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Timakova E, Zavgorodni SF. Effect of modulation factor and low dose threshold level on gamma pass rates of single isocenter multi-target SRT treatment plans. J Appl Clin Med Phys 2024:e14459. [PMID: 39053489 DOI: 10.1002/acm2.14459] [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: 07/17/2023] [Revised: 04/16/2024] [Accepted: 06/19/2024] [Indexed: 07/27/2024] Open
Abstract
PURPOSE SRS MapCHECK (SMC) is a commercially available patient-specific quality assurance (PSQA) tool for stereotactic radiosurgery (SRS) applications. This study investigates the effects of degree of modulation, location off-axis, and low dose threshold (LDT) selection on gamma pass rates (GPRs) between SMC and treatment planning system, Analytical Anisotropic Algorithm (AAA), or Vancouver Island Monte Carlo (VMC++ algorithm) system calculated dose distributions. METHODS Volumetric-modulated arc therapy (VMAT) plans with modulation factors (MFs) ranging from 2.7 to 10.2 MU/cGy were delivered to SMC at isocenter and 6 cm off-axis. SMC measured dose distributions were compared against AAA and VMC++ via gamma analysis (3%/1 mm) with LDT of 10% to 80% using SNC Patient software. RESULTS Comparing on-axis SMC dose against AAA and VMC++ with LDT of 10%, all AAA-calculated plans met the acceptance criteria of GPR ≥ 90%, and only one VMC++ calculated plan was marginally outside the acceptance criteria with pass rate of 89.1%. Using LDT of 80% revealed decreasing GPR with increasing MF. For AAA, GPRs reduced from 100% at MF of 2.7 MU/cGy to 57% at MF of 10.2 MU/cGy, and for VMC++ calculated plans, the GPRs reduced from 89% to 60% in the same MF range. Comparison of SMC dose off-axis against AAA and VMC++ showed more pronounced reduction of GPR with increasing MF. For LDT of 10%, AAA GPRs reduced from 100% to 83% in the MF range of 2.7 to 9.8 MU/cGy, and VMC++ GPR reduced from 100% to 91% in the same range. With 80% LDT, GPRs dropped from 100% to 42% for both algorithms. CONCLUSIONS MF, dose calculation algorithm, and LDT selections are vital in VMAT-based SRT PSQA. LDT of 80% enhances sensitivity of gamma analysis for detecting dose differences compared to 10% LDT. To achieve better agreement between calculated and SMC dose, it is recommended to limit the MF to 4.6 MU/cGy on-axis and 3.6 MU/cGy off-axis.
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Affiliation(s)
- Elena Timakova
- University of Victoria, Victoria, British Columbia, Canada
- BC Cancer Agency, Vancouver Island Centre, Victoria, British Columbia, Canada
| | - Sergei F Zavgorodni
- University of Victoria, Victoria, British Columbia, Canada
- BC Cancer Agency, Vancouver Island Centre, Victoria, British Columbia, Canada
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Wang YF, Adamovics J, Wuu CS. Comprehensive stereotactic radiosurgery platform characterization: A novel end-to-end approach with anthropomorphic 3D dosimetry. Med Phys 2024. [PMID: 39042041 DOI: 10.1002/mp.17321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 06/12/2024] [Accepted: 07/01/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is a widely employed strategy for intracranial metastases, utilizing linear accelerators and volumetric modulated arc therapy (VMAT). Ensuring precise linear accelerator performance is crucial, given the small planning target volume (PTV) margins. Rapid dose falloff is vital to minimize brain radiation necrosis. Despite advances in SRS planning, tools for end-to-end testing of SRS treatments are lacking, hindering confidence in the procedure. PURPOSE This study introduces a novel end-to-end three-dimensional (3D) anthropomorphic dosimetry system for characterization of a radiosurgery platform, aiming to measure planning metrics, dose gradient index (DGI), brain volumes receiving at least 10 and 12 Gy (V10, V12), as well as assess delivery uncertainties in multitarget treatments. The study also compares metrics from benchmark plans to enhance understanding and confidence in SRS treatments. METHODS The developed anthropomorphic 3D dosimetry system includes a modified Stereotactic End-to-End Verification (STEEV) phantom with a customized insert integrating 3D dosimeters and a fiber optic CT scanner. Labview and MATLAB programs handle optical scanning, image preprocessing, and dosimetric analysis. SlicerRT is used for 3D dose visualization and analysis. A film stack insert was used to validate the 3D dosimeter measurements at specific slices. Benchmark plans were developed and measured to investigate off-axis errors, dose spillage, small field dosimetry, and multi-target delivery. RESULTS The accuracy of the developed 3D dosimetry system was rigorously assessed using radiochromic films. Two two-dimensional (2D) dose planes, extracted from the 3D dose distribution, were compared with film measurements, resulting in high passing rates of 99.9% and 99.6% in gamma tests. The mean relative dose difference between film and 3D dosimeter measurements was -1%, with a standard deviation of 2.2%, well within dosimeter uncertainties. In the first module, evaluating single-isocenter multitarget treatments, a 1.5 mm dose distribution shift was observed when targets were 7 cm off-axis. This shift was attributed to machine mechanical errors and image-guided system uncertainties, indicating potential limitations in conventional gamma tests. The second module investigated discrepancies in intermediate-to-low dose spillage, revealing higher measured doses in the connecting region between closely positioned targets. This discrepancy was linked to uncertainties in treatment planning system (TPS) modeling of out-of-field dose and multileaf collimator (MLC) characteristics, resulting in lower DGI values and higher V10 and V12 values compared to TPS calculations. In the third module, irradiating multiple targets showed consistent V10 and V12 values within 1 cm3 agreement with dose calculations. However, lower DGI values from measurements compared to calculations suggested intricacies in the treatment process. Conducting vital end-to-end testing demonstrated the anthropomorphic 3D dosimetry system's capacity to assess overall treatment uncertainty, offering a valuable tool for enhancing treatment accuracy in radiosurgery platforms. CONCLUSIONS The study introduces a novel anthropomorphic 3D dosimetry system for end-to-end testing of a radiosurgery platform. The system effectively measures plan quality metrics, captures mechanical errors, and visualizes dose discrepancies in 3D space. The comprehensive evaluation capability enhances confidence in the commissioning and verification process, ensuring patient safety. The system is recommended for commissioning new radiosurgery platforms and remote auditing of existing programs.
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Affiliation(s)
- Yi-Fang Wang
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York, USA
| | - John Adamovics
- Department of Chemistry, Rider University, Lawrenceville, New Jersey, USA
| | - Cheng-Shie Wuu
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York, USA
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Vaios EJ, Shenker RF, Hendrickson PG, Wan Z, Niedzwiecki D, Winter SF, Shih HA, Dietrich J, Wang C, Salama AKS, Clarke JM, Allen K, Sperduto P, Mullikin T, Kirkpatrick JP, Floyd SR, Reitman ZJ. Long-Term Intracranial Outcomes With Combination Dual Immune-Checkpoint Blockade and Stereotactic Radiosurgery in Patients With Melanoma and Non-Small Cell Lung Cancer Brain Metastases. Int J Radiat Oncol Biol Phys 2024; 118:1507-1518. [PMID: 38097090 PMCID: PMC11056239 DOI: 10.1016/j.ijrobp.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 10/26/2023] [Accepted: 12/02/2023] [Indexed: 01/18/2024]
Abstract
PURPOSE The intracranial benefit of offering dual immune-checkpoint inhibition (D-ICPI) with ipilimumab and nivolumab to patients with melanoma or non-small cell lung cancer (NSCLC) receiving stereotactic radiosurgery (SRS) for brain metastases (BMs) is unknown. We hypothesized that D-ICPI improves local control compared with SRS alone. METHODS AND MATERIALS Patients with melanoma or NSCLC treated with SRS from 2014 to 2022 were evaluated. Patients were stratified by treatment with D-ICPI, single ICPI (S-ICPI), or SRS alone. Local recurrence, intracranial progression (IP), and overall survival were estimated using competing risk and Kaplan-Meier analyses. IP included both local and distant intracranial recurrence. RESULTS Two hundred eighty-eight patients (44% melanoma, 56% NSCLC) with 1,704 BMs were included. Fifty-three percent of patients had symptomatic BMs. The median follow-up was 58.8 months. Twelve-month local control rates with D-ICPI, S-ICPI, and SRS alone were 94.73% (95% CI, 91.11%-96.90%), 91.74% (95% CI, 89.30%-93.64%), and 88.26% (95% CI, 84.07%-91.41%). On Kaplan-Meier analysis, only D-ICPI was significantly associated with reduced local recurrence (P = .0032). On multivariate Cox regression, D-ICPI (hazard ratio [HR], 0.4003; 95% CI, 0.1781-0.8728; P = .0239) and planning target volume (HR, 1.022; 95% CI, 1.004-1.035; P = .0059) correlated with local control. One hundred seventy-three (60%) patients developed IP. The 12-month cumulative incidence of IP was 41.27% (95% CI, 30.27%-51.92%), 51.86% (95% CI, 42.78%-60.19%), and 57.15% (95% CI, 44.98%-67.59%) after D-ICPI, S-ICPI, and SRS alone. On competing risk analysis, only D-ICPI was significantly associated with reduced IP (P = .0408). On multivariate Cox regression, D-ICPI (HR, 0.595; 95% CI, 0.373-0.951; P = .0300) and presentation with >10 BMs (HR, 2.492; 95% CI, 1.668-3.725; P < .0001) remained significantly correlated with IP. The median overall survival after D-ICPI, S-ICPI, and SRS alone was 26.1 (95% CI, 15.5-40.7), 21.5 (16.5-29.6), and 17.5 (11.3-23.8) months. S-ICPI, fractionation, and histology were not associated with clinical outcomes. There was no difference in hospitalizations or neurologic adverse events between cohorts. CONCLUSIONS The addition of D-ICPI for patients with melanoma and NSCLC undergoing SRS is associated with improved local and intracranial control. This appears to be an effective strategy, including for patients with symptomatic or multiple BMs.
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Affiliation(s)
- Eugene J Vaios
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Rachel F Shenker
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Peter G Hendrickson
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Zihan Wan
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
| | - Donna Niedzwiecki
- Duke Cancer Institute Biostatistics, Duke University Medical Center, Durham, North Carolina
| | - Sebastian F Winter
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jorg Dietrich
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Chunhao Wang
- Departments of Medical Physics, Duke University Medical Center, Durham, North Carolina
| | - April K S Salama
- Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey M Clarke
- Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Karen Allen
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Paul Sperduto
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Trey Mullikin
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - John P Kirkpatrick
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina; Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Scott R Floyd
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Zachary J Reitman
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina; Neurosurgery, Duke University Medical Center, Durham, North Carolina; Pathology, Duke University Medical Center, Durham, North Carolina.
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Floyd W, Carpenter D, Vaios E, Shenker R, Hendrickson P, Adamson JD, Giles WM, Wang C, Allen K, Mullikin T, Floyd SR, Kirkpatrick JP, Green M, Reitman ZJ. Effects of Ataxia-Telangiectasia Mutated Variants on Radionecrosis and Local Control After Stereotactic Radiation Surgery for Non-Small Cell Lung Cancer Brain Metastases. Adv Radiat Oncol 2024; 9:101320. [PMID: 38260227 PMCID: PMC10801648 DOI: 10.1016/j.adro.2023.101320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 07/13/2023] [Indexed: 01/24/2024] Open
Abstract
Purpose Genetic variants affecting the radiation response protein ataxia-telangiectasia mutated (ATM) have been associated with increased adverse effects of radiation but also with improved local control after conventional radiation therapy. However, it is unknown whether ATM variants affect rates of radionecrosis (RN) and local intracranial progression (LIP) after stereotactic radiosurgery (SRS) for brain metastases. Methods and Materials Patients undergoing an initial course of SRS for non-small cell lung cancer (NSCLC) brain metastases at a single institution were retrospectively identified. Kaplan-Meier estimates were calculated and Cox proportional hazards testing was performed based on ATM variant status. Results A total of 541 patients completed SRS for brain metastasis secondary to NSCLC, of whom 260 completed molecular profiling. Variants of ATM were identified in 36 cases (13.8%). Among patients who completed molecular profiling, RN incidence was 4.9% (95% CI, 1.6%-8.2%) at 6 months and 9.9% (95% CI, 4.8%-15.0%) at 12 months. Incidence of RN was not significantly increased among patients with ATM variants, with an RN incidence of 5.3% (95% CI, 0.0%-15.3%) at both 6 and 12 months (P = .46). For all patients who completed genomic profiling, LIP was 5.4% (95% CI, 2.4%-8.4%) at 6 months and 9.8% (5.5%-14.1%) at 12 months. A significant improvement in LIP was not detected among patients with ATM variants, with an LIP incidence of 3.1% (0.0%-9.1%) at both 6 and 12 months (P = .26). Although differences according to ATM variant type (pathologic variant or variant of unknown significance) did not reach significance, no patients with ATM pathologic variants experienced LIP. Conclusions We did not detect significant associations between ATM variant status and RN or LIP after SRS for NSCLC brain metastases. The current data set allows estimation of patient cohort sizes needed to power future investigations to identify genetic variants that associate with significant differences in outcomes after SRS.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Michelle Green
- Department of Pathology, Duke University Medical Center, Durham, North Carolina
| | - Zachary J. Reitman
- Department of Radiation Oncology
- Department of Pathology, Duke University Medical Center, Durham, North Carolina
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Bodensohn R, Maier SH, Belka C, Minniti G, Niyazi M. Stereotactic Radiosurgery of Multiple Brain Metastases: A Review of Treatment Techniques. Cancers (Basel) 2023; 15:5404. [PMID: 38001664 PMCID: PMC10670108 DOI: 10.3390/cancers15225404] [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: 08/31/2023] [Revised: 10/22/2023] [Accepted: 11/11/2023] [Indexed: 11/26/2023] Open
Abstract
The advancement of systemic targeted treatments has led to improvements in the management of metastatic disease, particularly in terms of survival outcomes. However, brain metastases remain less responsive to systemic therapies, underscoring the significance of local interventions for comprehensive disease control. Over the past years, the threshold for treating brain metastases through stereotactic radiosurgery has risen. Yet, as the number of treated metastases increases, treatment complexity and duration also escalate. This trend has made multi-isocenter radiosurgery treatments, such as those with the Gamma Knife, challenging to plan and lengthy for patients. In contrast, single-isocenter approaches employing linear accelerators offer an efficient and expeditious treatment option. This review delves into the literature, comparing different linear-accelerator-based techniques with each other and in relation to dedicated systems, focusing on dosimetric considerations and feasibility.
