Stereotactic body radiation therapy for adrenal gland metastases: Outcomes and toxicity

Adrenal Insufficiency following Stereotactic Ablative Radiotherapy (SAbR) of Adrenal Gland Metastases

BACKGROUND

Adrenal metastases are often treated with stereotactic ablative radiation (SAbR). We aimed to assess the incidence, timing, and factors associated with the development of primary adrenal insufficiency (PAI) following SAbR.

METHODS

A retrospective cohort study comprised 66 consecutive patients (73% men, median age 61 years) who underwent SAbR for adrenal metastasis.

RESULTS

The series encompassed metastases from renal cell carcinoma (41%), lung tumors (38%), colorectal adenocarcinoma (9%), melanoma (5%), and others (7%). Median follow-up was 17 months from SAbR. Nine (14%) patients developed PAI at a median of 4.3 months (range, 0.7-20.2). The incidence of PAI was 44% in patients with prior adrenalectomy receiving unilateral SAbR, 44% with bilateral SAbR, 2% with unaffected contralateral gland, and 0% with bilateral metastases treated with unilateral SAbR. PAI was associated with prior adrenalectomy (odds ratio [OR] 32) and bilateral SAbR (OR 8.2), but not age, sex, metastasis size, or biological effective dose. Post-SAbR 6-month and 1-year local control rates were 82% and 75%, respectively.

CONCLUSIONS

Patients undergoing SAbR for adrenal metastasis are at high risk of developing PAI. PAI is associated with bilateral SAbR and contralateral adrenalectomy. PAI is unlikely with a remaining unaffected adrenal gland or in the setting of bilateral adrenal metastases with unilateral SAbR.

Retrospective Analysis of Efficacy and Toxicity of Stereotactic Body Radiotherapy and Surgical Resection of Adrenal Metastases from Solid Tumors

BACKGROUND

This single-center retrospective study aimed to evaluate the efficacy and toxicity profiles of stereotactic body radiotherapy (SBRT) and surgical resection in patients with adrenal metastases originating from solid tumors.

METHODS/MATERIALS

Patients with advanced tumor conditions or comorbidities typically received SBRT, whereas those considered physically fit underwent standard surgical treatment. Endpoints included local control (LC), progression free survival (PFS), overall survival (OS), and complication rates (CR).

RESULTS

41 patients with 48 adrenal metastases were included, with 27 (65.9%) patients receiving SBRT and 14 (34.1%) patients undergoing adrenalectomy. One- and two-year LC values were 100% for both periods after adrenalectomy, and 70.0% and 52.5% after SBRT (p = 0.001). PFS showed values of 40.2% and 32.1% at one and two years after adrenalectomy and of 10.6% for both periods after SBRT (p = 0.223). OS was 83.3% both one and two years after surgery and 67.0% and 40.2% after SBRT (p = 0.031). There was no statistically significant difference between the two groups regarding acute complications (p = 0.123).

CONCLUSION

Despite potential confounders, adrenalectomy exhibited statistically significant superior LC and OS compared to SBRT in managing adrenal metastases, while both treatment methods displayed acceptable toxicity profiles. However, patient selection bias must be taken into account when directly comparing the two therapy modalities. Nevertheless, the study provides new and important results for the scientific and medical communities regarding oncological outcomes after SBRT or surgical resection of adrenal metastases.

Multi-institutional experience of MR-guided stereotactic body radiation therapy for adrenal gland metastases

Purpose

While dose escalation is associated with improved local control (LC) for adrenal gland metastases (AGMs), the proximity of gastrointestinal (GI) organs-at-risk (OARs) limits the dose that can be safely prescribed via CT-based stereotactic body radiation therapy (SBRT). The advantages of magnetic resonance-guided SBRT (MRgSBRT), including tumor tracking and online plan adaptation, facilitate safe dose escalation.

