The estmated BM incidence of patients without extra-cranial metastases in th extended HAR (7.5-mm and 10-mm expansion) did not differ significantly from that in the conventional HAR. In conclusion, NSCLC patients with extra-cranial metastases were more likely to have BMs in the HAR than those without extra-cranial metastases.
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Affiliation(s)
- Sung Jun Ahn
- Department of Radiology, Gangnam Severance Hospital, Yonsei University, College of Medicine, Seoul, South Korea
| | - Hyeokjin Kwon
- Department of Electronic Engineering, Hanyang University, Seoul, South Korea
| | - Jun Won Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University, College of Medicine, Seoul, South Korea
| | - Goeun Park
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, South Korea
| | - Mina Park
- Department of Radiology, Gangnam Severance Hospital, Yonsei University, College of Medicine, Seoul, South Korea
| | - Bio Joo
- Department of Radiology, Gangnam Severance Hospital, Yonsei University, College of Medicine, Seoul, South Korea
| | - Sang Hyun Suh
- Department of Radiology, Gangnam Severance Hospital, Yonsei University, College of Medicine, Seoul, South Korea
| | - Yoon Soo Chang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University, College of Medicine, Seoul, South Korea
| | - Jong-Min Lee
- Department of Biomedical Engineering, Hanyang University, Seoul, South Korea
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5
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Kocher M, Jockwitz C, Lerche C, Sabel M, Lohmann P, Stoffels G, Filss C, Mottaghy FM, Ruge MI, Fink GR, Shah NJ, Galldiks N, Caspers S, Langen KJ. Case Report: Disruption of Resting-State Networks and Cognitive Deficits After Whole Brain Irradiation for Singular Brain Metastasis. Front Neurosci 2021; 15:738708. [PMID: 34776847 PMCID: PMC8578854 DOI: 10.3389/fnins.2021.738708] [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: 07/09/2021] [Accepted: 09/30/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Long-term survivors of whole brain radiation (WBRT) are at significant risk for developing cognitive deficits, but knowledge about the underlying pathophysiological mechanisms is limited. Therefore, we here report a rare case with a singular brain metastasis treated by resection and WBRT that survived for more than 10 years where we investigated the integrity of brain networks using resting-state functional MRI. Methods: A female patient with a left frontal non-small cell lung cancer (NSCLC) brain metastasis had resection and postoperative WBRT (30.0 in 3.0 Gy fractions) and stayed free from brain metastasis recurrence for a follow-up period of 11 years. Structural magnetic resonance imaging (MRI) and amino acid [O-(2-[18F]fluoroethyl)-L-tyrosine] positron emission tomography (FET PET) were repeatedly acquired. At the last follow up, neurocognitive functions and resting-state functional connectivity (RSFC) using resting-state fMRI were assessed. Within-network and inter-network connectivity of seven resting-state networks were computed from a connectivity matrix. All measures were compared to a matched group of 10 female healthy subjects. Results: At the 11-year follow-up, T2/FLAIR MR images of the patient showed extended regions of hyper-intensities covering mainly the white mater of the bilateral dorsal frontal and parietal lobes while sparing most of the temporal lobes. Compared to the healthy subjects, the patient performed significantly worse in all cognitive domains that included executive functions, attention and processing speed, while verbal working memory, verbal episodic memory, and visual working memory were left mostly unaffected. The connectivity matrix showed a heavily disturbed pattern with a widely distributed, scattered loss of RSFC. The within-network RSFC revealed a significant loss of connectivity within all seven networks where the dorsal attention and fronto-parietal control networks were affected most severely. The inter-network RSFC was significantly reduced for the visual, somato-motor, and dorsal and ventral attention networks. Conclusion: As demonstrated here in a patient with a metastatic NSCLC and long-term survival, WBRT may lead to extended white matter damage and cause severe disruption of the RSFC in multiple resting state networks. In consequence, executive functioning which is assumed to depend on the interaction of several networks may be severely impaired following WBRT apart from the well-recognized deficits in memory function.
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Affiliation(s)
- Martin Kocher
- Institute of Neuroscience and Medicine (INM-4), Research Center Juelich, Juelich, Germany.,Department of Stereotaxy and Functional Neurosurgery, Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.,Center of Integrated Oncology, Universities of Aachen, Bonn, Cologne and Duesseldorf, Cologne, Germany
| | - Christiane Jockwitz
- Institute of Neuroscience and Medicine (INM-1), Research Center Juelich, Juelich, Germany.,Institute for Anatomy I, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Christoph Lerche
- Institute of Neuroscience and Medicine (INM-4), Research Center Juelich, Juelich, Germany
| | - Michael Sabel
- Center of Integrated Oncology, Universities of Aachen, Bonn, Cologne and Duesseldorf, Cologne, Germany.,Department of Neurosurgery, Medical Faculty, Center of Neuro-Oncology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Philipp Lohmann
- Institute of Neuroscience and Medicine (INM-4), Research Center Juelich, Juelich, Germany.,Department of Stereotaxy and Functional Neurosurgery, Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.,Center of Integrated Oncology, Universities of Aachen, Bonn, Cologne and Duesseldorf, Cologne, Germany
| | - Gabriele Stoffels
- Institute of Neuroscience and Medicine (INM-4), Research Center Juelich, Juelich, Germany
| | - Christian Filss
- Institute of Neuroscience and Medicine (INM-4), Research Center Juelich, Juelich, Germany.,Department of Nuclear Medicine, University Hospital Aachen, Rheinisch-Westfaelische Technische Hochschule (RWTH) Aachen University, Aachen, Germany
| | - Felix M Mottaghy
- Center of Integrated Oncology, Universities of Aachen, Bonn, Cologne and Duesseldorf, Cologne, Germany.,Department of Nuclear Medicine, University Hospital Aachen, Rheinisch-Westfaelische Technische Hochschule (RWTH) Aachen University, Aachen, Germany.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Maximilian I Ruge
- Department of Stereotaxy and Functional Neurosurgery, Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.,Center of Integrated Oncology, Universities of Aachen, Bonn, Cologne and Duesseldorf, Cologne, Germany
| | - Gereon R Fink
- Center of Integrated Oncology, Universities of Aachen, Bonn, Cologne and Duesseldorf, Cologne, Germany.,Institute of Neuroscience and Medicine (INM-3), Research Center Juelich, Juelich, Germany.,Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Nadim J Shah
- Institute of Neuroscience and Medicine (INM-4), Research Center Juelich, Juelich, Germany.,Department of Neurology, University Hospital Aachen, Rheinisch-Westfaelische Technische Hochschule (RWTH) Aachen University, Aachen, Germany.,Juelich-Aachen Research Alliance-Section JARA-Brain, Juelich, Germany
| | - Norbert Galldiks
- Center of Integrated Oncology, Universities of Aachen, Bonn, Cologne and Duesseldorf, Cologne, Germany.,Institute of Neuroscience and Medicine (INM-3), Research Center Juelich, Juelich, Germany.,Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Svenja Caspers