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Affiliation(s)
- Raphael Bodensohn
- Department of Radiation Oncology, University Hospital Tübingen, 72076 Tübingen, Germany;
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, 72076 Tübingen, Germany
| | - Sebastian H. Maier
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, 81377 Munich, Germany; (S.H.M.); (C.B.)
| | - Claus Belka
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, 81377 Munich, Germany; (S.H.M.); (C.B.)
- German Cancer Consortium (DKTK), Partner Site Munich, A Partnership between DKFZ and LMU University Hospital, 81377 Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Giuseppe Minniti
- IRCCS Neuromed, 86077 Pozzilli, Italy;
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital Tübingen, 72076 Tübingen, Germany;
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, 72076 Tübingen, Germany
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, 81377 Munich, Germany; (S.H.M.); (C.B.)
- German Cancer Consortium (DKTK), Partner Site Tübingen, A Partnership between DKFZ and University Hospital, 72076 Tübingen, Germany
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Hao Y, Tang T, Ren J, Li G. Prognostic analysis of stereotactic radiosurgery for brain metastases: a single-center retrospective study. LA RADIOLOGIA MEDICA 2023; 128:1271-1283. [PMID: 37648956 DOI: 10.1007/s11547-023-01698-3] [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: 01/19/2023] [Accepted: 08/09/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVES Brain metastasis (BM) is a common event during the development of many cancers, and is also one of the main causes of death of patients. Stereotactic radiosurgery (SRS) is an effective treatment for BM. The prognostic effects of various clinical factors on local control (LC) and overall survival (OS) after SRS treatment are still unclear. The purpose of this study is to retrospectively analyze the intracranial progression free survival (iPFS) and OS of patients receiving SRS treatment, and explore the relationship between various clinical characteristics and patient prognosis. MATERIALS AND METHODS We collected the clinical information of patients who were diagnosed with BM and received SRS treatment in our center between 2018 and 2021. Univariate and multivariate Cox regression analysis and KM analysis for iPFS and OS were conducted in R software to investigate the prognostic effects of clinical characteristics. RESULTS In total, 183 patients that received SRS in our center were enrolled in the cohort. The median iPFS for all patients was 8.87 months (95% CI 6.9-10.6), and the median OS was 16.5 months (95% CI 12.9-20.7). BM number > = 5 (HR 1.965 [95% CI 1.381-2.796], p < 0.001, FDR-corrected p < 0.001) was found to be strong predictor for shorter iPFS and OS. Subgroup analysis showed that patients with cumulative intracranial tumor volume (CITV) > = 2.14 cm3 and number > = 5 had shortest iPFS (P < 0.001) and OS (P = 0.007), compared with other subgroups. For patients with more than 5 BMs, SRS plus whole brain radiotherapy (WBRT) could achieve better local control, compared with SRS alone group (P = 0.0357). Peripheral blood inflammation indicators were associated with the prognosis of BM patients in univariate Cox analysis, but not in multivariate Cox analysis. CONCLUSIONS BM number is an independent prognostic factor for BM patients. The prognosis of patients in the subgroup with larger CITV and more BM is the worst. For patients with more than 5 BM, the combination of SRS and WBRT can improve the local control, but cannot prolong the OS.
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Affiliation(s)
- Yongping Hao
- Department of Radiation Oncology, The First Affiliated Hospital of China Medical University, No.155 North NanJing Street, Heping District, Shenyang, 110001, Liaoning, China
| | - Ting Tang
- Department of Radiation Oncology, The First Affiliated Hospital of China Medical University, No.155 North NanJing Street, Heping District, Shenyang, 110001, Liaoning, China
| | - Jing Ren
- Department of Radiation Oncology, The First Affiliated Hospital of China Medical University, No.155 North NanJing Street, Heping District, Shenyang, 110001, Liaoning, China
| | - Guang Li
- Department of Radiation Oncology, The First Affiliated Hospital of China Medical University, No.155 North NanJing Street, Heping District, Shenyang, 110001, Liaoning, China.
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Faccenda V, Panizza D, Pisoni V, Trivellato S, Daniotti MC, Bianchi SP, De Ponti E, Arcangeli S. Single-Isocenter Linac-Based Radiosurgery for Brain Metastases with Coplanar Arcs: A Dosimetric and Clinical Analysis. Cancers (Basel) 2023; 15:4496. [PMID: 37760466 PMCID: PMC10526167 DOI: 10.3390/cancers15184496] [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: 07/11/2023] [Revised: 09/04/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
The efficacy of linac-based SRS/fSRS treatments using the single-isocenter coplanar FFF-VMAT technique for both single and multiple BM was investigated. Seventy patients (129 BM) treated with 15-21 Gy in 1 (n = 59) or 27 Gy in 3 (n = 11) fractions were analyzed. For each fraction, plans involving the intra-fractional errors measured by post-treatment CBCT were recalculated. The relationships of BM size, distance-to-isocenter, and barycenter shift with the difference in target coverage were evaluated. Clinical outcomes were assessed using logistic regression and Kaplan-Meier analysis. The median delivery time was 3.78 min (range, 1.83-9.25). The median post-treatment 3D error was 0.5 mm (range, 0.1-2.7) and the maximum rotational error was 0.3° (range, 0.0-1.3). In single BM patients, the GTV D95% was never reduced by >5%, whereas PTV D95% reductions >1% occurred in only 11 cases (29%). In multiple BM patients, dose deficits >5% and >1% occurred in 2 GTV (2%) and 34 PTV (37%), respectively. The differences in target coverage showed a moderate-to-strong correlation only with barycenter shift. Local failure of at least one treated BM occurred in 13 (21%) patients and the 1-year and 2-year local control rates for all lesions were 94% and 90%, respectively. The implemented workflow ensured that the degradation of target and brain dose metrics in delivered treatments was negligible. Along with encouraging clinical outcomes, these findings warrant a reduction in the PTV margins at our institution.
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Affiliation(s)
- Valeria Faccenda
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (V.F.); (D.P.); (S.T.); (M.C.D.); (E.D.P.)
| | - Denis Panizza
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (V.F.); (D.P.); (S.T.); (M.C.D.); (E.D.P.)
- School of Medicine and Surgery, University of Milan Bicocca, 20126 Milan, Italy;
| | - Valerio Pisoni
- Radiation Oncology Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy;
| | - Sara Trivellato
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (V.F.); (D.P.); (S.T.); (M.C.D.); (E.D.P.)
| | - Martina Camilla Daniotti
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (V.F.); (D.P.); (S.T.); (M.C.D.); (E.D.P.)
| | - Sofia Paola Bianchi
- School of Medicine and Surgery, University of Milan Bicocca, 20126 Milan, Italy;
| | - Elena De Ponti
- Medical Physics Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (V.F.); (D.P.); (S.T.); (M.C.D.); (E.D.P.)
- School of Medicine and Surgery, University of Milan Bicocca, 20126 Milan, Italy;
| | - Stefano Arcangeli
- School of Medicine and Surgery, University of Milan Bicocca, 20126 Milan, Italy;
- Radiation Oncology Department, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy;
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Berger A, Mullen R, Bernstein K, Alzate JD, Silverman JS, Sulman EP, Donahue BR, Chachoua A, Shum E, Velcheti V, Sabari J, Golfinos JG, Kondziolka D. Extended Survival in Patients With Non-Small-Cell Lung Cancer-Associated Brain Metastases in the Modern Era. Neurosurgery 2023; 93:50-59. [PMID: 36722962 DOI: 10.1227/neu.0000000000002372] [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: 09/26/2022] [Accepted: 11/17/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Brain metastases (BM) have long been considered a terminal diagnosis with management mainly aimed at palliation and little hope for extended survival. Use of brain stereotactic radiosurgery (SRS) and/or resection, in addition to novel systemic therapies, has enabled improvements in overall and progression-free (PFS) survival. OBJECTIVE To explore the possibility of extended survival in patients with non-small-cell lung cancer (NSCLC) BM in the current era. METHODS During the years 2008 to 2020, 606 patients with NSCLC underwent their first Gamma Knife SRS for BM at our institution with point-of-care data collection. We reviewed clinical, molecular, imaging, and treatment parameters to explore the relationship of such factors with survival. RESULTS The median overall survival was 17 months (95% CI, 13-40). Predictors of increased survival in a multivariable analysis included age <65 years ( P < .001), KPS ≥80 ( P < .001), absence of extracranial metastases ( P < .001), fewer BM at first SRS (≤3, P = .003), and targeted therapy ( P = .005), whereas chemotherapy alone was associated with shorter survival ( P = .04). In a subgroup of patients managed before 2016 (n = 264), 38 (14%) were long-term survivors (≥5 years), of which 16% required no active cancer treatment (systemic or brain) for ≥3 years by the end of their follow-up. CONCLUSION Long-term survival in patients with brain metastases from NSCLC is feasible in the current era of SRS when combined with the use of effective targeted therapeutics. Of those living ≥5 years, the chance for living with stable disease without the need for active treatment for ≥3 years was 16%.
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Affiliation(s)
- Assaf Berger
- Department of Neurological Surgery, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Reed Mullen
- Department of Neurological Surgery, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Juan Diego Alzate
- Department of Neurological Surgery, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Joshua S Silverman
- Department of Radiation Oncology, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Erik P Sulman
- Department of Radiation Oncology, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Bernadine R Donahue
- Department of Radiation Oncology, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Abraham Chachoua
- Medical Oncology, Perlmutter Cancer Center, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Elaine Shum
- Medical Oncology, Perlmutter Cancer Center, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Vamsidhar Velcheti
- Medical Oncology, Perlmutter Cancer Center, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Joshua Sabari
- Medical Oncology, Perlmutter Cancer Center, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - John G Golfinos
- Department of Neurological Surgery, NYU Langone Health Medical Center, New York University, New York, New York, USA
| | - Douglas Kondziolka
- Department of Neurological Surgery, NYU Langone Health Medical Center, New York University, New York, New York, USA
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Church C, MacDonald RL, Parsons D, Syme A. Evaluation of plan quality and treatment efficiency in cranial stereotactic radiosurgery treatment plans with a variable source-to-axis distance. Med Phys 2023; 50:3039-3054. [PMID: 36774531 DOI: 10.1002/mp.16288] [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: 04/26/2022] [Revised: 10/03/2022] [Accepted: 01/31/2023] [Indexed: 02/13/2023] Open
Abstract
INTRODUCTION Radiotherapy deliveries with dynamic couch motions that shorten the source-to-axis distance (SAD) on a C-arm linac have the potential to increase treatment efficiency through the increase of the effective dose rate. In this investigation, we convert clinically deliverable volumetric modulated arc therapy (VMAT) and dynamic conformal arc (DCA) plans for cranial radiosurgery into virtual isocenter plans through implementation of couch trajectories that maintain the target at a shortened but variable SAD throughout treatment. MATERIALS AND METHODS A randomly sampled population of patients treated with cranial radiosurgery from within the last three years were separated into groups with one, two, and three lesions. All plans had a single isocenter (regardless of number of targets), and a single prescription dose. Patient treatment plans were converted from their original delivery at a standard isocenter to a dynamic virtual isocenter in MATLAB. The virtual isocenter plan featured a variable isocenter position based upon the closest achievable source-to-target distance (referred to herein as a virtual source-to-axis distance [vSAD]) which avoided collision zones on a TrueBeam STx platform. Apertures were magnified according to the vSAD and monitor units at a given control point were scaled based on the inverse square law. Doses were calculated for the plans with a virtual isocenter in the Eclipse (v13.6.23) treatment planning system (TPS) and were compared with the clinical plans. Plan metrics (MU, Paddick conformity index, gradient index, and the volume receiving 12 Gy or more), normal brain dose-volume differences, as well as maximum doses received by organs at risk (OARs) were assessed. The values were compared between standard and virtual isocenter plans with Wilcoxon Sign Ranked tests to determine significance. A subset of the plans were mapped to the MAX-HD anthropomorphic phantom which contained an insert housing EBT3 GafChromic film and a PTW 31010 microion chamber for dose verification on a linac. RESULTS Delivering plans at a virtual isocenter resulted in an average reduction of 20.9% (p = 3×10-6 ) and 20.6% (p = 3.0×10-6 ) of MUs across all VMAT and all DCA plans, respectively. There was no significant change in OAR max doses received by plans delivered at a virtual isocenter. The low dose wash (1.0-2.0 Gy or 5-11% of the prescription dose) was increased (by approximately 20 cc) for plans with three lesions. This was equivalent to a 2.7%-3.8% volumetric increase in normal tissue receiving the respective dose level when comparing the plan with a virtual isocenter to a plan with a standard isocenter. Gamma pass rates with a 5%/1mm analysis criteria were 96.40% ± 2.90% and 95.07% ± 3.10% for deliveries at standard and virtual isocenter, respectively. Absolute point dose agreements were within -0.36% ± 3.45% and -0.55% ± 3.39% for deliveries at a standard and virtual isocenter, respectively. Potential time savings per arc were found to have linear relationship with the monitor units delivered per arc (savings of 0.009 s/MU with an r2 = 0.866 when fit to plans with a single lesion). CONCLUSIONS Converting clinical plans at standard isocenter to a virtual isocenter design did not show any losses to plan quality while simultaneously improving treatment efficiency through MU reductions.