Methods

This is a multi-institutional review of 57 consecutive patients who received MRgSBRT on a 0.35-T MR linac to 61 AGMs from 2019 to 2021. The Kaplan-Meier method was used to estimate overall survival (OS), progression-free survival (PFS), and LC, and the Cox proportional hazards model was utilized for univariate analysis (UVA).

Results

Median follow up from MRgSBRT was 16.4 months (range [R]: 1.1-39 months). Median age was 67 years (R: 28-84 years). Primary histologies included non-small cell lung cancer (N = 38), renal cell carcinoma (N = 6), and melanoma (N = 5), amongst others. The median maximum diameter was 2.7 cm (R: 0.6-7.6 cm), and most AGMs were left-sided (N = 32). The median dose was 50 Gy (R: 30-60 Gy) in 5-10 fractions with a median BED10 of 100 Gy (R: 48-132 Gy). 45 cases (74 %) required adaptation for at least 1 fraction (median: 4 fractions, R: 0-10). Left-sided AGMs required adaptation in at least 1 fraction more frequently than right-sided AGMs (88 % vs 59 %, p = 0.018). There were 3 cases of reirradiation, including 60 Gy in 10 fractions (N = 1) and 40 Gy in 5 fractions (N = 2). One-year LC, PFS, and OS were 92 %, 52 %, and 78 %, respectively. On UVA, melanoma histology predicted for inferior 1-year LC (80 % vs 93 %, p = 0.012). There were no instances of grade 3+ toxicity.

Conclusions

We demonstrate that MRgSBRT achieves favorable early LC and no grade 3 + toxicity despite prescribing a median BED10 of 100 Gy to targets near GI OARs.

Lower fluorodeoxyglucose positron emission tomography maximum standardized uptake value may show a better response to stereotactic body radiotherapy of adrenals in oligometastatic disease

Introduction

Stereotactic body radiotherapy (SBRT) is well established for oligometastatic disease, and it is increasingly used to treat adrenal metastases.

Material and methods

In this retrospective study we performed an analysis of 75 metastatic adrenal lesions in 64 patients with oligometastatic disease. According to the fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) maximum standardized uptake value (SUVmax) of adrenal metastases, patients were categorized into three groups: low, intermediate, and high SUVmax.

Results

For all clinicopathological characteristics we found significant relationships for levels of SUVmax and objective response rate (Kendall Tau-c = 0.290; p = 0.017). Patients who responded to SBRT had a significantly lower SUVmax value than those who did not respond (7.6 ±2.4 vs. 9.7 ±3.8; p = 0.015). At the appropriate SUVmax cut-off values, the biomarker distinguished between patients with and without a response significantly and moderately (area under the curve = 0.670, 95% confidence intervals: 0.540-0.790; p = 0.015).

Conclusions

Lower SUVmax is associated with a better response to SBRT in patients whose disease progressed mainly in the adrenal glands.

Risk factors of local control in adrenal metastases treated by stereotactic body radiation therapy - a systematic review and meta-analysis

Purpose

This study is aimed to explore risk factors affect the therapy outcomes of adrenal metastases (AM) for stereotactic body radiation therapy (SBRT) and guide clinical dose selection.

Methods and materials

PubMed, Embase and Web of Science were searched in September 22, 2022 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). Subgroup analysis and meta-regression were used to search for sources of heterogeneity and identify risky outcomes factors. Publication bias test and sensitivity analysis were also conducted.

Results

Thirty-three studies with full text from 2009 to 2022 about AM with SBRT on 1483 patients were included. Pooled 1- and 2-year local control (LC) and overall survival(OS) were 81.7% (95% confidence interval [CI], 75.6%-86.5%), 62.8% (95% CI, 53.8%-71.8%), 67.4% (95%CI, 61.8%-73.1%) and 46.5% (95%CI, 40.4%-52.6%), respectively. Biological effective dose (BED, α/β=10Gy) and dose per fraction affected 1-year LC (Qm=23.89, 15.10; P<0.0001, 0.0001). In the range of 60-80Gy (BED10), the group of dose per fraction ≥ 9Gy achieved the excellent 1-year LC (< 9Gy: ≥ 9Gy =78%, 91%; χ2 = 10.16, P = 0.001). Tracking technology significantly affected 1- and 2-year OS (Qm = 5.73, 8.75; P = 0.017, 0.003) and high tracking adoption group showed excellent 1- and 2- year OS (78.7% [95%CI, 68.6%- 88.9%]; and 62.9% [95%CI, 53.1%-72.7%]).