- Institute of Neuroscience and Medicine (INM-1), Research Center Juelich, Juelich, Germany.,Institute for Anatomy I, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Karl-Josef Langen
- Institute of Neuroscience and Medicine (INM-4), Research Center Juelich, Juelich, Germany.,Center of Integrated Oncology, Universities of Aachen, Bonn, Cologne and Duesseldorf, Cologne, Germany.,Department of Nuclear Medicine, University Hospital Aachen, Rheinisch-Westfaelische Technische Hochschule (RWTH) Aachen University, Aachen, Germany.,Juelich-Aachen Research Alliance-Section JARA-Brain, Juelich, Germany
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6
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Kocher M, Jockwitz C, Lohmann P, Stoffels G, Filss C, Mottaghy FM, Ruge MI, Weiss Lucas C, Goldbrunner R, Shah NJ, Fink GR, Galldiks N, Langen KJ, Caspers S. Lesion-Function Analysis from Multimodal Imaging and Normative Brain Atlases for Prediction of Cognitive Deficits in Glioma Patients. Cancers (Basel) 2021; 13:cancers13102373. [PMID: 34069074 PMCID: PMC8156090 DOI: 10.3390/cancers13102373] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/09/2021] [Accepted: 05/10/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary This prospective cross-sectional study utilized standard structural MR imaging and amino acid PET in conjunction with brain atlases of gray matter functional regions and white matter tracts, and elastic registration techniques to estimate the influence of the type and location of treatment-related brain damage or recurrent tumors on cognitive functioning in a group of well-doing WHO Grade III/IV glioma patients at follow-up after treatment. The negative impact of T2/FLAIR hyperintensities, supposed to be mainly caused by radiotherapy, on cognitive performance far exceeded that of surgical brain defects or recurrent tumors. The affection of functional nodes and fiber tracts of the left hemisphere and especially of the left temporal lobe by T2/FLAIR hyperintensities was highly correlated with verbal episodic memory dysfunction. These observations imply that radiotherapy for gliomas of the left hemisphere should be individually tailored by means of publicly available brain atlases and registration techniques. Abstract Cognitive deficits are common in glioma patients following multimodality therapy, but the relative impact of different types and locations of treatment-related brain damage and recurrent tumors on cognition is not well understood. In 121 WHO Grade III/IV glioma patients, structural MRI, O-(2-[18F]fluoroethyl)-L-tyrosine FET-PET, and neuropsychological testing were performed at a median interval of 14 months (range, 1–214 months) after therapy initiation. Resection cavities, T1-enhancing lesions, T2/FLAIR hyperintensities, and FET-PET positive tumor sites were semi-automatically segmented and elastically registered to a normative, resting state (RS) fMRI-based functional cortical network atlas and to the JHU atlas of white matter (WM) tracts, and their influence on cognitive test scores relative to a cohort of matched healthy subjects was assessed. T2/FLAIR hyperintensities presumably caused by radiation therapy covered more extensive brain areas than the other lesion types and significantly impaired cognitive performance in many domains when affecting left-hemispheric RS-nodes and WM-tracts as opposed to brain tissue damage caused by resection or recurrent tumors. Verbal episodic memory proved to be especially vulnerable to T2/FLAIR abnormalities affecting the nodes and tracts of the left temporal lobe. In order to improve radiotherapy planning, publicly available brain atlases, in conjunction with elastic registration techniques, should be used, similar to neuronavigation in neurosurgery.
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Affiliation(s)
- Martin Kocher
- Institute of Neuroscience and Medicine (INM-4), Research Center Juelich, 52428 Juelich, Germany; (P.L.); (G.S.); (C.F.); (N.J.S.); (K.-J.L.)
- Department of Stereotaxy and Functional Neurosurgery, Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, 50937 Cologne, Germany;
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne and Duesseldorf, 50937 Cologne, Germany; (C.W.L.); (R.G.); (G.R.F.); (N.G.)
- Correspondence:
| | - Christiane Jockwitz
- Institute of Neuroscience and Medicine (INM-1), Research Center Juelich, 52428 Juelich, Germany; (C.J.); (S.C.)
| | - Philipp Lohmann
- Institute of Neuroscience and Medicine (INM-4), Research Center Juelich, 52428 Juelich, Germany; (P.L.); (G.S.); (C.F.); (N.J.S.); (K.-J.L.)
- Department of Stereotaxy and Functional Neurosurgery, Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, 50937 Cologne, Germany;
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne and Duesseldorf, 50937 Cologne, Germany; (C.W.L.); (R.G.); (G.R.F.); (N.G.)
| | - Gabriele Stoffels
- Institute of Neuroscience and Medicine (INM-4), Research Center Juelich, 52428 Juelich, Germany; (P.L.); (G.S.); (C.F.); (N.J.S.); (K.-J.L.)
| | - Christian Filss
- Institute of Neuroscience and Medicine (INM-4), Research Center Juelich, 52428 Juelich, Germany; (P.L.); (G.S.); (C.F.); (N.J.S.); (K.-J.L.)
| | - Felix M. Mottaghy
- Department of Nuclear Medicine, University Hospital Aachen, RWTH Aachen University, 52074 Aachen, Germany;
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, 6229 HX Maastricht, The Netherlands
| | - Maximilian I. Ruge
- Department of Stereotaxy and Functional Neurosurgery, Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, 50937 Cologne, Germany;
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne and Duesseldorf, 50937 Cologne, Germany; (C.W.L.); (R.G.); (G.R.F.); (N.G.)
| | - Carolin Weiss Lucas
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne and Duesseldorf, 50937 Cologne, Germany; (C.W.L.); (R.G.); (G.R.F.); (N.G.)
- Department of Neurosurgery, Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, 50937 Cologne, Germany
| | - Roland Goldbrunner
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne and Duesseldorf, 50937 Cologne, Germany; (C.W.L.); (R.G.); (G.R.F.); (N.G.)
- Department of Neurosurgery, Center for Neurosurgery, Faculty of Medicine and University Hospital Cologne, 50937 Cologne, Germany
| | - Nadim J. Shah
- Institute of Neuroscience and Medicine (INM-4), Research Center Juelich, 52428 Juelich, Germany; (P.L.); (G.S.); (C.F.); (N.J.S.); (K.-J.L.)
- Department of Neurology, University Hospital Aachen, RWTH Aachen University, 52074 Aachen, Germany
- Juelich-Aachen Research Alliance (JARA)–Section JARA-Brain, 52428 Juelich, Germany
| | - Gereon R. Fink
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne and Duesseldorf, 50937 Cologne, Germany; (C.W.L.); (R.G.); (G.R.F.); (N.G.)
- Institute of Neuroscience and Medicine (INM-3), Research Center Juelich, 52428 Juelich, Germany
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Norbert Galldiks
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne and Duesseldorf, 50937 Cologne, Germany; (C.W.L.); (R.G.); (G.R.F.); (N.G.)
- Institute of Neuroscience and Medicine (INM-3), Research Center Juelich, 52428 Juelich, Germany
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Karl-Josef Langen
- Institute of Neuroscience and Medicine (INM-4), Research Center Juelich, 52428 Juelich, Germany; (P.L.); (G.S.); (C.F.); (N.J.S.); (K.-J.L.)
- Department of Nuclear Medicine, University Hospital Aachen, RWTH Aachen University, 52074 Aachen, Germany;
| | - Svenja Caspers
- Institute of Neuroscience and Medicine (INM-1), Research Center Juelich, 52428 Juelich, Germany; (C.J.); (S.C.)