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Affiliation(s)
- Cody Church
- Department of Physics and Atmospheric Science, Dalhousie University, Halifax, Nova Scotia, Canada
| | - R Lee MacDonald
- Department of Radiation Oncology and Department of Physics and Atmospheric Science, Dalhousie University, Halifax, Nova Scotia, Canada
| | - David Parsons
- Department of Radiation Oncology, University of Texas Southwestern Medical Centre, Dallas, Texas, USA
| | - Alasdair Syme
- Department of Radiation Oncology and Department of Physics and Atmospheric Science, Dalhousie University, Halifax, Nova Scotia, Canada
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Kuperman VY, Altundal Y. Novel approach for the evaluation of dose conformity in radiotherapy. Med Phys 2023; 50:1086-1095. [PMID: 36272439 DOI: 10.1002/mp.15998] [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: 01/31/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE We describe a new approach to evaluate conformity of dose distributions in radiotherapy. METHODS The suggested conformity factor λ is defined by using existing conformity indices and expansion of the planning target volume (PTV). If the average distance ( d ¯ $\bar d$ ) between the PTV and reference isodose surface and an arbitrarily selected PTV expansion margin ( d e x p ${d_{exp}}$ ) are both much smaller than the size of the PTV, then λ approximately equals the ratio d ¯ d e x p $\frac{{\bar d}}{{{d_{exp}}}}$ . We use λ to analyze several cases of stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT). RESULTS In the case of SRS with a single target or multiple targets, treatment plans produced with the help of volumetric modulated arc therapy (VMAT) have smaller λ than plans produced by using dynamic conformal arcs (DCA). Likewise, it is demonstrated that in the case of SBRT, λ is reduced by employing VMAT instead of DCA. It is also shown that if the distance between the reference isodose surface and surface of the PTV is fixed, λ varies less with variations in PTV volume compared to frequently used conformity indices. CONCLUSIONS The described conformity factor λ can be applied clinically to compare and rank treatment plans for lesions of different sizes. It is suggested that conditions λ < 1 $\lambda < 1$ and λ > 1 can be employed as "pass" and "fail" criteria, respectively, for dose conformity assessment with appropriate choice of d e x p ${d_{exp}}$ .
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Affiliation(s)
- Vadim Y Kuperman
- Florida Cancer Specialists & Research Institute, Hudson, Florida, USA
| | - Yücel Altundal
- Florida Cancer Specialists & Research Institute, Hudson, Florida, USA
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11
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Amelioration of Radiation-Induced Cell Death in Neuro2a Cells by Neutralizing Oxidative Stress and Reducing Mitochondrial Dysfunction Using N-Acetyl-L-Tryptophan. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:9124365. [PMID: 36471866 PMCID: PMC9719430 DOI: 10.1155/2022/9124365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 11/28/2022]
Abstract
The deleterious effects of ionizing radiation on the central nervous system (CNS) are poorly understood. Radiation exposure during an accidental nuclear explosion, nuclear war, or radiotherapy causes severe brain damage. As a result, the current work is carried out to assess the radioprotective potential of N-acetyl-L-tryptophan (L-NAT) in neuronal cells. Radiation-induced cell death and its amelioration by L-NAT pretreatment were investigated using MTT, SRB, CFU, and comet assays. Flow cytometric and microscopic fluorescence assays were used to investigate radiation-induced oxidative stress, alteration in mitochondrial redox, Ca2+ homeostasis, depolarization of mitochondrial membrane potential, and its prevention with L-NAT pretreatment. Western blot analysis of Caspase-3, γ-H2aX, p53, ERK-1/2, and p-ERK-1/2 expression was carried out to identify the effects of L-NAT pretreatment on radiation-induced apoptosis and its regulatory proteins expression. The study demonstrated (MTT, SRB, and CFU assay) significant (~80%; p <0.001%) radioprotection in irradiated (LD50 IR dose) Neuro2a cells that were pretreated with L-NAT. In comparison to irradiated cells, L-NAT pretreatment resulted in significant (p <0.001%) DNA protection. A subsequent study revealed that L-NAT pretreatment of irradiated Neuro2a cells establishes oxidative stress by increasing antioxidant enzymes and mitochondrial redox homeostasis by inhibiting Ca2+ migration from the cytoplasm to the mitochondrial matrix and thus protects the mitochondrial membrane hyperpolarization. Caspase-3 and γ-H2aX protein expression decreased, while p-ERK1/2 and p53 expression increased in L-NAT pretreated irradiated cells compared to irradiated cells. Hence, L-NAT could be a potential radioprotective that may inhibit oxidative stress and DNA damage and maintain mitochondrial health and Ca2+ levels by activating p-ERK1/2 and p53 expression in Neuronal cells.
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V HP, R M, N ANR, S S. A Comprehensive Evaluation of Single Isocenter Multiple Target SRS Plans and the Analytical Relationship between Plan Quality Indices with the Number and Volume of Targets. Asian Pac J Cancer Prev 2022; 23:3103-3112. [PMID: 36172673 PMCID: PMC9810297 DOI: 10.31557/apjcp.2022.23.9.3103] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To study the relationship of plan quality indices with the number and volume of target for 5 to 10 brain metastases treated with LINAC-based Single Isocenter Multiple Target (SIMT) Stereotactic radiosurgery (SRS) planning and to determine the maximum volume of spherical targets treated without exceeding the normal tissue tolerances. METHODS Spherical targets of 5 to 10 numbers per plan, with individual target volumes ranging from 0.025 cc to 11.5 cc, were simulated with randomly drawn planning target volumes (PTVs) within the brain. SIMT SRS plans were generated for the 21 Gy prescription dose with a 6 MV Flattening Filter Free photon beam. Target coverage, organ at risk sparing, plan quality indices, R50%, and gradient measure were studied. Mean brain dose, V12 for Brain minus PTV (BmP), V10, V12, V15, V18, V20, and V24 for brain volume were evaluated. Equations relating the gradient index, mean brain dose, and V12 (BmP) to the given number and volume of the targets were constructed. RESULTS PTV coverage D98 was 98.77 ± 1.37 %. The mean CIRTOG, QRTOG, HIRTOG, CIP, GI, and R50% of the individual targets were 1.02 ± 0.08, 0.94 ± 0.02, 1.49 ± 0.11, 0.91 ± 0.06, 4.74 ± 2.3, and 4.95 ± 2.67, respectively. The gradient measure achieved was in the range of 0.49 to 1.35 cm. The mean brain dose was in the range of 1.62 to 6.69 Gy. The mean V12 (BmP) per target obtained was 3.85 ± 2.83 cc. CONCLUSION Equations relating the number and volume of targets to the gradient measure, mean brain dose, V12 (BmP), and V10-24 can serve as a baseline for multiple brain metastases SIMT planning. The target volume for 5, 6, 7, 8, 9, and 10 targets that can be treated without exceeding V12 (BmP) is 6, 5, 4.7, 4, 3.7, and 3.4 cc, respectively, for the 21 Gy prescription dose.
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Affiliation(s)
- Hemalatha Priyadarsini V
- Tamil Nadu Medical Services Corporation Ltd, 417, Pantheon road, Egmore, Chennai, Tamil Nadu, India. ,Department of Physics, School of Advanced Sciences, Vellore Institute of Technology, Vellore, Tamil Nadu, India. ,Department of Radiation Oncology, Government Royapettah Hospital, 1, West Cott road, Royapettah, Chennai, Tamil Nadu, India.
| | - Murali R
- Department of Physics, School of Advanced Sciences, Vellore Institute of Technology, Vellore, Tamil Nadu, India. ,For Correspondence:
| | - Arunai Nambi Raj N
- Department of Physics, School of Advanced Sciences, Vellore Institute of Technology, Vellore, Tamil Nadu, India.
| | - Saravanan S
- Department of Radiation Oncology, Government Royapettah Hospital, 1, West Cott road, Royapettah, Chennai, Tamil Nadu, India.
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Raza GH, Capone L, Tini P, Giraffa M, Gentile P, Minniti G. Single-isocenter multiple-target stereotactic radiosurgery for multiple brain metastases: dosimetric evaluation of two automated treatment planning systems. Radiat Oncol 2022; 17:116. [PMID: 35778741 PMCID: PMC9250172 DOI: 10.1186/s13014-022-02086-3] [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: 03/29/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022] Open
Abstract
Purpose Automated treatment planning systems are available for linear accelerator (linac)-based single-isocenter multi-target (SIMT) stereotactic radiosurgery (SRS) of brain metastases. In this study, we compared plan quality between Brainlab Elements Multiple Brain Metastases (Elements MBM) software which utilizes dynamic conformal arc therapy (DCAT) and Varian HyperArc (HA) software using a volumetric modulated arc therapy (VMAT) technique. Patients and methods Between July 2018 and April 2021, 36 consecutive patients ≥ 18 years old with 367 metastases who received SIMT SRS at UPMC Hillman Cancer San Pietro Hospital, Rome, were retrospectively evaluated. SRS plans were created using the commercial software Elements MBM SRS (Version 1.5 and 2.0). Median cumulative gross tumor volume (GTV) and planning tumor volume (PTV) were 1.33 cm3 and 3.42 cm3, respectively. All patients were replanned using HA automated software. Extracted dosimetric parameters included mean dose (Dmean) to the healthy brain, volumes of the healthy brain receiving more than 5, 8,10, and 12 Gy (V5Gy, V8Gy, V10Gy and V12Gy), and doses to hippocampi. Results Both techniques resulted in high-quality treatment plans, although Element MBM DCAT plans performed significantly better than HA VMAT plans, especially in cases of more than 10 lesions). Median V12Gy was 13.6 (range, 1.87–45.9) cm3 for DCAT plans and 18.5 (2.2–62,3) cm3 for VMAT plans (p < 0.0001), respectively. Similarly, V10Gy, V8Gy, V5Gy (p < 0.0001) and median dose to the normal brain (p = 0.0001) were favorable for DCAT plans. Conclusions Both Elements MBM and HA systems were able to generate high-quality plans in patients with up to 25 brain metastases. DCAT plans performed better in terms of normal brain sparing, especially in patients with more than ten lesions and limited total tumor volume.
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Affiliation(s)
- Giorgio Hamid Raza
- UPMC Hillman Cancer Center, San Pietro Hospital FBF, Via Cassia 600, 00189, Rome, Italy
| | - Luca Capone
- UPMC Hillman Cancer Center, San Pietro Hospital FBF, Via Cassia 600, 00189, Rome, Italy
| | - Paolo Tini
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Martina Giraffa
- UPMC Hillman Cancer Center, San Pietro Hospital FBF, Via Cassia 600, 00189, Rome, Italy
| | - Piercarlo Gentile
- UPMC Hillman Cancer Center, San Pietro Hospital FBF, Via Cassia 600, 00189, Rome, Italy
| | - Giuseppe Minniti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy. .,IRCCS Neuromed, 86077, Pozzilli, IS, Italy.