Conclusion

Increasing the dose per fraction appropriately may help control locally AM lesious. Tracking technology might contribute to improve survival of advanced patients with AM. But these results need prospective studies to verify them.

Radiation of bilateral adrenal metastases is associated with a high risk of primary adrenal insufficiency

BACKGROUND

Adrenal metastasis is the most common adrenal malignancy and can be bilateral in up to 43% of patients. Radiotherapy (RT) is one option available to treat adrenal metastases. The risk of primary adrenal insufficiency (PAI) after adrenal RT is unclear.

OBJECTIVE

Determine the incidence and the timeline of PAI in patients undergoing adrenal RT.

DESIGN, SETTING AND PARTICIPANTS

Single-centre longitudinal retrospective cohort study of adult patients with adrenal metastases treated with RT between 2010 and 2021.

RESULTS

Of 56 patients with adrenal metastases treated with adrenal RT, eight (14.3%) patients developed PAI at a median of 6.1 months (interquartile range [IQR]: 3.9-13.8) after RT All patients developing PAI had either unilateral RT in the setting of contralateral adrenalectomy or bilateral adrenal RT. Patients who developed PAI received a median RT dose of 50 Gy (IQR: 44-50 Gy), administered in a median of five fractions (IQR: 5-6). Treated metastases decreased in size and/or metabolic activity on positron emission tomography in seven patients (87.5%). Patients were initiated on hydrocortisone (median daily dose of 20 mg, IQR: 18-40) and fludrocortisone (median daily dose of 0.05 mg, IQR: 0.05-0.05 mg). At the end of the study period, five patients died, all due to extra-adrenal malignancy, at a median time of 19.7 months (IQR: 16-21.1 months) since RT and median time of 7.7 months (IQR: 2.9-12.5 months) since the diagnosis of PAI.

CONCLUSION

Patients receiving unilateral adrenal RT with two intact adrenal glands have a low risk of PAI. Patients receiving bilateral adrenal RT have a high risk of PAI and require close monitoring.

Adrenal Metastasectomy in the Era of Immuno- and Targeted Therapy

Adrenal metastasectomy has an increasing role in multimodality oncologic care for diverse primary cancer types. In this review, we discuss the epidemiology, evaluation, and contemporary best practices in the management of adrenal metastases from various primaries. Initial evaluation of suspected adrenal metastases should include diagnostic imaging to assess the extent of tumor involvement and determine surgical resectability, as well as biochemical evaluation for hormone secretion. Biopsy has a minimal role and should only be performed in tumors that are established to be non-hormone secreting and when the biopsy results would change clinical management. Adrenal metastasectomy is associated with survival benefit in selected patients. We suggest that adrenal metastasectomy has the greatest benefit in four clinical scenarios: (1) disease limited to the adrenal gland in which adrenalectomy renders the patient disease-free; (2) isolated progression in the adrenal gland in the setting of otherwise controlled metastatic extra-adrenal disease; (3) need for palliation of symptoms related to adrenal metastases; or (4) in the context of tissue-based clinical trials. Both minimally invasive and open adrenalectomy techniques are safe and appear to have equivalent oncologic outcomes. Minimally invasive approaches are favored when technically feasible while maintaining oncologic principles. A multidisciplinary evaluation including clinicians with expertise in the primary cancer type is essential to the successful management of adrenal metastases.