- Institute for Anatomy I, Medical Faculty & University Hospital Düsseldorf, Heinrich Heine University Duesseldorf, 40225 Duesseldorf, Germany
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Sharma MB, Jensen K, Amidi A, Eskildsen SF, Johansen J, Grau C. Late toxicity in the brain after radiotherapy for sinonasal cancer: Neurocognitive functioning, MRI of the brain and quality of life. Clin Transl Radiat Oncol 2020; 25:52-60. [PMID: 33024844 PMCID: PMC7530204 DOI: 10.1016/j.ctro.2020.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 12/12/2022] Open
Abstract
Compared with matched normative data, impaired cognitive function was substantial. Several correlations between radiation dose and cognitive impairment were present. Radiation-induced white matter hyperintensities were present in 2/27 participants. One participant displayed radiation-induced necrosis in the temporal lobe. The domains affecting quality of life the most were fatigue and quality of sleep.
Purpose The aim of the study was to evaluate neurocognitive late effects, structural alterations and associations between cognitive impairment and radiation doses as well as cerebral tissue damage after radiotherapy for sinonasal cancer. Furthermore, the aim was to report quality of life (QoL) and self-reported cognitive capacity. Materials and methods Recurrence-free patients previously treated with intensity-modulated radiotherapy with a curative intent were eligible for the study. Study examinations comprised comprehensive neurocognitive testing, MRI of the brain, and self-reported outcomes. Results A total of 27 patients were included. Median age was 67 years (range 47–83). The majority of test outcomes were below normative values in any degree, and 37% of the participants had clinically significant neurocognitive impairment when compared with normative data. Correlations between absorbed doses to specific substructures of the brain and neurocognitive outcomes were present for Wechsler’s Adult Intelligence Scale-digit span and Controlled Oral Word Association Test-S. Structural MRI revealed macroscopic abnormalities in three patients; infarction (n = 1), diffuse white matter intensities (n = 2) and necrosis (n = 1). In the analysis of atrophy of cerebral tissue, no correlations were present with neither radiation dose to cerebral substructures nor neurocognitive impairment. The global QoL of the cohort was 75. The most affected outcomes were ‘fatigue’, ‘insomnia’, and ‘drowsiness’. A total of 59% of participants reported significantly impaired quality of sleep. Self-reported cognitive function revealed that ‘memory’ was the most affected cognitive domain. For the domains of ‘memory’ and ‘language’, self-reported functioning was associated with objectively measured neurocognitive outcomes. Conclusion Cerebral toxicity after radiotherapy for sinonasal cancer was substantial. Clinically significant cognitive impairment was present in more than one third of the participants, and several dose–response associations were present. Furthermore, the presence of macroscopic radiation sequelae indicated considerable impact of radiotherapy on brain tissue.
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Affiliation(s)
- M B Sharma
- Department of Oncology, Aarhus University Hospital, Palle Juul Jensen Boulevard 99, DK-8200 Aarhus N, Denmark
| | - K Jensen
- Danish Center for Particle Therapy, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, B420, 8200 Aarhus N, Denmark
| | - A Amidi
- Unit for Psychooncology and Health Psychology, Department of Psychology, Aarhus University, Bartholins Allé 9, Build. 1351, 8000 Aarhus C, Denmark
| | - S F Eskildsen
- Center of Functionally Integrative Neuroscience, Aarhus University, Nørrebrogade 44, Build. 1A, 8000 Aarhus C, Denmark
| | - J Johansen
- Department of Oncology, Odense University Hospital, J.B. Winsløvs Vej 4, 5000 Odense, Denmark
| | - C Grau
- Department of Oncology, Aarhus University Hospital, Palle Juul Jensen Boulevard 99, DK-8200 Aarhus N, Denmark.,Danish Center for Particle Therapy, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, B420, 8200 Aarhus N, Denmark
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8
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Parente A, Maciel ES, J O Dierckx RA, Langendijk JA, de Vries EFJ, Doorduin J. Delayed effects of a single-dose whole-brain radiation therapy on glucose metabolism and myelin density: a longitudinal PET study. Int J Radiat Biol 2020; 96:1135-1143. [PMID: 32602390 DOI: 10.1080/09553002.2020.1787542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE Radiotherapy is an important treatment option for brain tumors, but the unavoidable irradiation of normal brain tissue can lead to delayed cognitive impairment. The mechanisms involved are still not well explained and, therefore, new tools to investigate the processes leading to the delayed symptoms of brain irradiation are warranted. In this study, positron emission tomography (PET) is used to explore delayed functional changes induced by brain irradiation. MATERIALS AND METHODS Male Wistar rats were subjected to a single 25-Gy dose of whole brain X-ray irradiation, or sham-irradiation. To investigate delayed effects of radiation on cerebral glucose metabolism and myelin density, 18F-fluorodeoxyglucose (18F-FDG) PET scans were performed at baseline and on day 64 and 94, whereas N-11C-methyl-4,4'-diaminostilbene (11C-MeDAS) PET scans were performed at baseline and on day 60 and 90 post-irradiation. In addition, the open field test (OFT) and novel spatial recognition (NSR) test were performed at baseline and on days 59 and 89 to investigate whether whole brain irradiation induces behavioral changes. RESULTS Whole-brain irradiation caused loss of bodyweight and delayed cerebral hypometabolism, with 18F-FDG uptake in all brain regions being significantly decreased in irradiated rat on day 64 while it remained unchanged in control animals. Only amygdala and cortical brain regions of irradiated rats still showed reduced 18F-FDG uptake on day 94. 11C-MeDAS uptake in control animals was significantly lower on days 60 and 90 than at the baseline, suggesting a reduction in myelin density in young adults. In irradiated animals, 11C-MeDAS uptake was similarly reduced on day 60, but on day 90 tracer uptake was somewhat increased and not significantly different from baseline anymore. Behavioral tests showed a similar pattern in control and irradiated animals. In both groups, the OFT showed significantly reduced mobility on days 59 and 89, whereas the NSR did not reveal any significant changes in spatial memory over time. Interestingly, a positive correlation between the NSR and 11C-MeDAS uptake was observed in irradiated rats. CONCLUSIONS Whole-brain irradiation causes delayed brain hypometabolism, which is not accompanied by white matter loss. Irradiated animals showed similar behavioral changes over time as control animals and, therefore, cerebral hypometabolism could not be linked to behavioral abnormalities. However, spatial memory seems to be associated with myelin density in irradiated rats.