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14
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Grabowski MM, Srinivasan ES, Vaios EJ, Sankey EW, Otvos B, Krivosheya D, Scott A, Olufawo M, Ma J, Fomchenko EI, Herndon JE, Kim AH, Chiang VL, Chen CC, Leuthardt EC, Barnett GH, Kirkpatrick JP, Mohammadi AM, Fecci PE. Combination Laser Interstitial Thermal Therapy Plus Stereotactic Radiotherapy (SRT) Increases Time to Progression for Biopsy-Proven Recurrent Brain Metastases. Neurooncol Adv 2022; 4:vdac086. [PMID: 35795470 PMCID: PMC9248774 DOI: 10.1093/noajnl/vdac086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Improved survival for patients with brain metastases has been accompanied by a rise in tumor recurrence after stereotactic radiotherapy (SRT). Laser interstitial thermal therapy (LITT) has emerged as an effective treatment for SRT failures as an alternative to open resection or repeat SRT. We aimed to evaluate the efficacy of LITT followed by SRT (LITT+SRT) in recurrent brain metastases. Methods A multicenter, retrospective study was performed of patients who underwent treatment for biopsy-proven brain metastasis recurrence after SRT at an academic medical center. Patients were stratified by “planned LITT+SRT” versus “LITT alone” versus “repeat SRT alone.” Index lesion progression was determined by modified Response Assessment in Neuro-Oncology Brain Metastases (RANO-BM) criteria. Results Fifty-five patients met inclusion criteria, with a median follow-up of 7.3 months (range: 1.0–30.5), age of 60 years (range: 37–86), Karnofsky Performance Status (KPS) of 80 (range: 60–100), and pre-LITT/biopsy contrast-enhancing volume of 5.7 cc (range: 0.7–19.4). Thirty-eight percent of patients underwent LITT+SRT, 45% LITT alone, and 16% SRT alone. Median time to index lesion progression (29.8, 7.5, and 3.7 months [P = .022]) was significantly improved with LITT+SRT. When controlling for age in a multivariate analysis, patients treated with LITT+SRT remained significantly less likely to have index lesion progression (P = .004). Conclusions These data suggest that LITT+SRT is superior to LITT or repeat SRT alone for treatment of biopsy-proven brain metastasis recurrence after SRT failure. Prospective trials are warranted to validate the efficacy of using combination LITT+SRT for treatment of recurrent brain metastases.
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Affiliation(s)
- Matthew M Grabowski
- Corresponding Author: Matthew M. Grabowski, MD, Cleveland Clinic, 9500 Euclid Ave. S4, Cleveland, OH 44195, USA ()
| | - Ethan S Srinivasan
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Eugene J Vaios
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Eric W Sankey
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Balint Otvos
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic & Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Daria Krivosheya
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic & Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Alex Scott
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael Olufawo
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jun Ma
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Elena I Fomchenko
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - James E Herndon
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Albert H Kim
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Veronica L Chiang
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Eric C Leuthardt
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Gene H Barnett
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic & Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - John P Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina, USA
- Duke Center for Brain and Spine Metastasis, Durham, North Carolina, USA
| | - Alireza M Mohammadi
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic & Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
- Duke Center for Brain and Spine Metastasis, Durham, North Carolina, USA
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15
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Han EY, Wang H, Briere TM, Yeboa DN, Boursianis T, Kalaitzakis G, Pappas E, Castillo P, Yang J. Brain stereotactic radiosurgery using MR-guided online adaptive planning for daily setup variation: An end-to-end test. J Appl Clin Med Phys 2022; 23:e13518. [PMID: 34994101 PMCID: PMC8906207 DOI: 10.1002/acm2.13518] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/02/2021] [Accepted: 12/09/2021] [Indexed: 11/21/2022] Open
Abstract
Online magnetic resonance (MR)‐guided radiotherapy is expected to benefit brain stereotactic radiosurgery (SRS) due to superior soft tissue contrast and capability of daily adaptive planning. The purpose of this study was to investigate daily adaptive plan quality with setup variations and to perform an end‐to‐end test for brain SRS with multiple metastases treated with a 1.5‐Tesla MR‐Linac (MRL). The RTsafe PseudoPatient Prime brain phantom was used with a delineation insert that includes two predefined structures mimicking gadolinium contrast‐enhanced brain lesions. Daily adaptive plans were generated using six preset and six random setup variations. Two adaptive plans per daily MR image were generated using the adapt‐to‐position (ATP) and adapt‐to‐shape (ATS) workflows. An adaptive patient plan was generated on a diagnostic MR image with simulated translational and rotational daily setup variation and was compared with the reference plan. All adaptive plans were compared with the reference plan using the target coverage, Paddick conformity index, gradient index (GI), Brain V12 or V20, optimization time and total monitor units. Target doses were measured as an end‐to‐end test with two ionization chambers inserted into the phantom. With preset translational variations, V12 from the ATS plan was 17% lower than that of the ATP plan. With a larger daily setup variation, GI and V12 of the ATS plan were 10% and 16% lower than those of the ATP plan, respectively. Compared to the ATP plans, the plan quality index of the ATS plans was more consistent with the reference plan, and within 5% in both phantom and patient plans. The differences between the measured and planned target doses were within 1% for both treatment workflows. Treating brain SRS using an MRL is feasible and could achieve satisfactory dosimetric goals. Setup uncertainties could be accounted for using online plan adaptation. The ATS workflow achieved better dosimetric results than the ATP workflow at the cost of longer optimization time.
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Affiliation(s)
- Eun Young Han
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - He Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tina Marie Briere
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Debra Nana Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | | | - Evangelos Pappas
- Department of Biomedical Sciences, Radiology and Radiotherapy Sector, University of West Attica, Athens, Greece
| | - Pamela Castillo
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jinzhong Yang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Outcomes in Patients With 4 to 10 Brain Metastases Treated With Dose-Adapted Single-Isocenter Multitarget Stereotactic Radiosurgery: A Prospective Study. Adv Radiat Oncol 2021; 6:100760. [PMID: 34934856 PMCID: PMC8655418 DOI: 10.1016/j.adro.2021.100760] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/13/2021] [Indexed: 12/20/2022] Open
Abstract
Purpose To examine the effectiveness and safety of single-isocenter multitarget stereotactic radiosurgery using a volume-adapted dosing strategy in patients with 4 to 10 brain metastases. Methods and Materials Adult patients with 4 to 10 brain metastases were eligible for this prospective trial. The primary endpoint was overall survival. Secondary endpoints were local recurrence, distant brain failure, neurologic death, and rate of adverse events. Exploratory objectives were neurocognition, quality of life, dosimetric data, salvage rate, and radionecrosis. Dose was prescribed in a single fraction per RTOG 90-05 or as 5 Gy × 5 fractions for lesions ≥3 cm diameter, lesions involving critical structures, or single-fraction brain V12Gy >20 mL. Results Forty patients were treated with median age of 61 years, Karnofsky performance status 90, and 6 brain metastases. Twenty-two patients survived longer than expected from the time of protocol SRS, with 1 living patient who has not reached that milestone. Median overall survival was 8.1 months with a 1-year overall survival of 35.7%. The 1-year local recurrence rate was 5% (10 of 204 of evaluable lesions) in 12.5% (4 of 32) of the patients. Distant brain failure was observed in 19 of 32 patients with a 1-year rate of 35.8%. Grade 1-2 headache was the most common complaint, with no grade 3-5 treatment-related adverse events. Radionecrosis was observed in only 5 lesions, with a 1-year rate of 1.5%. Rate of neurologic death was 20%. Neurocognition and quality of life did not significantly change 3 months after SRS compared with pretreatment. Conclusions These results suggest that volume-adapted dosing single-isocenter multitarget stereotactic radiosurgery is an effective and safe treatment for patients with 4 to 10 brain metastases.
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Menon SV, P R, Bhasi S, Gopalakrishnan Z, B S, K S, Nair RK. Dosimetric comparison and validation of Eclipse Anisotropic Analytical Algorithm (AAA) and AcurosXB (AXB) algorithms in RapidArc-based radiosurgery plans of patients with solitary brain metastasis. Med Dosim 2021; 47:e7-e12. [PMID: 34740518 DOI: 10.1016/j.meddos.2021.09.001] [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: 05/28/2021] [Revised: 08/02/2021] [Accepted: 09/01/2021] [Indexed: 11/28/2022]
Abstract
Stereotactic radiosurgery (SRS) is increasingly being used to manage solitary or multiple brain metastasis. This study aims to compare and validate Anisotropic Analytical Algorithm (AAA) and AcurosXB (AXB) algorithms of Eclipse Treatment Planning System (TPS) in RapidArc-based SRS plans of patients with solitary brain metastasis. Twenty patients with solitary brain metastasis who have been already treated with RapidArc SRS plans calculated using AAA plans were selected for this study. These plans were recalculated using AXB algorithm keeping the same arc orientations, multi-leaf collimator apertures, and monitor units. The two algorithms were compared for target coverage parameters, isodose volumes, plan quality metrics, dose to organs at risk and integral dose. The dose calculated by the TPS using AAA and AXB algorithms was validated against measured dose for all patient plans using an in-house developed cylindrical phantom. An Exradin A14SL ionization chamber was positioned at the center of this phantom to measure the in-field dose. NanoDot Optically Stimulated Luminescent Dosimeters (OSLDs) (Landauer Inc.) were placed at distances 3.0 cm, 4.0 cm, 5.0 cm, and 6.0 cm respectively from the center of the phantom to measure the non-target dose. In addition, the planar dose distribution was measured using amorphous silicon aS1000 Electronic Portal Imaging Device. The measured 2D dose distribution was compared against AAA and AXB estimated 2D distribution using gamma analysis. All results were tested for significance using the paired t-test at 5% level of significance. Significant differences between the AAA and AXB plans were found only for a few parameters analyzed in this study. In the experimental verification using cylindrical phantom, the difference between the AAA calculated dose and the measured dose was found to be highly significant (p < 0.001). However, the difference between the AXB calculated dose and the measured dose was not significant (p = 0.197). The difference between AAA/AXB calculated and measured at non-target locations was statistically insignificant at all four non-target locations and the dose calculated by both AAA and AXB algorithms shows a strong positive correlation with the measured dose. The results of the gamma analysis show that the AXB calculated planar dose is in better agreement with measurements compared to the AAA. Even though the results of the dosimetric comparison show that the differences are mostly not significant, the measurements show that there are differences between the two algorithms within the target volume. The AXB algorithm may be therefore more accurate in the dose calculation of VMAT plans for the treatment of small intracranial targets. For non-target locations either algorithm can be used for the estimation of dose accounting for their limitations in non-target dose estimations.
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Affiliation(s)
- Sharika Venugopal Menon
- Division of Radiation Physics, Regional Cancer Centre, Thiruvananthapuram, Kerala, India; Centre for Research and Evaluation, Bharathiar University, Coimbatore, Tamil Nadu, India
| | - Raghukumar P
- Division of Radiation Physics, Regional Cancer Centre, Thiruvananthapuram, Kerala, India.
| | - Saju Bhasi
- Division of Radiation Physics, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - Zhenia Gopalakrishnan
- Division of Radiation Physics, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - Sarin B
- Division of Radiation Physics, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - Shilpa K
- Division of Radiation Physics, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - Raghuram K Nair
- SUT Royal Hospital, Ulloor, Thiruvananthapuram, Kerala, India
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Gude Z, Adamson J, Kirkpatrick JP, Giles W. Hippocampal Avoidance in Multitarget Radiosurgery. Cureus 2021; 13:e15399. [PMID: 34249548 PMCID: PMC8253338 DOI: 10.7759/cureus.15399] [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] [Accepted: 05/22/2021] [Indexed: 11/16/2022] Open
Abstract
Brain metastases are a common complication for patients diagnosed with cancer. As stereotactic radiosurgery (SRS) becomes a more prevalent treatment option for patients with many brain metastases, further research is required to better characterize the ability of SRS to treat large numbers of metastases (≥4) and the impact on normal brain tissue and, ultimately, neurocognition and quality of life (QOL). This study serves first as an evaluation of the feasibility of hippocampal avoidance for SRS patients, specifically receiving single-isocenter multitarget treatments (SIMT) planned with volumetric modulated arc therapy (VMAT). Second, this study analyzes the effects of standard-definition (SD) multileaf collimators (MLCs) (5 mm width) on plan quality and hippocampal avoidance. The 40 patients enrolled in this Institutional Review Board (IRB)-approved study had between four and 10 brain metastases and were treated with SIMT using VMAT. From the initial 40 patients, eight hippocampi across seven patients had hippocampal doses exceeding the maximum biologically effective dose (BED) constraint given by RTOG 0933. With the addition of upper constraints in the optimization objectives and one arc angle adjustment in one patient plan, four out of seven patient plans were able to meet the maximum hippocampal BED constraint, avoiding five out of eight total hippocampi at risk. High-definition (HD) MLCs allowed for an average decrease of 29% ± 23% (p = 0.007) in the maximum BED delivered to all eight hippocampi at risk. The ability to meet dose constraints depended on the distance between the hippocampus and the nearest planning target volume (PTV). Meeting the maximum hippocampal BED constraint in re-optimized plans was equally likely with the use of SD-MLCs (five out of eight hippocampi at risk were avoided) but resulted in increased dose to normal tissue volumes (23.67% ± 16.3% increase in V50%[cc] of normal brain tissue, i.e., brain volume subtracted by the total PTV) when compared to the HD-MLC re-optimized plans. Comparing the effects of SD-MLCs on plans not optimized for hippocampal avoidance resulted in increases of 48.2% ± 32.2% (p = 0.0056), 31.5% ± 16.3% (p = 0.024), and 16.7% ± 8.5% (p = 0.022) in V20%[cc], V50%[cc], and V75%[cc], respectively, compared to the use of HD-MLCs. The conformity index changed significantly neither when plans were optimized for hippocampal avoidance nor when SD-MLC leaves were used for treatment. In plans not optimized for hippocampal avoidance, mean hippocampal dose increased with the use of SD-MLCs by 38.0% ± 37.5% (p = 0.01). However, the use of SD-MLCs did not result in an increased number of hippocampi at risk.