Radiation Therapy in the Management of Adrenal Metastases

Adrenal glands represent a common site of metastases from several primary tumors, including lung cancer, breast cancer and melanoma. Surgical resection is considered the standard of care, but surgery is not always feasible given the challenges related to anatomical site and/or due to patient and/or disease characteristics. Stereotactic body radiation therapy (SBRT) represents a promising treatment for oligometastases, though the literature on its role for adrenal metastases is still heterogeneous. Herein are summarized the most relevant published studies on the efficacy and safety of SBRT for adrenal gland metastases. The preliminary data suggests that SBRT yields high local control rates and symptom relief with a mild pattern of toxicity. Advanced radiotherapy techniques including IMRT and VMAT, a BED10 > 72 Gy and the use of 4DCT for motion control should be considered for a high quality ablative treatment of adrenal gland metastases.

The efficacy and outcomes of stereotactic body radiotherapy in adrenal gland metastases

Aim

This retrospective study presents our single-institutional experience with stereotactic body radiotherapy for adrenal gland metastases.

Materials and Methods

We evaluated patients with adrenal metastases treated by stereotactic body radiotherapy (SBRT) from 2014 to 2020. We performed an analysis of 35 patients. The median age of the patients was 62.2. Dosimetric parameters and treatment outcomes were evaluated.

Results

The primary diagnosis of the majority of patients was non-small cell lung cancer (94.3%). Treatment was performed in a median of 3 fractions, and the median prescribed dose was 24 Gy (range 22,5-27). The median follow-up was 17 months. Treatment response according to Response Evaluation Criteria in Solid Tumours was categorized as complete response in 11 patients, partial response in nine patients, stable disease in 7, and progressive disease in eight patients. Twenty seven patients had oligometastatic disease and treatment response. Patients with oligometastatic disease had a significantly higher rate of complete response and partial response to treatment than patients with common disease (P = 0,011). The 6-month and 1-year local control rates were 68.4% and 43%, respectively. In general, SBRT was well tolerated and no acute toxicities were observed.

Conclusion

Our retrospective study shows that SBRT can be applied safely in adrenal metastases with good results especially in patients with oligometastatic disease.

Two-institution results of Stereotactic Body Radiation Therapy (SBRT) for treating adrenal gland metastases from liver cancer

OBJECTIVE

Stereotactic Body Radiation Therapy (SBRT) has been found beneficial for adrenal gland metastases (AGMs) with a high local control rate and low toxicity. The role of SBRT for AGMs in patients with liver cancer has not been well-discussed before. We, therefore, report our two-institution experience to further elaborate on the feasibility and effectiveness of SBRT in the treatment of AGMs from liver cancer.

METHODS

A total of 23 liver cancer patients (19 males, 4 females) with 24 AGMs treated by SBRT from July 2006 to April 2021 were retrospectively included in this study. Toxicity was assessed based on clinical adverse events using the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. The effectiveness was assessed based on local control (LC), progression-free survival (PFS), and overall survival (OS), which were calculated using the Kaplan-Meier method. Univariate analyses were compared by log-rank test. The relevant covariates were evaluated using Cox proportional hazards models.

RESULTS

The median dose was 40 Gy in 5 fractions, with the corresponding median biological effective dose (BED10, α/β = 10 Gy) of 72 Gy. The median overall follow-up time was 15.4 months (range: 4.2-70.6 months). The complete response (CR), partial response (PR), stable disease (SD) and progressive disease (PD) rates were 25.0%, 20.8%, 33.3%, and 20.8%, respectively. All 6 patients with AGMs accompanying symptoms had varying degrees of alleviation after SBRT. The 0.5-, 1-year and 2-year LC rates were 87.5%, 77.8%, and 77.8%, respectively. The 0.5-, 1-year and 2-year OS rates were 95.5%, 66.8%, and 41.1%, respectively. The treatments were all tolerated with only one patient reporting a grade-3 hepatic injury. The univariate analysis concluded that only gross tumor volume (GTV) < 34.5 ml (p = 0.039) was associated with a favorable LC rate. After multivariate analysis, favorable predictors correlated with OS were GTV < 34.5 ml (p = 0.043), systemic therapy (p = 0.017), and without additional organ metastasis after SBRT (p = 0.009).