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Affiliation(s)
- Andrea Parente
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Elisa Scandiuzzi Maciel
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rudi A J O Dierckx
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Erik F J de Vries
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Janine Doorduin
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Nagtegaal SHJ, David S, Snijders TJ, Philippens MEP, Leemans A, Verhoeff JJC. Effect of radiation therapy on cerebral cortical thickness in glioma patients: Treatment-induced thinning of the healthy cortex. Neurooncol Adv 2020; 2:vdaa060. [PMID: 32642712 PMCID: PMC7284116 DOI: 10.1093/noajnl/vdaa060] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background With overall survival of brain tumors improving, radiation induced brain injury is becoming an increasing issue. One of the effects of radiation therapy (RT) is thinning of the cerebral cortex, which could be one of the factors contributing to cognitive impairments after treatment. In healthy brain, cortex thickness varies between 1 and 4.5 mm. In this study, we assess the effect of RT on the thickness of the cerebral cortex and relate the changes to the local dose. Methods We identified 28 glioma patients with optimal scan quality. Clinical CTs and MRIs at baseline and 1 year post-RT were collected and coregistered. The scans were processed via an automated image processing pipeline, which enabled measuring changes of the cortical thickness, which were related to local dose. Results Three areas were identified where significant dose-dependent thinning occurred, with thinning rates of 5, 6, and 26 μm/Gy after 1 year, which corresponds to losses of 5.4%, 7.2%, and 21.6% per 30 Gy per year. The first area was largely located in the right inferior parietal, supramarginal, and superior parietal regions, the second in the right posterior cingulate and paracentral regions, and the third almost completely in the right lateral orbital frontal region. Conclusions We have identified three areas susceptible to dose-dependent cortical thinning after radiation therapy. Should future prospective studies conclude that irradiation of these areas lead to cognitive decline, they need to be spared in order to prevent this debilitating consequence of treatment.
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Affiliation(s)
- Steven H J Nagtegaal
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | - Szabolcs David
- Image Sciences Institute, University Medical Center, Utrecht, The Netherlands
| | - Tom J Snijders
- Department of Neurology, University Medical Center, Utrecht, The Netherlands
| | | | - Alexander Leemans
- Image Sciences Institute, University Medical Center, Utrecht, The Netherlands
| | - Joost J C Verhoeff
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
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10
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Nakazaki K, Yomo S, Kondoh T, Serizawa T, Kenai H, Kawagishi J, Sato S, Nagano O, Aiyama H, Kawai H, Hasegawa T, Iwai Y, Nagatomo Y, Kida Y, Nishigaki M. Salvage gamma knife radiosurgery for active brain metastases from small-cell lung cancer after whole-brain radiation therapy: a retrospective multi-institutional study (JLGK1701). J Neurooncol 2020; 147:67-76. [PMID: 31933257 DOI: 10.1007/s11060-020-03397-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 01/08/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the efficacy of gamma knife radiosurgery (GKS) for brain metastases (BMs) from small-cell lung cancer after whole-brain radiotherapy (WBRT). METHODS We retrospectively analyzed the usefulness and safety of GKS in 163 patients from 15 institutions with 1-10 active BMs after WBRT. The usefulness and safety of GKS were evaluated using statistical methods. RESULTS The median age was 66 years, and 79.1% of patients were men. The median number and largest diameter of BM were 2.0 and 1.4 cm, respectively. WBRT was administered prophylactically in 46.6% of patients. The median overall survival (OS) was 9.3 months, and the neurologic mortality was 20.0%. Crude incidences of local control failure and new lesion appearance were 36.6% and 64.9%, respectively. A BM diameter ≥ 1.0 cm was a significant risk factor for local progression (hazard ratio [HR] 2.556, P = 0.039) and neurologic death (HR 4.940, P = 0.031). Leukoencephalopathy at the final follow-up was more prevalent in the therapeutic WBRT group than in the prophylactic group (P = 0.019). The symptom improvement rate was 61.3%, and neurological function was preserved for a median of 7.6 months. Therapeutic WBRT was not a significant risk factor for OS, neurological death, local control, or functional deterioration (P = 0.273, 0.490, 0.779, and 0.560, respectively). Symptomatic radiation-related adverse effects occurred in 7.4% of patients. CONCLUSIONS GKS can safely preserve neurological function and prevent neurologic death in patients with 1-10 small, active BMs after prophylactic and therapeutic WBRT.
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Affiliation(s)
- Kiyoshi Nakazaki
- Department of Neurosurgery, Brain Attack Center Ota Memorial Hospital, 3-6-28 Okinogami, Fukuyama, Hiroshima, 7200825, Japan.
| | - Shoji Yomo
- Department of Neurosurgery, Aizawa Hospital, Matsumoto, Nagano, Japan
| | - Takeshi Kondoh
- Department of Neurosurgery, Shinsuma General Hospital, Kobe, Hyogo, Japan
| | - Toru Serizawa
- Tokyo Gamma Unit Center, Tsukiji Neurological Clinic, Tokyo, Japan
| | - Hiroyuki Kenai
- Department of Neurosurgery, Nagatomi Neurosurgical Hospital, Oita, Japan
| | - Jun Kawagishi
- Jiro Suzuki Memorial GammaHouse, Furukawa Seiryo Hospital, Osaki, Miyagi, Japan
| | - Sonomi Sato
- Department of Neurosurgery, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital, Koriyama, Fukushima, Japan
| | - Osamu Nagano
- Gamma Knife House, Chiba Cerebral and Cardiovascular Center, Ichihara, Chiba, Japan
| | - Hitoshi Aiyama
- Katsuta Hospital Mito GammaHouse, Hitachi-naka, Ibaraki, Japan
| | - Hideya Kawai
- Department of Neurosurgery, Research Institute for Brain and Blood-Vessels-Akita, Akita, Japan
| | | | - Yoshiyasu Iwai
- Department of Neurosurgery, Osaka City General Hospital, Osaka, Japan
| | - Yasushi Nagatomo
- Department of Neurosurgery, Kouseikai Takai Hospital, Tenri, Nara, Japan
| | - Yoshihisa Kida
- Department of Neurosurgery, Ookuma Hospital, Nagoya, Japan
| | - Masakazu Nishigaki
- Department of Human Health Sciences, School of Medicine, Kyoto University, Kyoto, Japan
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11
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Nagtegaal SHJ, David S, van der Boog ATJ, Leemans A, Verhoeff JJC. Changes in cortical thickness and volume after cranial radiation treatment: A systematic review. Radiother Oncol 2019; 135:33-42. [PMID: 31015168 DOI: 10.1016/j.radonc.2019.02.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 12/10/2018] [Accepted: 02/15/2019] [Indexed: 12/23/2022]
Abstract
Cognitive decline has a clear impact on quality of life in patients who have received cranial radiation treatment. The pathophysiological process is most likely multifactorial, with a possible role for decreased cortical thickness and volume. As radiotherapy treatment systems are becoming more sophisticated, precise sparing of vulnerable regions and tissue is possible. This allows radiation oncologists to make treatment more patient-tailored. A systematic search was performed to collect and review all available evidence regarding the effect of cranial radiation treatment on cortical thickness and volume. We searched the Pubmed, Embase and Cochrane databases, with an additional reference check in the Scopus database. Studies that examined cortical changes on MRI within patients as well as between treated and non-treated patients were included. The quality of the studies was assessed with a checklist specially designed for this review. No meta-analysis was performed due to the lack of randomised trials. Out of 1915 publications twenty-one papers were selected, of which fifteen observed cortical changes after radiation therapy. Two papers reported radiation-dependent decrease in cortical thickness within patients one year after radiation treatment, suggesting a clear relation between the two. However, study quality was considered mostly suboptimal, and there was great inhomogeneity between the included studies. This means that, although there has been increasing interest in the effects of radiation treatment on cortex morphology, no reliable conclusion can be drawn based on the currently available evidence. This calls for more research, preferably with a sufficiently large patient population, and adequate methodology.