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Affiliation(s)
| | - Justus Adamson
- Radiation Oncology, Duke University Medical Center, Durham, USA
| | | | - William Giles
- Radiation Oncology, Duke University Medical Center, Durham, USA
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Calvo‐Ortega J, Greer PB, Hermida‐López M, Moragues‐Femenía S, Laosa‐Bello C, Casals‐Farran J. Validation of virtual water phantom software for pre-treatment verification of single-isocenter multiple-target stereotactic radiosurgery. J Appl Clin Med Phys 2021; 22:241-252. [PMID: 34028955 PMCID: PMC8200437 DOI: 10.1002/acm2.13269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 02/05/2021] [Accepted: 04/13/2021] [Indexed: 11/09/2022] Open
Abstract
The aim of this study was to benchmark the accuracy of the VIrtual Phantom Epid dose Reconstruction (VIPER) software for pre-treatment dosimetric verification of multiple-target stereotactic radiosurgery (SRS). VIPER is an EPID-based method to reconstruct a 3D dose distribution in a virtual phantom from in-air portal images. Validation of the VIPER dose calculation was assessed using several MLC-defined fields for a 6 MV photon beam. Central axis percent depth doses (PDDs) and output factors were measured with an ionization chamber in a water tank, while dose planes at a depth of 10 cm in a solid flat phantom were acquired with radiochromic films. The accuracy of VIPER for multiple-target SRS plan verification was benchmarked against Monte Carlo simulations. Eighteen multiple-target SRS plans designed with the Eclipse treatment planning system were mapped to a cylindrical water phantom. For each plan, the 3D dose distribution reconstructed by VIPER within the phantom was compared with the Monte Carlo simulation, using a 3D gamma analysis. Dose differences (VIPER vs. measurements) generally within 2% were found for the MLC-defined fields, while film dosimetry revealed gamma passing rates (GPRs) ≥95% for a 3%/1 mm criteria. For the 18 multiple-target SRS plans, average 3D GPRs greater than 93% and 98% for the 3%/2 mm and 5%/2 mm criteria, respectively. Our results validate the use of VIPER as a dosimetric verification tool for pre-treatment QA of single-isocenter multiple-target SRS plans. The method requires no setup time on the linac and results in an accurate 3D characterization of the delivered dose.
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Affiliation(s)
- Juan‐Francisco Calvo‐Ortega
- Servicio de Oncología RadioterápicaHospital QuirónsaludBarcelonaSpain
- Servicio de Oncología RadioterápicaHospital Universitari DexeusBarcelonaSpain
| | - Peter B. Greer
- Department of Radiation OncologyCalvary Mater Newcastle HospitalNewcastleNSW2298Australia
- School of Mathematical and Physical SciencesUniversity of NewcastleNewcastleNSW2300Australia
| | | | - Sandra Moragues‐Femenía
- Servicio de Oncología RadioterápicaHospital QuirónsaludBarcelonaSpain
- Servicio de Oncología RadioterápicaHospital Universitari DexeusBarcelonaSpain
| | - Coral Laosa‐Bello
- Servicio de Oncología RadioterápicaHospital QuirónsaludBarcelonaSpain
- Servicio de Oncología RadioterápicaHospital Universitari DexeusBarcelonaSpain
| | - Joan Casals‐Farran
- Servicio de Oncología RadioterápicaHospital QuirónsaludBarcelonaSpain
- Servicio de Oncología RadioterápicaHospital Universitari DexeusBarcelonaSpain
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Milano MT, Chiang VLS, Soltys SG, Wang TJC, Lo SS, Brackett A, Nagpal S, Chao S, Garg AK, Jabbari S, Halasz LM, Gephart MH, Knisely JPS, Sahgal A, Chang EL. Executive summary from American Radium Society's appropriate use criteria on neurocognition after stereotactic radiosurgery for multiple brain metastases. Neuro Oncol 2021; 22:1728-1741. [PMID: 32780818 DOI: 10.1093/neuonc/noaa192] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The American Radium Society (ARS) Appropriate Use Criteria brain malignancies panel systematically reviewed (PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses]) published literature on neurocognitive outcomes after stereotactic radiosurgery (SRS) for patients with multiple brain metastases (BM) to generate consensus guidelines. METHODS The panel developed 4 key questions (KQs) to guide systematic review. From 11 614 original articles, 12 were selected. The panel developed model cases addressing KQs and potentially controversial scenarios not addressed in the systematic review (which might inform future ARS projects). Based upon quality of evidence, the panel confidentially voted on treatment options using a 9-point scale of appropriateness. RESULTS The panel agreed that SRS alone is usually appropriate for those with good performance status and 2-10 asymptomatic BM, and usually not appropriate for >20 BM. For 11-15 and 16-20 BM there was (between 2 case variants) agreement that SRS alone may be appropriate or disagreement on the appropriateness of SRS alone. There was no scenario (among 6 case variants) in which conventional whole-brain radiotherapy (WBRT) was considered usually appropriate by most panelists. There were several areas of disagreement, including: hippocampal sparing WBRT for 2-4 asymptomatic BM; WBRT for resected BM amenable to SRS; fractionated versus single-fraction SRS for resected BM, larger targets, and/or brainstem metastases; optimal treatment (WBRT, hippocampal sparing WBRT, SRS alone to all or select lesions) for patients with progressive extracranial disease, poor performance status, and no systemic options. CONCLUSIONS For patients with 2-10 BM, SRS alone is an appropriate treatment option for well-selected patients with good performance status. Future study is needed for those scenarios in which there was disagreement among panelists.
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Affiliation(s)
- Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, NY
| | - Veronica L S Chiang
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, CT
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, CT
| | - Tony J C Wang
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Alexandria Brackett
- Cushing/Whitney Medical Library, Yale School of Medicine, Yale University, New Haven, CT
| | - Seema Nagpal
- Department of Neurology, Stanford University School of Medicine, Stanford, CT
| | - Samuel Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Amit K Garg
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Albuquerque, NM
| | - Siavash Jabbari
- Laurel Amtower Cancer Institute and Neuro-oncology Center, Sharp Healthcare, San Diego, CA
| | - Lia M Halasz
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | | | - Jonathan P S Knisely
- Department of Radiation Oncology, Weill Cornell Medicine, Cornell University, New York, NY
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
| | - Eric L Chang
- Department of Radiation Oncology, Keck School of Medicine of University of Southern California, Los Angeles, CA
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Bodensohn R, Kaempfel AL, Fleischmann DF, Hadi I, Hofmaier J, Garny S, Reiner M, Forbrig R, Corradini S, Thon N, Belka C, Niyazi M. Simultaneous stereotactic radiosurgery of multiple brain metastases using single-isocenter dynamic conformal arc therapy: a prospective monocentric registry trial. Strahlenther Onkol 2021; 197:601-613. [PMID: 33884441 PMCID: PMC8219560 DOI: 10.1007/s00066-021-01773-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 03/23/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Single-isocenter dynamic conformal arc (SIDCA) therapy is a technically efficient way of delivering stereotactic radiosurgery (SRS) to multiple metastases simultaneously. This study reports on the safety and feasibility of linear accelerator (LINAC) based SRS with SIDCA for patients with multiple brain metastases. METHODS All patients who received SRS with this technique between November 2017 and June 2019 within a prospective registry trial were included. The patients were irradiated with a dedicated planning tool for multiple brain metastases using a LINAC with a 5 mm multileaf collimator. Follow-up was performed every 3 months, including clinical and radiological examination with cranial magnetic resonance imaging (MRI). These early data were analyzed using descriptive statistics and the Kaplan-Meier method. RESULTS A total of 65 patients with 254 lesions (range 2-12) were included in this analysis. Median beam-on time was 23 min. The median follow-up at the time of analysis was 13 months (95% CI 11.1-14.9). Median overall survival and median intracranial progression-free survival was 15 months (95% CI 7.7-22.3) and 7 months (95% CI 3.9-10.0), respectively. Intracranial and local control after 1 year was 64.6 and 97.5%, respectively. During follow-up, CTCAE grade I adverse effects (AE) were experienced by 29 patients (44.6%; 18 of them therapy related, 27.7%), CTCAE grade II AEs by four patients (6.2%; one of them therapy related, 1.5%), and CTCAE grade III by three patients (4.6%; none of them therapy related). Two lesions (0.8%) in two patients (3.1%) were histopathologically proven to be radiation necrosis. CONCLUSION Simultaneous SRS using SIDCA seems to be a feasible and safe treatment for patients with multiple brain metastases.
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Affiliation(s)
- Raphael Bodensohn
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Anna-Lena Kaempfel
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Daniel Felix Fleischmann
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.,German Cancer Consortium (DKTK), Munich, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Indrawati Hadi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Jan Hofmaier
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Sylvia Garny
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Michael Reiner
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Robert Forbrig
- Institute of Neuroradiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Niklas Thon
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.,German Cancer Consortium (DKTK), Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany. .,German Cancer Consortium (DKTK), Munich, Germany.
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Use of radiotherapy in breast cancer patients with brain metastases: a retrospective 11-year single center study. J Med Imaging Radiat Sci 2021; 52:214-222. [PMID: 33549504 DOI: 10.1016/j.jmir.2021.01.002] [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: 11/28/2020] [Revised: 01/07/2021] [Accepted: 01/14/2021] [Indexed: 11/22/2022]
Abstract
AIM To analyse the use of radiotherapy (RT) and factors affecting overall survival (OS) after RT in breast cancer patients with brain metastases. METHODS Breast cancer patients treated from 2008 to 2018 with whole brain RT (WBRT) or stereotactic radiosurgery (SRS) at a large regional cancer referral center were identified from the hospital's RT register. Clinical variables were extracted from medical records. OS was calculated from date of first RT until death or last follow up. Potential factors affecting OS were analyzed. RESULTS 255 females with WBRT (n = 206) or SRS (n = 49) as first RT were included. An increased use of initial SRS was observed in the second half of the study period. The most common WBRT fractionation regimen was 3 Gy × 10. SRS was most often single fractions; 18 or 25 Gy between 2009 and 2016, while fractionated SRS was mostly used in 2017 and 2018. Median OS in the WBRT group was 6 months (CI 1-73) relative to 23 (CI 0-78) in the SRS group. Age, performance status, initial RT technique, extracranial disease, brain metastasis surgery, number of brain metastases and DS-GPA score had significant impact on OS. Only ECOG 0 and brain metastasis surgery were associated with superior OS in multivariate analysis. CONCLUSION WBRT was the most frequent primary RT. An increased use of initial SRS was observed in the second half of the study period. Only ECOG 0 and brain metastasis surgery were associated with superior OS in multivariate analysis.
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23
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Muñoz L, Kron T, Petasecca M, Bucci J, Jackson M, Metcalfe P, Rosenfeld AB, Biasi G. Consistency of small-field dosimetry, on and off axis, in beam-matched linacs used for stereotactic radiosurgery. J Appl Clin Med Phys 2021; 22:185-193. [PMID: 33440049 PMCID: PMC7882112 DOI: 10.1002/acm2.13160] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 12/08/2020] [Accepted: 12/17/2020] [Indexed: 11/24/2022] Open
Abstract
PURPOSE Stereotactic radiosurgery (SRS) can be delivered with a standard linear accelerator (linac). At institutions having more than one linac, beam matching is common practice. In the literature, there are indications that machine central axis (CAX) matching for broad fields does not guarantee matching of small fields with side ≤2 cm. There is no indication on how matching for broad fields on axis translates to matching small fields off axis. These are of interest to multitarget single-isocenter (MTSI) SRS planning and the present work addresses that gap in the literature. METHODS We used 6 MV flattening filter free (FFF) beams from four Elekta VersaHD® linacs equipped with an Agility™ multileaf collimator (MLC). The linacs were strictly matched for broad fields on CAX. We compared output factors (OPFs) and effective field size, measured concurrently using a novel 2D solid-state dosimeter "Duo" with a spatial resolution of 0.2 mm, in square and rectangular static fields with sides from 0.5 to 2 cm, either on axis or away from it by 5 to 15 cm. RESULTS Among the four linacs, OPF for fields ≥1 × 1 cm2 ranged 1.3% on CAX, whereas off axis a maximum range of 1.9% was observed at 15 cm. A larger variability in OPF was noted for the 0.5 × 0.5 cm2 field, with a range of 5.9% on CAX, which improved to a maximum of 2.3% moving off axis. Two linacs showed greater consistency with a range of 1.4% on CAX and 2.2% at 15 cm off axis. Between linacs, the effective field size varied by <0.04 cm in most cases, both on and off axis. Tighter matching was observed for linacs with a similar focal spot position. CONCLUSIONS Verification of small-field consistency for matched linacs used for SRS is an important task for dosimetric validation. A significant benefit of concurrent measurement of field size and OPF allowed for a comprehensive assessment using a novel diode array. Our study showed the four linacs, strictly matched for broad fields on CAX, were still matched down to a field size of 1 x 1 cm2 on and off axis.