CONCLUSION

Our results suggest that SBRT is a safe and effective technique to treat AGM from liver cancer, especially for small GTV (< 34.5ml). Moreover, the small metastatic lesion volume, fewer metastatic lesions, and intervention of systemic therapy are more likely to improve OS.

Outcomes and toxicities in oligometastatic patients treated with stereotactic body radiotherapy for adrenal gland metastases: A multi-institutional retrospective study

•

SBRT to adrenal gland oligometastases achieves a satisfactory local control and OS.

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A minimum PTV dose BED₁₀ > 46 Gy was associated with an improved OS and LRFS.

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A prescribed BED₁₀ > 70 Gy was correlated with improved local control.

•

High adrenal metastases volume should not preclude the delivery of SBRT.

Background

Studies reporting SBRT outcomes in oligometastatic patients with adrenal gland metastases (AGM) are limited. Herein, we present a multi-institutional analysis of oligometastatic patients treated with SBRT for AGM.

Material/methods

The Consortium for Oligometastases Research (CORE) is among the largest retrospective series of patients with oligometastases. Among CORE patients, those treated with SBRT for AGM were included. Clinical and dosimetric data were collected. Adrenal metastatic burden (AMB) was defined as the sum of all adrenal GTV if more than one oligometastases is present.

Competing risk analysis was used to estimate actuarial cumulative local recurrence (LR) and widespread progression (WP). Kaplan-Meier method was used to report overall survival (OS), local recurrence-free survival (LRFS), and progression-free survival (PFS). Treatment related toxicities were also reported.

Results

The analysis included 47 patients with 57 adrenal lesions. Median follow-up was 18.2 months. Median LRFS, PFS, and OS were 15.3, 5.3, and 19.1 months, respectively. A minimum PTV dose BED₁₀ > 46 Gy was associated with an improved OS and LRFS. A prescribed BED₁₀ > 70 Gy was an independent predictor of a lower LR probability. AMB>10 cc was an independent predictor of a lower risk for WP. Only one patient developed an acute Grade 3 toxicity consisting of abdominal pain.

Conclusion

SBRT to AGM achieved a satisfactory local control and OS in oligometastatic patients. High minimum PTV dose and BED₁₀ prescription doses were predictive of improved LR and OS, respectively. Prospective studies are needed to determine comprehensive criteria for patients SBRT eligibility and dosimetric planning.

Dosimetric comparison of mDCAT and VMAT techniques according to 6MV-FFF and 10MV-FFF energies in patients with single adrenal metastasis

OBJECTIVE

To compare dosimetric and radiobiological terms of modified dynamic conformal arc therapy (mDCAT) and volumetric modulated arc therapy (VMAT) techniques using different flattening-filter free (FFF) energies in patients with single adrenal metastasis.

METHODS

In this study, plans were prepared for 10 patients drawing on the mDCAT and VMAT techniques with 6MV-FFF and 10MV-FFF energies. Target volume doses, biological effective doses (BED), quality indices, Monitor Unit (MU), number of segments, beam-on time and critical organ doses were compared in the plans.

RESULTS

Plans with the significantly lower gradient index (GI) and conformity index (CI) values were obtained with 6MV-FFF energy VMAT planning (p < 0.05). The higher values were obtained for dose to 95% of internal target volume (ITVD95), ITVD95-BED10 with 10MV-FFF energy VMAT planning, whereas lower results were obtained for high dose spillage (HDS%) values (p < 0,05). With 10MV-FFF energy, HDS% values were 21.1% lower in VMAT plans and 5.6% lower in mDCAT plans compared to 6MV-FFF energy. Plans with approximately 50% fewer segments were obtained in mDCAT plans than VMAT plans (p < 0,05). Beam-on time values with mDCAT was 1.84 times lower when 6MV-FFF energies were analyzed, and 2.11 times lower when 10MV-FFF was analyzed (p < 0,05). Additionally, when 6MV-FFF and 10MV-FFF energies were examined, MU values with mDCAT were 2.1 and 2.5 times lower (p < 0,05). In general, the smaller the target volume size, the greater the differences between MU and beam-on time values mDCAT and VMAT.