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Affiliation(s)
- Steven H J Nagtegaal
- Department of Radiation Oncology, University Medical Center, Utrecht, the Netherlands.
| | - Szabolcs David
- Image Sciences Institute, University Medical Center, Utrecht, the Netherlands.
| | | | - Alexander Leemans
- Image Sciences Institute, University Medical Center, Utrecht, the Netherlands.
| | - Joost J C Verhoeff
- Department of Radiation Oncology, University Medical Center, Utrecht, the Netherlands.
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12
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Mechanisms of radiotherapy-associated cognitive disability in patients with brain tumours. Nat Rev Neurol 2016; 13:52-64. [PMID: 27982041 DOI: 10.1038/nrneurol.2016.185] [Citation(s) in RCA: 295] [Impact Index Per Article: 36.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Standard treatment of primary and metastatic brain tumours includes high-dose megavoltage-range radiation to the cranial vault. About half of patients survive >6 months, and many attain long-term control or cure. However, 50-90% of survivors exhibit disabling cognitive dysfunction. The radiation-associated cognitive syndrome is poorly understood and has no effective prevention or long-term treatment. Attention has primarily focused on mechanisms of disability that appear at 6 months to 1 year after radiotherapy. However, recent studies show that CNS alterations and dysfunction develop much earlier following radiation exposure. This finding has prompted the hypothesis that subtle early forms of radiation-induced CNS damage could drive chronic pathophysiological processes that lead to permanent cognitive decline. This Review presents evidence of acute radiation-triggered CNS inflammation, injury to neuronal lineages, accessory cells and their progenitors, and loss of supporting structure integrity. Moreover, injury-related processes initiated soon after irradiation could synergistically alter the signalling microenvironment in progenitor cell niches in the brain and the hippocampus, which is a structure critical to memory and cognition. Progenitor cell niche degradation could cause progressive neuronal loss and cognitive disability. The concluding discussion addresses future directions and potential early treatments that might reverse degenerative processes before they can cause permanent cognitive disability.
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13
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Cohen-Inbar O, Melmer P, Lee CC, Xu Z, Schlesinger D, Sheehan JP. Leukoencephalopathy in long term brain metastases survivors treated with radiosurgery. J Neurooncol 2016; 126:289-98. [PMID: 26468138 DOI: 10.1007/s11060-015-1962-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/10/2015] [Indexed: 12/28/2022]
Abstract
Brain metastases (BM) develop in 10-30 % of patients. Stereotactic radiosurgery (SRS) was shown to improve local control, and performance status, in certain cohorts of brain metastasis patients. The cumulative neurocognitive effect of numerous SRS sessions remains unknown. Leukoencephalopathy is significant diffuse white matter changes and it usually implies a neurocognitive decline. We report patients with BM who survived >2 years after SRS. Clinical and treatment parameters were analyzed for development of leukoencephalopathy. Multiple parameters as well as leukoencephalopathy grade changes were recorded. The median clinical and radiological follow-up was 42 and 41 months (range 24–115 and 24–115) respectively. The cohort included 92 patients and 704 lesions. The most common malignancies were non-small cell lung carcinoma (44.5 % n = 41), breast adenocarcinoma (23.9 %, n = 22) and melanoma (16.3 %,n = 15). 27.6 % (n = 26) of patients underwent adjuvant WBRT. At last follow up, local tumor control was achieved in 76.3 % (n = 61) of patients and 71.8 % (n = 461) of lesions. Overall prevalence of leukoencephalopathy was 42, 60, 73 and 84 % at 1, 2, 3, and 4 years after SRS. Moderate-severe leukoencephalopathy development was related to an integral dose to skull >3 Joules (p = 0.012) at any radiosurgical treatment and prior WBRT (p<0.042). Leukoencephalopathy incidence was consistently higher in the WBRT + SRS group at each following year of survival from initial SRS. Long-term BM survivors treated with SRS are at progressive risk for developing leukoencephalopathy.Those with a higher BM burden, higher integral SRS dose to the skull, and treatment with WBRT are at increased risk of leukoencephalopathy.
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Kotecha R, Zimmerman A, Murphy ES, Ahmed Z, Ahluwalia MS, Suh JH, Reddy CA, Angelov L, Vogelbaum MA, Barnett GH, Chao ST. Management of Brain Metastasis in Patients With Pulmonary Neuroendocrine Carcinomas. Technol Cancer Res Treat 2016; 15:566-72. [DOI: 10.1177/1533034615589033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 05/06/2015] [Indexed: 01/01/2023] Open
Abstract
Background: The patterns of intracranial failure in patients with brain metastasis from pulmonary neuroendocrine carcinoma (PNEC) remain unknown. Methods: From 1998 to 2013, 29 patients with the diagnosis of PNEC were treated for brain metastasis: 16 patients (55%) underwent whole-brain radiation therapy (WBRT), 5 (17%) patients underwent WBRT with a stereotactic radiosurgery (SRS) boost, and 8 (28%) patients underwent primary SRS alone. Results: The median age at treatment was 61 years (range: 44-84 years) and the median follow-up was 9.6 months (0-157.4 months). Of the patients treated with SRS alone, 1 patient had radiographic local progression of disease and 1 patient had a distant intracranial failure. Of the patients treated with WBRT with or without an SRS boost, 9 patients developed intracranial progression, including 1 local failure. No differences in rates of intracranial progression or local failure between the 2 groups ( P = .94 and P = .44, respectively) were observed. The actuarial rates of distant intracranial failure at 12 months were 32.9% (95% confidence interval [95% CI] 8.9%-56.8%) and 25% (95% CI 0.0%-67.4%) in patients undergoing primary WBRT or SRS, respectively ( P = .31). The median overall survival was 15.8 months in patients treated with WBRT and 20.4 months in patients treated with primary SRS ( P = .78). Conclusion: Patients with brain metastasis from PNECs can be effectively treated with either WBRT or SRS alone, with a pattern of failure more consistent with non-small cell lung cancer than small cell lung cancer. In this series, there was not a statistically significant increased risk of distant intracranial failure when patients were treated with primary SRS.
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Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy Zimmerman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Erin S. Murphy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Zain Ahmed
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Manmeet S. Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John H. Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Chandana A. Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lilyana Angelov
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
| | - Michael A. Vogelbaum
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
| | - Gene H. Barnett
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
| | - Samuel T. Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
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Zhong X, Huang B, Feng J, Yang W, Liu H. Delayed leukoencephalopathy of non-small cell lung cancer patients with brain metastases underwent whole brain radiation therapy. J Neurooncol 2015; 125:177-81. [PMID: 26275366 DOI: 10.1007/s11060-015-1888-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 08/08/2015] [Indexed: 01/11/2023]
Abstract
To explore the incidence, MR imaging findings, dynamic developing process of delayed leukoencephalopathy (DLE) in non-small cell lung cancer (NSCLC) patients with brain metastases patients who undergone whole brain radiation (WBRT) therapy, we retrospectively reviewed 48 NSCLC patients who underwent WBRT for brain metastases from January 2010 through June 2015 and had evaluable magnetic resonance imaging after treatment. The DLE were graded using a scale to evaluate T2-FLAIR (fluid attenuated image recovery) images: grade 1 = little or no white matter hyperintensity, grade 2 = limited periventricular hyperintensity and grade 3 = diffuse white matter hyperintensity. 48 NSCLC patients with brain metastases were enrolled. The median age of these patients was 55.7 years (range 33-75 years). The median follow-up was 12 months. The characteristic MR imaging of DLE in those patients was bilaterally diffuse white matter T2 hyperintensity around the periventricular areas without enhancement, sparing from U-fiber, callosum and gray matter structure. The incidence of DLE developed 6.25% (3/48), 30.00% (12/40), 48.39% (15/31), 61.90% (13/21), 85.71% (6/7), 100% (3/3) in those patients who were followed up for 3, 6, 9, 12, 24, 36 months, respectively. Through increased understanding of it, it may be possible to help clinicians develop further therapeutic strategies to maximize benefit while limiting potential long term toxicities. These data supplement existing reports regarding the late effects of WBRT in NSCLC patients with brain metastasis.