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Affiliation(s)
- Luis Muñoz
- Genesiscare Flinders Private HospitalBedford ParkSAAustralia
- Centre for Medical Radiation PhysicsUniversity of WollongongNSWAustralia
| | - Tomas Kron
- Centre for Medical Radiation PhysicsUniversity of WollongongNSWAustralia
- Peter MacCallum Cancer CentreMelbourneVICAustralia
| | - Marco Petasecca
- Centre for Medical Radiation PhysicsUniversity of WollongongNSWAustralia
| | - Joseph Bucci
- St. George Cancer Care CentreSt George HospitalKogarahNSWAustralia
- Genesiscare Waratah Private HospitalHurstvilleNSWAustralia
| | - Michael Jackson
- Centre for Medical Radiation PhysicsUniversity of WollongongNSWAustralia
- University of New South WalesKensingtonNSWAustralia
| | - Peter Metcalfe
- Centre for Medical Radiation PhysicsUniversity of WollongongNSWAustralia
| | | | - Giordano Biasi
- Centre for Medical Radiation PhysicsUniversity of WollongongNSWAustralia
- Peter MacCallum Cancer CentreMelbourneVICAustralia
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Saenz D, Papanikolaou N, Zoros E, Pappas E, Reiner M, Chew LT, Lim HY, Hancock S, Nebelsky A, Njeh C, Anagnostopoulos G. Robustness of single-isocenter multiple-metastasis stereotactic radiosurgery end-to-end testing across institutions. JOURNAL OF RADIOSURGERY AND SBRT 2021; 7:223-232. [PMID: 33898086 PMCID: PMC8055241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/31/2020] [Indexed: 06/12/2023]
Abstract
The accuracy of stereotactic radiosurgery (SRS) to multiple metastases with a single-isocenter using high definition dynamic radiosurgery (HDRS) was evaluated across institutions. An SRS plan was delivered at six HDRS-capable institutions to an anthropomorphic phantom consisting of point, film, and 3D-gel dosimeters. Direct dose comparison and gamma analysis were used to evaluate the accuracy. Point measurements averaged across institutions were within 1.2±0.5%. The average gamma passing rate in the film was 96.6±2.2% (3%/2 mm). For targets within 4 cm of the isocenter, the 3D dosimetric gel gamma passing rate averaged across institutions was >90% (3%/2 mm). The targeting accuracy of high definition dynamic radiosurgery assessed by geometrical offset of the center of dose distributions across multiple institutions in this study was within 1 mm for targets within 4 cm of isocenter. Across variations in clinical practice, comparable dosimetry and localization is possible with this treatment planning and delivery technique.
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Affiliation(s)
- Daniel Saenz
- University of Texas Health Science Center, San Antonio, TX, USA
| | | | - Emmanouil Zoros
- National and Kapodistrian University of Athens Medical School, Athens, Greece
| | | | | | | | | | - Sam Hancock
- Southeast Health, Cape Girardeau, Missouri, USA
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Starkweather CK, Choi BD, Alvarez-Breckenridge C, Brastianos PK, Oh K, Wang N, Shih H, Nahed BV. Initial Approach to the Patient with Multiple Newly Diagnosed Brain Metastases. Neurosurg Clin N Am 2020; 31:505-513. [PMID: 32921347 DOI: 10.1016/j.nec.2020.05.002] [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: 10/23/2022]
Abstract
Brain metastases are the most common intracranial tumor in adults, with increasing incidence owing to prolonged survival times. Roughly half of patients diagnosed with new brain metastases have greater than 1 brain metastasis at the time of diagnosis, raising the question of how to optimize patient care with multiple brain metastases. The authors review studies relevant to the care of patients with brain metastasis, with emphasis on those relevant to the care of patients with multiple brain metastases. They discuss evolving strategies involving multiple modalities and the benefit of surgical management in patients with a large symptomatic brain metastasis.
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Affiliation(s)
- Clara Kwon Starkweather
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Bryan D Choi
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | | | | | - Kevin Oh
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Nancy Wang
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Helen Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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26
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Radiosurgery treatment planning using conformal arc informed volumetric modulated arc therapy. Med Dosim 2020; 46:3-12. [PMID: 32807612 DOI: 10.1016/j.meddos.2020.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/14/2020] [Accepted: 06/04/2020] [Indexed: 11/23/2022]
Abstract
Linac based radiosurgery to multiple metastases is commonly planned with volumetric modulated arc therapy (VMAT) as it effectively achieves high conformality to complex target arrangements. However, as the number of targets increases, VMAT can struggle to block between targets, which can lead to highly modulated and/or nonconformal multi-leaf collimator (MLC) trajectories that unnecessarily irradiation of healthy tissue. In this study we introduce, describe, and evaluate a treatment planning technique called Conformal Arc Informed VMAT (CAVMAT), which aims to reduce the dose to healthy tissue while generating highly conformal treatment plans. CAVMAT is a hybrid technique which combines the conformal MLC trajectories of dynamic conformal arcs with the MLC modulation and versatility of inverse optimization. CAVMAT has 3 main steps. First, targets are assigned to subgroups to maximize MLC blocking between targets. Second, arc weights are optimized to achieve the desired target dose, while minimizing MU variation between arcs. Third, the optimized conformal arc plan serves as the starting point for limited inverse optimization to improve dose conformity to each target. Twenty multifocal VMAT cases were replanned with CAVMAT with 20Gy applied to each target. The total volume receiving 2.5Gy[cm3], 6Gy[cm3], 12Gy[cm3], and 16Gy[cm3], conformity index, treatment delivery time, and the total MU were used to compare the VMAT and CAVMAT plans. In addition, CAVMAT was compared to a broad range of planning strategies from various institutions (108 linear accelerator based plans, 14 plans using other modalities) for a 5-target case utilized in a recent plan challenge. For the linear accelerator-based plans, a plan complexity metric based on aperture opening area and perimeter, total monitor units (MU), and MU for a given aperture opening was utilized in the plan challenge scoring algorithm to compare the submitted plans to CAVMAT. After re-planning the 20 VMAT cases, CAVMAT reduced the average V2.5Gy[cm3] by 25.25 ± 19.23%, V6Gy[cm3] by 13.68 ± 18.97%, V12Gy[cm3] by 11.40 ± 19.44%, and V16Gy[cm3] by 6.38 ± 19.11%. CAVMAT improved conformity by 3.81 ± 7.57%, while maintaining comparable target dose. MU for the CAVMAT plans increased by 24.35 ± 24.66%, leading to an increased treatment time of 2 minutes. For the plan challenge case, CAVMAT was 1 of 12 linac based plans that met all plan challenge scoring criteria. Compared to the average submitted VMAT plan, CAVMAT increased the V10%Gy[%] of healthy tissue (Brain-PTV) by roughly 3.42%, but in doing so was able to reduce the V25%Gy[%] by roughly 3.73%, while also reducing V50%Gy[%], V75%Gy[%], and V100%Gy[%]. The CAVMAT technique successfully eliminated insufficient MLC blocking between targets prior to the inverse optimization, leading to less complex treatment plans and improved tissue sparing. Tissue sparing, improved conformity, and decreased plan complexity at the cost of slight increase in treatment delivery time indicates CAVMAT to be a promising method to treat brain metastases.
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Initial Experience With Single-Isocenter Radiosurgery to Target Multiple Brain Metastases Using an Automated Treatment Planning Software: Clinical Outcomes and Optimal Target Volume Margins Strategy. Adv Radiat Oncol 2020; 5:856-864. [PMID: 33083647 PMCID: PMC7557192 DOI: 10.1016/j.adro.2020.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 03/24/2020] [Accepted: 06/16/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose Our purpose was to assess the clinical outcomes and target positioning accuracy of frameless linear accelerator single-isocenter multiple-target (SIMT) dynamic conformal arc (DCA) stereotactic radiosurgery (SRS) for multiple brain metastases (BM). Methods and Materials Between October 2016 and September 2018, 31 consecutive patients ≥18 years old with 204 BM <3 cm in maximum size receiving SIMT DCA SRS were retrospectively evaluated. All plans were created using a dedicated automated treatment planning software (Brainlab, Munich, Germany), and treatments were performed with a Truebeam STx or a Novalis Tx (Brainlab and Varian Medical Systems, CA). The accuracy of setup and interfraction patient repositioning was assessed by Brainlab ExacTrac radiograph 6-dimensional image system and the risk of compromised target dose coverage evaluated. Brain control and overall survival were estimated by Kaplan-Meier method calculated from the time of SRS. Results Fourteen patients were treated for 4 to 6 and 17 patients for 7 to 10 BM. The mean gross tumor volume (GTV) was 0.65 cm3 and the mean planning target volume (PTV) was 0.89 cm3. Mean V95 (the volume of the PTV covered by 95% of the prescription dose) and D95 (the prescription dose covering 95% of the PTV) were 99.5% and 21.1 Gy, respectively. With a median clinical follow-up of 11 months (range, 4-26 months), the 1-year survival was 68% and local control was 89%. As a consequence of plan isocenter residual errors, a loss of target coverage, defined as V95 < 95%, occurred in 28 PTVs (10 patients); using a 1 mm GTV-to-PTV margin, adequate dose coverage was maintained for all lesions. Conclusions SIMT DCA SRS represents a fast and effective approach for patients with up to 10 BM. The dosimetric effects of residual set-up and intrafraction positioning errors are modest, although a GTV-to-PTV margin of 1 mm is recommended.
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Cui Y, Gao H, Zhang J, Kirkpatrick JP, Yin FF. Retrospective quality metrics review of stereotactic radiosurgery plans treating multiple targets using single-isocenter volumetric modulated arc therapy. J Appl Clin Med Phys 2020; 21:93-99. [PMID: 32239746 PMCID: PMC7324703 DOI: 10.1002/acm2.12869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 02/10/2020] [Accepted: 03/09/2020] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To characterize key plan quality metrics in multi-target stereotactic radiosurgery (SRS) plans treated using single-isocenter volumetric modulated arc therapy (VMAT) in comparison to dynamic conformal arc (DCA) plans treating single target. To investigate the feasibility of quality improvement in VMAT planning based on previous planning knowledge. MATERIALS AND METHODS 97 VMAT plans of multi-target and 156 DCA plans of single-target treated in 2017 at a single institution were reviewed. A total of 605 targets were treated with these SRS plans. The prescription dose was normalized to 20 Gy in all plans for this analysis. Two plan quality metrics, target conformity index (CI) and normal tissue volume receiving more than 12 Gy (V12Gy), were calculated for each target. The distribution of V12Gy per target was plotted as a function of the target volume. For multi-target VMAT plans, the number of targets being treated in the same plan and the distance between targets were calculated to evaluate their impact on V12Gy. VMAT plans that had a large deviation of V12Gy from the average level were re-optimized to determine the possibility of reducing the variation of V12Gy in VMAT planning. RESULTS Conformity index of multi-target VMAT plans were lower than that of DCA plans while the mean values of 12 Gy were comparable. The V12Gy for a target in VMAT plan did not show apparent dependence on the total number of targets or the distance between targets. The distribution of V12Gy exhibited a larger variation in VMAT plans compared to DCA plans. Re-optimization of outlier plans reduced V12 Gy by 33.9% and resulted in the V12Gy distribution in VMAT plans more closely resembling that of DCA plans. CONCLUSION The benchmark data on key plan quality metrics were established for single-isocenter multi-target SRS planning. It is feasible to use this knowledge to guide VMAT planning and reduce high V12Gy outliers.
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Affiliation(s)
- Yunfeng Cui
- Department of Radiation Oncology, Duke University, Durham, NC, USA
| | - Hao Gao
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - Jiahan Zhang
- Department of Radiation Oncology, Duke University, Durham, NC, USA
| | | | - Fang-Fang Yin
- Department of Radiation Oncology, Duke University, Durham, NC, USA
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Sebastian NT, Glenn C, Hughes R, Raval R, Chu J, DiCostanzo D, Bell EH, Grecula J, Arnett A, Gondal H, McGregor J, Elder JB, Lonser R, Chakravarti A, Trifiletti D, Brown PD, Chan M, Palmer JD. Linear accelerator-based radiosurgery is associated with lower incidence of radionecrosis compared with gamma knife for treatment of multiple brain metastases. Radiother Oncol 2020; 147:136-143. [PMID: 32294607 DOI: 10.1016/j.radonc.2020.03.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 02/22/2020] [Accepted: 03/22/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Gamma knife (GK) and linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) both offer excellent local control in the management of multiple brain metastases. The efficacy and toxicity of LINAC and GK SRS have not been directly compared in the modern era. We studied outcomes in patients treated with LINAC SRS and GK at two separate institutions. METHODS We identified patients treated with either LINAC or GK who were treated to ≥2 lesions and had available follow up. LINAC patients were treated using single-isocenter multitarget technique. We used Cox regression, Fine and Gray competing risks regression, and nearest neighbor propensity score matching to account for confounders and imbalance between cohorts. Kaplan-Meier curves were used to estimate overall survival and rates of radionecrosis. RESULTS We identified 391 patients who were treated in 537 courses to a total 2699 lesions (LINAC: 1014, GK: 1685). After propensity score matching, GK was associated with similar overall survival (HR = 0.86; 95% CI 0.59-1.24; p = 0.41) and higher rate of radionecrosis (HR = 3.83; 95% CI 1.66-8.84; p = 0.002) compared to LINAC. In a secondary propensity score matched analysis comparing radionecrosis in single-fraction LINAC and GK, GK remained associated with higher incidence of radionecrosis (HR = 4.42; 95% CI 1.28-15.29; p = 0.019). CONCLUSIONS In this multi-institutional study, we found similar overall survival with lower incidence of radionecrosis in patients treated with LINAC compared to GK SRS. These findings are hypothesis generating and should be validated in an independent cohort.