CONCLUSIONS

The study results implied that VMAT enabled to offer significantly more conformal SBRT plans with steeper dose fall-off beyond the target volume for single adrenal metastasis than the mDCAT, which attained at the cost of significantly higher MU and beam-on times. Especially with 10MV-FFF energy mDCAT plans, low-dose-bath zones can be reduced, and shorter-term treatments can be implemented with large segments. In adrenal gland SBRT, higher effective doses can be achieved with the right energy and technique, critical organ doses can be reduced, thus increasing the possibility of local control of the tumor with low toxicity.

The Role of Ablative Radiotherapy to Liver Oligometastases from Colorectal Cancer

Purpose of Review

This review describes recent data supporting locoregional ablative radiation in the treatment of oligometastatic colorectal cancer liver metastases.

Recent Findings

Stereotactic body radiotherapy (SBRT) demonstrates high rates of local control in colorectal cancer liver metastases when a biologically equivalent dose of > 100 Gy is delivered. Future innovations to improve the efficacy of SBRT include MRI-guided radiotherapy (MRgRT) to enhance target accuracy, systemic immune activation to treat extrahepatic disease, and genomic customization. Selective internal radiotherapy (SIRT) with y-90 is an intra-arterial therapy that delivers high doses to liver metastases internally which has shown to increase liver disease control in phase 3 trials. Advancements in transarterial radioembolization (TARE) dosimetry could improve local control and decrease toxicity.

Summary

SBRT and SIRT are both promising options in treating unresectable metastatic colorectal cancer liver metastases. Identification of oligometastatic patients who receive long-term disease control from either therapy is essential. Future advancements focusing on improving radiation design and customization could further improve efficacy and toxicity.

Palliative Radiotherapy Provided Good Pain Relief for Painful Adrenal Metastasis

Adrenal metastases often occur in patients with metastasized lung cancer, but symptoms rarely develop. A 45-year-old man presented with right abdominal pain requiring strong opioids due to large right adrenal metastasis of lung adenocarcinoma. The tumor was 7.3 × 5.6 × 8.4 cm in size. He was treated with palliative radiotherapy (RT) up to 39 Gy in 13 fractions for this lesion without severe adverse effects. After RT, he had good pain relief, and opioids were no longer needed. Palliative RT for a large adrenal tumor can provide a good analgesic effect without relevant toxicity.

Stereotactic body radiation therapy (SBRT) for patients with oligometastatic/oligoprogressive adrenal metastases: Outcomes and toxicities profile in a monoinstitutional study

AIMS

To evaluate survival outcomes and toxicology profiles in oligometastatic/oligoprogressive patients treated with SBRT for adrenal metastases.

METHODS

We retrospectively analyzed 25 metastatic adrenal lesions in 24 oligometastatic/oligoprogressive patients undergoing ablative Stereotactic Body Radiation Therapy (SBRT) between February 2010 and November 2019 in our department. The primary endpoint was overall survival (OS). Secondary endpoints were local overall response rate (ORR), acute and late toxicities.

RESULTS

The most common primary tumor was non-small cell lung cancer (54%). Twenty-one patients received chemo or immuno-therapy. The median planning target volume (PTV) was 41.7 cm³. Median SBRT dose was 36 Gy. Median dose per fraction was 15 Gy. Median survival was 35-months with OS outcomes ranging from 6-months (100%), 1-year (87.5%) and 2-years (66.7%). ORR based on RECIST criteria was 66.5%. 12 patients experienced acute toxicities, mostly grade 1-2 (8 patients, 32%).

CONCLUSIONS

SBRT for oligometastatic/oligoprogressive patients with adrenal metastases showed acceptable survival outcomes and a safe toxicity profile.