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Affiliation(s)
- Xiaoling Zhong
- Department of Radiology, Guangdong Academy of Medical Sciences, Guangdong General Hospital, 106 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, People's Republic of China.,Southern Medical School, 1023 Shatai South Road, Baiyun District, Guangzhou, 510515, Guangdong, People's Republic of China
| | - Biao Huang
- Department of Radiology, Guangdong Academy of Medical Sciences, Guangdong General Hospital, 106 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, People's Republic of China.
| | - Jieying Feng
- Department of Radiology, Guangdong Academy of Medical Sciences, Guangdong General Hospital, 106 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Wanqun Yang
- Department of Radiology, Guangdong Academy of Medical Sciences, Guangdong General Hospital, 106 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Hongjun Liu
- Department of Radiology, Guangdong Academy of Medical Sciences, Guangdong General Hospital, 106 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, People's Republic of China
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16
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Trifiletti DM, Lee CC, Schlesinger D, Larner JM, Xu Z, Sheehan JP. Leukoencephalopathy After Stereotactic Radiosurgery for Brain Metastases. Int J Radiat Oncol Biol Phys 2015; 93:870-8. [PMID: 26530756 DOI: 10.1016/j.ijrobp.2015.07.2280] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 07/19/2015] [Accepted: 07/21/2015] [Indexed: 11/19/2022]
Abstract
PURPOSE Although the use of stereotactic radiosurgery (SRS) in the treatment of multiple brain metastases has increased dramatically during the past decade to avoid the neurocognitive dysfunction induced by whole brain radiation therapy (WBRT), the cumulative neurocognitive effect of numerous SRS sessions remains unknown. Because leukoencephalopathy is a sensitive marker for radiation-induced central nervous system damage, we studied the clinical and dosimetric predictors of SRS-induced leukoencephalopathy. METHODS AND MATERIALS Patients treated at our institution with at least 2 sessions of SRS for brain metastases from 2007 to 2013 were reviewed. The pre- and post-SRS magnetic resonance imaging sequences were reviewed and graded for white matter changes associated with radiation leukoencephalopathy using a previously validated scale. Patient characteristics and SRS dosimetric parameters were reviewed for factors that contributed to leukoencephalopathy using Cox proportional hazards modeling. RESULTS A total of 103 patients meeting the inclusion criteria were identified. The overall incidence of leukoencephalopathy was 29% at year 1, 38% at year 2, and 53% at year 3. Three factors were associated with radiation-induced leukoencephalopathy: (1) the use of WBRT (P=.019); (2) a higher SRS integral dose to the cranium (P=.036); and (3) the total number of intracranial metastases (P=.003). CONCLUSIONS Our results have established that WBRT plus SRS produces leukoencephalopathy at a much higher rate than SRS alone. In addition, for patients who did not undergo WBRT before SRS, the integral dose was associated with the development of leukoencephalopathy. As the survival of patients with central nervous system metastases increases and as the neurotoxicity of chemotherapeutic and targeted agents becomes established, these 3 potential risk factors will be important to consider.
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Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia.
| | - Cheng-Chia Lee
- Department of Neurosurgery, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - David Schlesinger
- Department of Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia; Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - James M Larner
- Department of Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P Sheehan
- Department of Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia; Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Seidel C, Hambsch P, Hering K, Bresch A, Rohde S, Kortmann RD, Gaudino C. Analysis of frequency of deep white matter metastasis on cerebral MRI. J Neurooncol 2015; 123:135-9. [DOI: 10.1007/s11060-015-1773-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 04/02/2015] [Indexed: 12/17/2022]
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Lu YS, Chen TWW, Lin CH, Yeh DC, Tseng LM, Wu PF, Rau KM, Chen BB, Chao TC, Huang SM, Huang CS, Shih TTF, Cheng AL. Bevacizumab preconditioning followed by Etoposide and Cisplatin is highly effective in treating brain metastases of breast cancer progressing from whole-brain radiotherapy. Clin Cancer Res 2015; 21:1851-8. [PMID: 25700303 DOI: 10.1158/1078-0432.ccr-14-2075] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 01/19/2015] [Indexed: 11/16/2022]
Abstract
PURPOSE We hypothesized that a window period between bevacizumab and cytotoxic agents may enhance drug delivery into tumor tissue through bevacizumab-induced vascular normalization in patients with brain metastases of breast cancer (BMBC). EXPERIMENTAL DESIGN A single-arm phase II study was conducted in which BMBC patients refractory to whole-brain radiotherapy (WBRT) were enrolled. In a 21-day cycle, patients received bevacizumab (15 mg/kg) on day 1, which, with a 1-day window period, was followed by etoposide (70 mg/m(2)/day; days 2-4) and cisplatin (70 mg/m(2); day 2; BEEP regimen). The BEEP regimen was administered for a maximum of 6 cycles. The primary endpoint was the central nervous system (CNS)-objective response rate according to volumetric response criteria. RESULTS A total of 35 patients were enrolled between January 2011 and January 2013. The median age was 54.3 years (range, 33-75); 19 patients (54.3%) had an Eastern Cooperative Oncology Group performance status of 2 or 3. Twenty-seven patients [77.1%; 95% confidence interval (CI), 59.9-89.6] achieved a CNS-objective response, including 13 patients (37.1%) with a ≥80% volumetric reduction of CNS lesions. With a median follow-up of 16.1 months, the median CNS progression-free survival and overall survival times were 7.3 months (95% CI, 6.5-8.1) and 10.5 months (95% CI, 7.8-13.2), respectively. Common grade 3 or 4 toxicities included neutropenia (30.8%) and infection (21.3%). CONCLUSIONS By administering bevacizumab 1 day before etoposide and cisplatin, the BEEP regimen appeared highly effective in BMBC refractory to WBRT. Further study of vascular normalization window concept is warranted.