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Affiliation(s)
- Nikhil T Sebastian
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Chase Glenn
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, USA
| | - Ryan Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, USA
| | - Raju Raval
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Jacqueline Chu
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Dominic DiCostanzo
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Erica H Bell
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - John Grecula
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Andrea Arnett
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Hasan Gondal
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, USA
| | - John McGregor
- Department of Neurological Surgery, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - James B Elder
- Department of Neurological Surgery, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Russell Lonser
- Department of Neurological Surgery, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Arnab Chakravarti
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | | | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | - Michael Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA; Department of Neurological Surgery, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA.
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Riina MD, Stambaugh CK, Huber KE. Hippocampal Dosimetry and the Necessity of Hippocampal-Sparing in Gamma Knife Stereotactic Radiosurgery for Extensive Brain Metastases. Adv Radiat Oncol 2020; 5:180-188. [PMID: 32280817 PMCID: PMC7136666 DOI: 10.1016/j.adro.2019.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 10/15/2019] [Accepted: 10/19/2019] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To characterize hippocampal dosimetry in Gamma Knife stereotactic radiosurgery (GK-SRS) for extensive brain metastases and evaluate the need for hippocampal-sparing in GK-SRS treatment planning. METHODS AND MATERIALS We reviewed 75 GK-SRS plans for the treatment of 4 to 30 brain metastases generated without consideration of the hippocampi. The mean dose, maximum dose to 100% of the volume (D100), maximum dose to 40% of the volume (D40), and maximum point dose (Dmax, 0.03 cm3) were obtained for the unilateral and bilateral hippocampi and compared between plans with 4 to 9 and ≥10 lesions. The rate at which plans met hippocampal dose constraints (D100 ≤ 4.21 Gy, D40 ≤ 4.50 Gy, and Dmax ≤ 6.65 Gy) was compared between groups, and each was examined for risk factors associated with excessive hippocampal dosing. For plans that exceeded constraints, we attempted replanning to spare the hippocampi. RESULTS Compared with those for the treatment of 4 to 9 brain metastases, GK-SRS plans with ≥10 lesions were associated with significantly greater median bilateral mean dose (1.0 vs 2.0, P = .001), D100 (0.4 vs 0.8, P = .003), D40 (0.9 vs 1.9, P = .001), and Dmax (2.0 vs 4.9, P = .0005). These plans also less frequently met hippocampal constraints, with this difference trending toward significance (80% vs 93%; P = .1382; odds ratio 0.29; 95% CI, 0.06-1.4). Risk factors for exceeding constraints included greater total disease volume and closer approach of the nearest metastasis to the hippocampi, both of which depended upon the number of metastases present. Seven plans failed to meet constraints and were successfully replanned to spare the hippocampi with minimal increases in treatment time and without compromise to target coverage or conformity. CONCLUSIONS Patients with extensive brain metastases treated with GK-SRS are at increased risk for excessive hippocampal dosing when ≥10 lesions are present or when lesions are in close proximity to the hippocampi and may benefit from hippocampal-avoidant treatment planning.
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Affiliation(s)
| | | | - Kathryn E. Huber
- Department of Radiation Oncology, Tufts Medical Center, Boston, Massachusettes
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31
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Minniti G, Capone L, Nardiello B, El Gawhary R, Raza G, Scaringi C, Bianciardi F, Gentile P, Paolini S. Neurological outcome and memory performance in patients with 10 or more brain metastases treated with frameless linear accelerator (LINAC)-based stereotactic radiosurgery. J Neurooncol 2020; 148:47-55. [DOI: 10.1007/s11060-020-03442-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/20/2020] [Indexed: 01/10/2023]
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Moravan MJ, Fecci PE, Anders CK, Clarke JM, Salama AKS, Adamson JD, Floyd SR, Torok JA, Salama JK, Sampson JH, Sperduto PW, Kirkpatrick JP. Current multidisciplinary management of brain metastases. Cancer 2020; 126:1390-1406. [PMID: 31971613 DOI: 10.1002/cncr.32714] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/08/2019] [Accepted: 12/19/2019] [Indexed: 12/31/2022]
Abstract
Brain metastasis (BM), the most common adult brain tumor, develops in 20% to 40% of patients with late-stage cancer and traditionally are associated with a poor prognosis. The management of patients with BM has become increasingly complex because of new and emerging systemic therapies and advancements in radiation oncology and neurosurgery. Current therapies include stereotactic radiosurgery, whole-brain radiation therapy, surgical resection, laser-interstitial thermal therapy, systemic cytotoxic chemotherapy, targeted agents, and immune-checkpoint inhibitors. Determining the optimal treatment for a specific patient has become increasingly individualized, emphasizing the need for multidisciplinary discussions of patients with BM. Recognizing and addressing the sequelae of BMs and their treatment while maintaining quality of life and neurocognition is especially important because survival for patients with BMs has improved. The authors present current and emerging treatment options for patients with BM and suggest approaches for managing sequelae and disease recurrence.
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Affiliation(s)
- Michael J Moravan
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.,Department of Radiation Oncology, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Peter E Fecci
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina
| | - Carey K Anders
- Department of Internal Medicine, Division of Medical Oncology, Duke University Hospital, Durham, North Carolina
| | - Jeffrey M Clarke
- Department of Internal Medicine, Division of Medical Oncology, Duke University Hospital, Durham, North Carolina
| | - April K S Salama
- Department of Internal Medicine, Division of Medical Oncology, Duke University Hospital, Durham, North Carolina
| | - Justus D Adamson
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Scott R Floyd
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Jordan A Torok
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Joseph K Salama
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.,Department of Radiation Oncology, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - John H Sampson
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.,Department of Neurosurgery, Duke University Hospital, Durham, North Carolina
| | - Paul W Sperduto
- Minneapolis Radiation Oncology, Minneapolis, Minnesota.,University of Minnesota Gamma Knife Center, Minneapolis, Minnesota
| | - John P Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.,Department of Neurosurgery, Duke University Hospital, Durham, North Carolina
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Should Stereotactic Radiosurgery Be Considered for Salvage of Intracranial Recurrence after Prophylactic Cranial Irradiation or Whole Brain Radiotherapy in Small Cell Lung Cancer? A Population-Based Analysis and Literature Review. J Med Imaging Radiat Sci 2019; 51:75-87.e2. [PMID: 31759940 DOI: 10.1016/j.jmir.2019.10.001] [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: 05/24/2019] [Revised: 09/24/2019] [Accepted: 10/03/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Prophylactic cranial irradiation (PCI) improves survival and prevents intracranial recurrence (IR) in limited stage (LS) and extensive stage (ES) small cell lung cancer (SCLC). However, despite PCI, IR affects 12%-45%, and limited data exist regarding salvage brain reirradiation (ReRT). We performed a population-based review of IR in SCLC. METHODS Demographic, treatment, and outcome data of consecutive patients (N = 371) with SCLC assessed at a tertiary cancer centre (01/2013-12/2015) were abstracted, and summary statistics calculated. Kaplan-Meier estimates and univariate and multivariate analysis (MVA) via the Cox proportional hazard model were performed. RESULTS Median age was 66.1 years, and 59.8% were Eastern Cooperative Oncology Group (ECOG) performance status 0-2. Median survival was 24 months (95% CI 18.3-29.7 months) for LS (N = 103) and 7 months (95% CI 6.1-7.9 months) for ES (N = 268). 72 of 103 patients with LS and 97 of 214 of those with ES received PCI. 54 of 268 ES presented with brain metastases (BM) of whom 46 of 54 received whole brain RT (WBRT). 18.9% (32/169) recurred post-PCI (13 LS; 19 ES) and 30.4% (14/46) recurred after WBRT. Of those who recurred/progressed after cranial RT, 56.5% (26/46) had <5 BM, 39.1% had no extracranial disease, and 50% were ECOG 0-2. In retrospect, 17 of 46 would have been candidates for salvage stereotactic radiosurgery: 13 post-PCI and 4 post-WBRT. CONCLUSIONS This cohort challenges commonly held beliefs that IR is always diffuse, associated with clinical deterioration, and synchronous with systemic failure. Approximately 1 in 3 SCLC patients with IR after PCI or WBRT appear clinically appropriate for salvage stereotactic radiosurgery.
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Fecci PE, Champion CD, Hoj J, McKernan CM, Goodwin CR, Kirkpatrick JP, Anders CK, Pendergast AM, Sampson JH. The Evolving Modern Management of Brain Metastasis. Clin Cancer Res 2019; 25:6570-6580. [PMID: 31213459 PMCID: PMC8258430 DOI: 10.1158/1078-0432.ccr-18-1624] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/23/2019] [Accepted: 06/13/2019] [Indexed: 12/11/2022]
Abstract
The incidence of brain metastases is increasing as cancer therapies improve and patients live longer, providing new challenges to the multidisciplinary teams that care for these patients. Brain metastatic cancer cells possess unique characteristics that allow them to penetrate the blood-brain barrier, colonize the brain parenchyma, and persist in the intracranial environment. In addition, brain metastases subvert the innate and adaptive immune system, permitting evasion of the antitumor immune response. Better understanding of the above mechanisms will allow for development and delivery of more effective therapies for brain metastases. In this review, we outline the molecular mechanisms underlying development, survival, and immunosuppression of brain metastases. We also discuss current and emerging treatment strategies, including surgery, radiation, disease-specific and mutation-targeted systemic therapy, and immunotherapy.
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Affiliation(s)
- Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
- Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
| | - Cosette D Champion
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
- Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
| | - Jacob Hoj
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, North Carolina
| | - Courtney M McKernan
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, North Carolina
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
- Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
| | - John P Kirkpatrick
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
- Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Carey K Anders
- Duke Cancer Institute, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Ann Marie Pendergast
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, North Carolina
| | - John H Sampson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina.
- Duke Center for Brain and Spinal Metastases, Duke University Medical Center, Durham, North Carolina
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Schimmel WCM, Gehring K, Hanssens PEJ, Sitskoorn MM. Cognitive functioning and predictors thereof in patients with 1-10 brain metastases selected for stereotactic radiosurgery. J Neurooncol 2019; 145:265-276. [PMID: 31552588 PMCID: PMC6856035 DOI: 10.1007/s11060-019-03292-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 09/16/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE Information on predictive factors of cognitive functioning in patients with (multiple) brain metastases (BM) selected for radiosurgery may allow for more individual care and may play a role in predicting cognitive outcome after radiosurgery. The aim of this study was to evaluate cognitive performance, and predictors thereof, in patients with 1-10 BM before radiosurgery. METHODS Cognition was measured before radiosurgery using a standardized neuropsychological test battery in patients with 1-10 BM (expected survival > 3 months; KPS ≥ 70; no prior BM treatment). Regression formulae were constructed to calculate sociodemographically corrected z scores. Group and individual cognitive functioning was analyzed. Multivariable regression was used to explore potential predictors. RESULTS Patients (N = 92) performed significantly worse than controls (N = 104) on all 11 test variables (medium-large effect sizes for 8 variables). Percentages of impairment were highest for information processing (55.3%), dexterity (43.2%) and cognitive flexibility (28.7%). 62% and 46% of patients had impairments in at least two, or three test variables, respectively. Models including combinations of clinical and psychological variables were predictive of verbal memory, psychomotor speed, information processing and dexterity. Neither number nor volume of metastases predicted patients' test performance. CONCLUSIONS Already before radiosurgery, almost half of the patients suffered from severe cognitive deficits in at least three test variables. At group and individual level, information processing, cognitive flexibility, and dexterity were most affected. These cognitive impairments may impair daily functioning and patients' ability to make (shared) treatment decisions. Both clinical (symptomatic BM; timing of BM diagnosis) and psychological (mental fatigue) characteristics influenced cognitive performance. CLINICAL TRIAL INFORMATION Cognition and Radiation Study A (CAR-Study A; ClinicalTrials.gov Identifier: NCT02953756; Medical Ethics Committee file number: NL53472.028.15/P1515).