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Affiliation(s)
- Yen-Shen Lu
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan. Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tom Wei-Wu Chen
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Hung Lin
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan. Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Dah-Cherng Yeh
- Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ling-Ming Tseng
- Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Pei-Fang Wu
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kun-Ming Rau
- Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Bang-Bin Chen
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Ta-Chung Chao
- Division of Hematology and Oncology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shu-Min Huang
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chiun-Sheng Huang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Ann-Lii Cheng
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan. Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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Kotecha R, Angelov L, Barnett GH, Reddy CA, Suh JH, Murphy ES, Neyman G, Chao ST. Calvarial and skull base metastases: expanding the clinical utility of Gamma Knife surgery. J Neurosurg 2015; 121 Suppl:91-101. [PMID: 25434942 DOI: 10.3171/2014.7.gks141272] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Traditionally, the treatment of choice for patients with metastases to the calvaria or skull base has been conventional radiation therapy. Because patients with systemic malignancies are also at risk for intracranial metastases, the utility of Gamma Knife surgery (GKS) for these patients has been explored to reduce excess radiation exposure to the perilesional brain parenchyma. The purpose of this study was to report the efficacy of GKS for the treatment of calvarial metastases and skull base lesions. METHODS The authors performed a retrospective chart review of 21 patients with at least 1 calvarial or skull base metastatic lesion treated with GKS during 2001-2013. For 7 calvarial lesions, a novel technique, in which a bolus was placed over the treatment site, was used. For determination of local control or disease progression, radiation therapy data were examined and posttreatment MR images and oncology records were reviewed. Survival times from the date of procedure were estimated by using Kaplan-Meier analyses. RESULTS The median patient age at treatment was 57 years (range 29-84 years). A total of 19 (90%) patients received treatment for single lesions, 1 patient received treatment for 3 lesions, and 1 patient received treatment for 4 lesions. The most common primary tumor was breast cancer (24% of patients). Per lesion, the median clinical and radiographic follow-up times were 10.3 months (range 0-71.9 months) and 7.1 months (range 0-61.3 months), respectively. Of the 26 lesions analyzed, 14 (54%) were located in calvarial bones and 12 (46%) were located in the skull base. The median lesion volume was 5.3 cm(3) (range 0.3-55.6 cm(3)), and the median prescription margin dose was 15 Gy (range 13-24 Gy). The median overall survival time for all patients was 35.9 months, and the 1-year local control rate was 88.9% (95% CI 74.4%-100%). Local control rates did not differ between lesions treated with the bolus technique and those treated with traditional methods or between calvarial lesions and skull base lesions (p > 0.05). Of the 3 patients for whom local treatment failed, 1 patient received no further treatment and 2 patients responded to salvage chemotherapy. Subsequent brain parenchymal metastases developed in 2 patients, who then underwent GKS. CONCLUSIONS GKS is an effective treatment modality for patients with metastases to the calvarial bones or skull base. For patients with superficial calvarial lesions, a novel approach with bolus application resulted in excellent rates of local control. GKS provides an effective therapeutic alternative to conventional radiation therapy and should be considered for patients at risk for calvarial metastases and brain parenchymal metastases.
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White matter changes in breast cancer brain metastases patients who undergo radiosurgery alone compared to whole brain radiation therapy plus radiosurgery. J Neurooncol 2014; 121:583-90. [PMID: 25445836 DOI: 10.1007/s11060-014-1670-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 11/23/2014] [Indexed: 12/21/2022]
Abstract
Delayed toxicity after whole brain radiation therapy (WBRT) is of increasing concern in patients who survive more than one year with brain metastases from breast cancer. Radiation-related white matter toxicity is detected by magnetic resonance imaging (MRI) and has been correlated with neurocognitive dysfunction. This study assessed the risk of developing white matter changes (WMC) in breast cancer patients who underwent either WBRT plus stereotactic radiosurgery (SRS) or SRS alone. We retrospectively compared 35 patients with breast cancer brain metastases who received WBRT and SRS to 30 patients who only received SRS. All patients had evaluable imaging at a median of one year after their initial management. The development of white matter T2 prolongation as detected by T2 or FLAIR imaging was graded: grade 1 = little or no white matter T2 hyperintensity; grade 2 = limited periventricular hyperintensity; and grade 3 = diffuse white matter hyperintensity. After WBRT plus SRS, patients demonstrated a significantly higher incidence of WMC (p < 0.0001). After one year, 71.5 % of patients whose treatment included WBRT demonstrated WMC (42.9 % grade 2; 28.6 % grade 3). Only one patient receiving only SRS developed WMC. In long-term survivors of breast cancer, the risk of WMC was significantly reduced when SRS alone was used for management. Further prospective studies are necessary to determine how these findings correlate with neurocognitive toxicity. WBRT usage as initial management of limited brain disease should be replaced by SRS alone to reduce the risk of delayed white matter toxicity.
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Monaco EA, Grandhi R, Niranjan A, Lunsford LD. The past, present and future of Gamma Knife radiosurgery for brain tumors: the Pittsburgh experience. Expert Rev Neurother 2014; 12:437-45. [DOI: 10.1586/ern.12.16] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Sabsevitz DS, Bovi JA, Leo PD, Laviolette PS, Rand SD, Mueller WM, Schultz CJ. The role of pre-treatment white matter abnormalities in developing white matter changes following whole brain radiation: a volumetric study. J Neurooncol 2013; 114:291-7. [PMID: 23813291 DOI: 10.1007/s11060-013-1181-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 06/19/2013] [Indexed: 11/25/2022]
Abstract
White matter injury is a known complication of whole brain radiation (WBRT). Little is known about the factors that predispose a patient to such injury. The current study used MR volumetrics to examine risk factors, in particular the influence of pre-treatment white matter health, in developing white matter change (WMC) following WBRT. Thirty-four patients with unilateral metastatic disease underwent FLAIR MRI pre-treatment and at several time points following treatment. The volume of abnormal FLAIR signal in the white matter was measured in the hemisphere contralateral to the diseased hemisphere at each time point. Analyses were restricted to the uninvolved hemisphere to allow for the measurement of WBRT effects without the potential confounding effects of the disease on imaging findings. The relationship between select pre-treatment clinical variables and the degree of WMC following treatment was examined using correlational and regression based analyses. Age when treated and volume of abnormal FLAIR prior to treatment were significantly associated with WMC following WBRT; however, pre-treatment FLAIR volume was the strongest predictor of post-treatment WMCs. Age did not add any predictive value once white matter status was considered. No significant relationships were found between biological equivalent dose and select cerebrovascular risk factors (total glucose, blood pressure, BMI) and development of WMCs. The findings from this study identify pre-treatment white matter health as an important risk factor in developing WMC following WBRT. This information can be used to make more informed decisions and counsel patients on their risk for treatment effects.
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Affiliation(s)
- David S Sabsevitz
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI 53226-3596, USA.
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Ebi J, Sato H, Nakajima M, Shishido F. Incidence of Leukoencephalopathy After Whole-Brain Radiation Therapy for Brain Metastases. Int J Radiat Oncol Biol Phys 2013; 85:1212-7. [DOI: 10.1016/j.ijrobp.2012.09.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 09/14/2012] [Accepted: 09/21/2012] [Indexed: 10/27/2022]
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Nakazaki K, Kano H. Evaluation of mini-mental status examination score after gamma knife radiosurgery as the first radiation treatment for brain metastases. J Neurooncol 2013; 112:421-5. [DOI: 10.1007/s11060-013-1071-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 02/05/2013] [Indexed: 11/30/2022]
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Monaco EA, Faraji AH, Berkowitz O, Parry PV, Hadelsberg U, Kano H, Niranjan A, Kondziolka D, Lunsford LD. Leukoencephalopathy after whole-brain radiation therapy plus radiosurgery versus radiosurgery alone for metastatic lung cancer. Cancer 2012; 119:226-32. [DOI: 10.1002/cncr.27504] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Revised: 01/06/2012] [Accepted: 02/02/2012] [Indexed: 01/30/2023]
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Bailon O, Kallel A, Chouahnia K, Billot S, Ferrari D, Carpentier AF. [Management of brain metastases from non-small cell lung carcinoma]. Rev Neurol (Paris) 2011; 167:579-91. [PMID: 21546046 DOI: 10.1016/j.neurol.2011.01.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Revised: 01/03/2011] [Accepted: 01/17/2011] [Indexed: 01/08/2023]
Abstract
INTRODUCTION In France, approximately 30,000 new patients per year develop brain metastases (BM), most of them resulting from a lung cancer. STATE OF THE ART Surgery and radiosurgery of all the BM must be considered when possible. In other cases, whole brain radiotherapy remains the standard of care. PERSPECTIVES The role of chemotherapy, poorly investigated so far, should be revisited. CONCLUSION This review focused on BM secondary to a non-small cell lung carcinoma.
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Affiliation(s)
- O Bailon
- Service de neurologie, hôpital Avicenne, AP-HP, 125, route de Stalingrad, 93000 Bobigny, France
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Szerlip N, Rutter C, Ram N, Yovino S, Kwok Y, Maggio W, Regine WF. Factors impacting volumetric white matter changes following whole brain radiation therapy. J Neurooncol 2010; 103:111-9. [PMID: 20725847 DOI: 10.1007/s11060-010-0358-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Accepted: 08/09/2010] [Indexed: 12/25/2022]
Abstract
Whole brain radiation therapy (WBRT) is one of the most effective modalities for treatment of brain metastases. With increasing cancer control there is growing concern regarding the long-term effects of treatment. These effects are seen as white matter change (WMC) on brain MRI. Severity of WMC is implicated in cognitive and functional decline in many patient groups. Our objective was to identify clinical factors associated with greater accumulation of WMC following WBRT. Through retrospective review of serial MRIs obtained from 30 patients surviving greater than 1 year after WBRT, treated at a single institution between 2002 and 2007, we calculated volumetric WMC over time using segmentation software. Changes related to tumor, secondary effects, surgery or radiosurgery were excluded. Factors that influenced the rate of WMC accumulation were identified through multivariate analysis. Following WBRT, patients accumulated WMC at an average rate of 0.07% of total brain volume per month. In multivariate analyses, greater rates of accumulation were independently associated with older age (β = 0.004, p < .0001), poor levels of glycemic control (β = 0.048, p < .0001) and hypertension diagnosis (β = 0.084, p < .0001). Long-term survivors of cancer allow assessment of late effects of treatment modalities. Radiation injury appears to be related to a steady rate of white matter damage over time, as indicated by progressive accumulation of WMC. Our results suggest that rate of WMC accumulation is enhanced by parameters such as hyperglycemia and hypertension. This has significant clinical impact by clearly identifying hyperglycemia, steroid-induced hyperglycemia, and other vascular risk factors as targets for intervention to decrease WMC in patients receiving WBRT.
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Affiliation(s)
- Nicholas Szerlip
- Department of Neurosurgery, University of Maryland Medical Center, Baltimore, MD, USA.
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Maintenance of white matter integrity in a rat model of radiation-induced cognitive impairment. J Neurol Sci 2009; 285:178-84. [PMID: 19625028 DOI: 10.1016/j.jns.2009.06.031] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Revised: 06/18/2009] [Accepted: 06/19/2009] [Indexed: 11/23/2022]
Abstract
Radiation therapy is used widely to treat primary and metastatic brain tumors, but also can lead to delayed neurological complications. Since maintenance of myelin integrity is important for cognitive function, the present study used a rat model that demonstrates spatial learning and memory impairment 12 months following fractionated whole-brain irradiation (WBI) at middle age to investigate WBI-induced myelin changes. In this model, 12-month Fischer 344 x Brown Norway rats received 9 fractions of 5 Gy delivered over 4.5 weeks (WBI rats); Sham-IR rats received anesthesia only. Twelve months later, the brains were collected and measures of white matter integrity were quantified. Qualitative observation did not reveal white matter necrosis one year post-WBI. In addition, the size of major forebrain commissures, the number of oligodendrocytes, the size and number of myelinated axons, and the thickness of myelin sheaths did not differ between the two groups. In summary, both the gross morphology and the structural integrity of myelin were preserved one year following fractionated WBI in a rodent model of radiation-induced cognitive impairment. Imaging studies with advanced techniques including diffusion tensor imaging may be required to elucidate the neurobiological changes associated with the cognitive impairment in this model.
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Aoyama H, Tago M, Kato N, Toyoda T, Kenjyo M, Hirota S, Shioura H, Inomata T, Kunieda E, Hayakawa K, Nakagawa K, Kobashi G, Shirato H. Neurocognitive Function of Patients with Brain Metastasis Who Received Either Whole Brain Radiotherapy Plus Stereotactic Radiosurgery or Radiosurgery Alone. Int J Radiat Oncol Biol Phys 2007; 68:1388-95. [PMID: 17674975 DOI: 10.1016/j.ijrobp.2007.03.048] [Citation(s) in RCA: 371] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2007] [Revised: 03/26/2007] [Accepted: 03/27/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE To determine how the omission of whole brain radiotherapy (WBRT) affects the neurocognitive function of patients with one to four brain metastases who have been treated with stereotactic radiosurgery (SRS). METHODS AND MATERIALS In a prospective randomized trial between WBRT+SRS and SRS alone for patients with one to four brain metastases, we assessed the neurocognitive function using the Mini-Mental State Examination (MMSE). Of the 132 enrolled patients, MMSE scores were available for 110. RESULTS In the baseline MMSE analyses, statistically significant differences were observed for total tumor volume, extent of tumor edema, age, and Karnofsky performance status. Of the 92 patients who underwent the follow-up MMSE, 39 had a baseline MMSE score of < or =27 (17 in the WBRT+SRS group and 22 in the SRS-alone group). Improvements of > or =3 points in the MMSEs of 9 WBRT+SRS patients and 11 SRS-alone patients (p = 0.85) were observed. Of the 82 patients with a baseline MMSE score of > or =27 or whose baseline MMSE score was < or =26 but had improved to > or =27 after the initial brain treatment, the 12-, 24-, and 36-month actuarial free rate of the 3-point drop in the MMSE was 76.1%, 68.5%, and 14.7% in the WBRT+SRS group and 59.3%, 51.9%, and 51.9% in the SRS-alone group, respectively. The average duration until deterioration was 16.5 months in the WBRT+SRS group and 7.6 months in the SRS-alone group (p = 0.05). CONCLUSION The results of the present study have revealed that, for most brain metastatic patients, control of the brain tumor is the most important factor for stabilizing neurocognitive function. However, the long-term adverse effects of WBRT on neurocognitive function might not be negligible.
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Affiliation(s)
- Hidefumi Aoyama
- Department of Radiology, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
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