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Affiliation(s)
- Wietske C M Schimmel
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands. .,Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands. .,Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands. .,Department of Cognitive Neuropsychology, Tilburg University, Simon Building; Room S221, P.O. Box 90153, 5000 LE, Tilburg, The Netherlands.
| | - Karin Gehring
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.,Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
| | - Patrick E J Hanssens
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.,Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Margriet M Sitskoorn
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.,Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
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Palmer JD, Sebastian NT, Chu J, DiCostanzo D, Bell EH, Grecula J, Arnett A, Blakaj DM, McGregor J, Elder JB, Lu L, Zoller W, Addington M, Lonser R, Chakravarti A, Brown PD, Raval R. Single-Isocenter Multitarget Stereotactic Radiosurgery Is Safe and Effective in the Treatment of Multiple Brain Metastases. Adv Radiat Oncol 2019; 5:70-76. [PMID: 32051892 PMCID: PMC7004936 DOI: 10.1016/j.adro.2019.08.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/14/2019] [Accepted: 08/22/2019] [Indexed: 12/20/2022] Open
Abstract
Purpose Multiple studies have reported favorable outcomes for stereotactic radiosurgery (SRS) in the treatment of limited brain metastases. An obstacle of SRS in the management of numerous metastases is the longer treatment time using traditional radiosurgery. Single-isocenter multitarget (SIMT) SRS is a novel technique that permits rapid therapy delivery to multiple metastases. There is a lack of clinical evidence regarding its efficacy and safety. We report the outcomes of patients treated with this technique. Methods and Materials We reviewed the records of patients with intact or resected brain metastases treated with SRS in 1 to 5 fractions using SIMT technique at our institution, with at least 1 available follow-up brain magnetic resonance imaging. Survival, disease control, and toxicity were evaluated using Cox regression, logistic regression, and Kaplan-Meier analysis. Results We identified 173 patients with 1014 brain metastases. Median follow up was 12.7 months. Median beam-on time was 4.1 minutes. The median dose to the brain was 219.4 cGy. Median overall survival and freedom from intracranial progression were 13.2 and 6.3 months, respectively. Overall survival did not differ between patients treated with greater than or less than 4 lesions (hazard ratio, 1.03; 95% confidence interval 0.66-1.61; P = .91). Actuarial 1- and 2-year local control were 99.0% and 95.1%, respectively. Rates of grade 2 and grade 3 or higher radionecrosis were 1.4% and 0.9%, respectively. Conclusions SIMT radiosurgery delivered in 1 to 5 fractions offers excellent local control and acceptable toxicity in the treatment of multiple intact and postoperative brain metastases. This technique should be evaluated prospectively.
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Affiliation(s)
- Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio.,Department of Neurosurgery, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - Nikhil T Sebastian
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - Jacquline Chu
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - Dominic DiCostanzo
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - Erica H Bell
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - John Grecula
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - Andrea Arnett
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - Dukagjin M Blakaj
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - John McGregor
- Department of Neurosurgery, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - James B Elder
- Department of Neurosurgery, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - Lanchun Lu
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - Wesley Zoller
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - Mark Addington
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - Russell Lonser
- Department of Neurosurgery, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - Arnab Chakravarti
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Raju Raval
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus Ohio
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Lee YC, Kim Y. Circular collimator arc versus dynamic conformal arc treatment planning for linac-based stereotactic radiosurgery of an intracranial small single lesion: a perspective of lesion asymmetry. Radiat Oncol 2019; 14:91. [PMID: 31159835 PMCID: PMC6545737 DOI: 10.1186/s13014-019-1307-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 05/24/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although circular collimator arcs (CCA) and dynamic conformal arcs (DCA) are commonly used linear accelerator-based treatment planning techniques for intracranial stereotactic radiosurgery (SRS) of a small single lesion, these two techniques have not been rigorously compared in terms of tumor shape. Therefore, this study compared clinical CCA plans with re-planned DCA plans using conformity index (CI) and V12Gy (volume of normal brain tissue receiving 12 Gy or higher) from a perspective of asymmetry (Asym) of planning target volume (PTV). METHODS Ninety-five clinical CCA plans delivered for a small single lesion with PTV size < 1.4 cm3 were selected and re-planned using DCA. PTV Asym (%) was defined and calculated from three dimensions of PTV. A pair of the 95 plans was first considered as one group without grouping and then categorized into two groups with respective to either PTV size or PTV Asym, and four groups with respect to PTV size and PTV Asym. For grouping, median values of PTV size and PTV Asym were used. A non-parametric paired test was performed for CI and V12Gy to compare CCA and DCA plans in each group. RESULTS Median values of PTV size and PTV Asym were 0.415 cm3 (range: 0.076 cm3-1.369 cm3) and 6.12% (range: 0.52-25.74%), respectively. DCA plans had a lower average CI value than CCA plans for all groups. CCA plans had a smaller average V12Gy value than DCA plans for lesions with PTV Asym ≤6.12%, while CCA and DCA plans had similar average V12Gy values for lesions with PTV Asym > 6.12%. CONCLUSIONS The DCA technique is recommended when a lesion has PTV Asym > 6.12% regardless of PTV size. For lesions with PTV Asym ≤6.12%, a technique choice would depend on the preference of CI or V12Gy.
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Affiliation(s)
- Yongsook C Lee
- Department of Radiation Oncology, The University of Arizona, Banner University Medicine North Building #2, 3838 N Campbell Avenue, Tucson, AZ, 85719, USA
| | - Yongbok Kim
- Department of Radiation Oncology, The University of Arizona, Banner University Medicine North Building #2, 3838 N Campbell Avenue, Tucson, AZ, 85719, USA.
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Nieder C, Yobuta R, Mannsåker B. Patterns of Treatment and Outcome in Patients With 20 or More Brain Metastases. In Vivo 2019; 33:173-176. [PMID: 30587619 DOI: 10.21873/invivo.11455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 11/12/2018] [Accepted: 11/15/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND/AIM The aim of this study was to analyze the patterns of treatment and outcomes in patients with a large number of brain metastases, arbitrarily defined as 20 or more lesions. These patients are typically excluded from studies of focal brain treatment, e.g., surgery or radiosurgery, and might have a limited prognosis. PATIENTS AND METHODS This was a retrospective single-institution analysis. Overall, 11 patients were identified from a prospectively maintained database. RESULTS Ten patients had received active treatment (9 whole-brain radiotherapy, 7 systemic therapy). Median survival was 5.0 months without long-term survival beyond 13 months. Patients with better performance status had numerically longer survival, however we did not identify baseline parameters with a significant impact on survival. CONCLUSION While long-term survival was not observed in this small study, most patients survived long enough to experience symptomatic improvement from whole-brain radiotherapy. Therefore, we recommend multidisciplinary assessment of the patients' prognosis and systemic treatment options, and initiation of whole-brain radiotherapy if survival is not limited to 1-2 months.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway .,Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Rosalba Yobuta
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway
| | - Bård Mannsåker
- Department of Oncology and Palliative Medicine, Nordland Hospital, Bodø, Norway
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Kraft J, Zindler J, Minniti G, Guckenberger M, Andratschke N. Stereotactic Radiosurgery for Multiple Brain Metastases. Curr Treat Options Neurol 2019; 21:6. [PMID: 30758726 DOI: 10.1007/s11940-019-0548-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW To give an overview on the current evidence for stereotactic radiosurgery of brain metastases with a special focus on multiple brain metastases. RECENT FINDINGS While the use of stereotactic radiosurgery in patients with limited brain metastases has been clearly defined, its role in patients with multiple lesions (> 4) is still a matter of controversy. Whole-brain radiation therapy (WBRT) has been the standard treatment approach for patients with multiple brain lesions and is still the most commonly used treatment approach worldwide. Although distant brain failure is improved by WBRT, the overall survival is not readily impacted. As WBRT is associated with significant neurocognitive decline compared to stereotactic radiosurgery (SRS), SRS has been explored and increasingly utilized for selected patients with multiple brain metastases. Recent clinical data indicated the feasibility of stereotactic radiosurgery to multiple brain metastases with a similar survival in patients with more than 4 brain metastases versus patients with a maximum of 4 brain metastases. Also, neurocognitive function and quality of life was maintained after stereotactic radiosurgery which is essential in a palliative setting. The application of stereotactic radiosurgery with Gamma Knife, Cyberknife, or LINAC-based equipment has emerged as an effective and widely available treatment option for patients with limited brain metastases. Although not formally proven in prospective studies, SRS may also be considered as a safe and effective treatment option in selected patients with multiple brain metastases. Especially in patients with a favorable prognosis, survival over several years is observed also in the setting of multiple BM. For these patients, avoidance of the neurocognitive damage of WBRT is desirable, and SRS is often a more appropriate treatment in the current multimodality treatment of BM in which systemic treatment is often the cornerstone of the treatment. For patients with an intermediate (3-12 months) and poor prognosis (< 3 months), the application of WBRT becomes more and more controversial, because of its acute side effects, such as hair loss and fatigue and, thereby, detrimental effect on quality of life. For these patients, best supportive care, primary systemic treatment, and even SRS may be preferred over WBRT on an individualized patient basis.
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Affiliation(s)
- Johannes Kraft
- Department of Radiation Oncology, University Hospital of Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - Jaap Zindler
- Erasmus MC Rotterdam/Holland Proton Therapy Center Delft, MAASTRO Clinic Maastricht, Maastricht, The Netherlands
| | - Giuseppe Minniti
- Radiation Oncology Unit, UPMC Hillman Cancer Center, San Pietro Hospital, Rome, Italy.,IRCCS Neuromed, Pozzilli, IS, Italy
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital of Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital of Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
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Rades D, Dziggel L, Manig L, Janssen S, Khoa MT, Duong VN, Khiem VH, Schild SE. Predicting Survival After Whole-brain Irradiation for Cerebral Metastases in Patients with Cancer of the Bladder. ACTA ACUST UNITED AC 2018; 32:633-636. [PMID: 29695570 DOI: 10.21873/invivo.11285] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 02/16/2018] [Accepted: 02/20/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM This study aimed to create a predictive tool for estimating the remaining lifespan of patients after whole-brain irradiation (WBI) for cerebral metastases from bladder cancer. PATIENTS AND METHODS In 34 of these patients clinical parameters were analyzed for survival including age at start of WBI, gender, Karnofsky score, number of cerebral metastases and involvement of extra-cranial sites of metastasis. RESULTS Involvement of extra-cranial sites (14%) and Karnofsky score (9%) showed the greatest difference regarding 6-month survival and were considered for the tool. Points were assigned based on the following: no involvement of extra-cranial sites=1 point, involvement of extra-cranial sites=0 points, Karnofsky score ≥70=1 point, Karnofsky score ≤60=0 points. Patients' scores were 0, 1 or 2 points with 6-month survival rates of 13%, 27% and 50%, respectively. CONCLUSION Based on two clinical parameters, a tool was developed that may help estimate the lifespan of patients irradiated for cerebral metastases from bladder cancer.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany .,Faculty of Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Liesa Dziggel
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - Lisa Manig
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - Stefan Janssen
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany.,Private Practice of Radiation Oncology, Hannover, Germany
| | - Mai Trong Khoa
- Faculty of Medicine, Hanoi Medical University, Hanoi, Vietnam.,Nuclear Medicine and Oncology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - Vuong Ngoc Duong
- Nuclear Medicine and Oncology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - Vu Huu Khiem
- Nuclear Medicine and Oncology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ, U.S.A
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Agnew A, Jordan K, Strbac B, Galal MM. Creating planning margins and imaging intervals for intracranial stereotactic radiosurgery treatment using patient log files. Biomed Phys Eng Express 2018. [DOI: 10.1088/2057-1976/aac57e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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RADES DIRK, DZIGGEL LIESA, MANIG LISA, JANSSEN STEFAN, KHOA MAITRONG, DUONG VUONGNGOC, KHIEM VUHUU, SCHILD STEVENE. Predicting Survival After Whole-brain Irradiation for Cerebral Metastases in Patients with Cancer of the Bladder. In Vivo 2018; 32. [PMID: 29695570 PMCID: PMC6000788 DOI: 10.21873/invivo.112285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND/AIM This study aimed to create a predictive tool for estimating the remaining lifespan of patients after whole-brain irradiation (WBI) for cerebral metastases from bladder cancer. PATIENTS AND METHODS In 34 of these patients clinical parameters were analyzed for survival including age at start of WBI, gender, Karnofsky score, number of cerebral metastases and involvement of extra-cranial sites of metastasis. RESULTS Involvement of extra-cranial sites (14%) and Karnofsky score (9%) showed the greatest difference regarding 6-month survival and were considered for the tool. Points were assigned based on the following: no involvement of extra-cranial sites=1 point, involvement of extra-cranial sites=0 points, Karnofsky score ≥70=1 point, Karnofsky score ≤60=0 points. Patients' scores were 0, 1 or 2 points with 6-month survival rates of 13%, 27% and 50%, respectively. CONCLUSION Based on two clinical parameters, a tool was developed that may help estimate the lifespan of patients irradiated for cerebral metastases from bladder cancer.
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Affiliation(s)
- DIRK RADES
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany,Faculty of Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - LIESA DZIGGEL
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - LISA MANIG
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - STEFAN JANSSEN
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany,Private Practice of Radiation Oncology, Hannover, Germany
| | - MAI TRONG KHOA
- Faculty of Medicine, Hanoi Medical University, Hanoi, Vietnam,Nuclear Medicine and Oncology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - VUONG NGOC DUONG
- Nuclear Medicine and Oncology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - VU HUU KHIEM
- Nuclear Medicine and Oncology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - STEVEN E. SCHILD
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ, U.S.A
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