Stereotactic body radiation therapy for adrenal gland metastases: outcome and predictive factors from a multicenter analysis

Adrenal metastases occur in 15-35% of oncological patients. Surgery is the first treatment option. Stereotactic body radiotherapy (SBRT) has been largely explored in oligometastatic patients unfit for surgery, representing an effective and non-invasive local treatment. The results of a multi-institutional experience of SBRT on adrenal metastases in the oligorecurrent or oligoprogressive setting are herein reported. We collected data of adrenal gland metastases treated with SBRT in three Italian centers from 2010 to 2020. End-points of the present study were: Overall survival (OS), Local control of treated metastases (LC), Progression free survival (PFS), and toxicity. 149 adrenal gland metastases were treated with SBRT in 142 patients. The most common primary tumor was lung cancer (58.4%), followed by kidney cancer (9.4%). Median lesion's volume was 28.5 cm³ (2.5-323.4). The median SBRT dose was 40 Gy (10-60). Median follow-up was 14.4 months. One- and two-year OS were 72.3% and 53.5%. At univariate analysis performance status correlated with survival (HR 1.57, p = 0.006). One- and two-year LC were 85.4% and 79.2%, with lung primary tumor (HR 0.33, p = 0.021) and BED10 (HR 0.97, p = 0.036) significant independent factors. One- and two-year PFS were 37.7% and 24.8%. Median time to polymetastatic disease was 11.3 months. Grade 1 and 2 toxicity occurred in 21 (14.7%) and 3 (2.1%) patients. The results from this large multi-center study confirm the efficacy and safety of SBRT in the management of adrenal gland metastases, as a valid alternative to other more invasive local approaches.

Phase II trial of stereotactic body radiation therapy on adrenal gland metastases: evaluation of efficacy and impact on hormonal production

PURPOSE

The purpose of this study was to assess prospectively the efficacy and safety of stereotactic body radiation therapy (SBRT) for adrenal gland metastasis, with a focus on the assessment of the irradiated subjects' endocrinological function.

MATERIALS AND METHODS

A total of 36 patients were enrolled from 2017 to 2020 in this prospective phase II trial. Patients were treated with Linac-based SBRT, with a dose of 45 Gy in 3 consecutive fractions. Primary end-point was local control (LC) of the treated lesions and secondary end-points included evaluation of acute and late toxicity, progression free survival (PFS), overall survival (OS) and the impact on the hormonal production of adrenal glands.

RESULTS

With a median follow-up of 9.5 months, LC rates at 1 and 2 years were 94.7% and 88.4%, respectively. Rates of PFS at 1 and 2 years were 50.5% and 29.8%, with a median PFS of 14.7 months. Rates of OS at 1 and 2 years were 62.9% and 44.1%. At univariate analysis, oligorecurrence was associated with better OS compared to oligoprogressive or synchronous metastatic disease. No grade 3 or greater toxicities were registered and only a minority of patients (22.2%) reported mild treatment-related side effects. Hormonal and electrolytes production was assessed before and after treatment, showing only a slight and transient variation within the reference ranges.

CONCLUSION

SBRT on adrenal metastases has been confirmed to be a feasible and effective treatment. With an excellent disease control and the preservation of the endocrine function, SBRT with ablative dose can be considered a viable alternative to more invasive approaches.

Modeling of Tumor Control Probability in Stereotactic Body Radiation Therapy for Adrenal Tumors

PURPOSE

Stereotactic body radiation therapy (SBRT) in the management of adrenal metastases is emerging as a well-tolerated, effective method of treatment for patients with limited metastatic disease. SBRT planning and treatment utilization are widely variable, and publications report heterogeneous radiation dose fractionation schemes and treatment outcomes. The objective of this analysis was to review the current literature on SBRT for adrenal metastases and to develop treatment guidelines and a model for tumor control probability of SBRT for adrenal metastases based on these publications.

METHODS AND MATERIALS

A literature search of all studies on SBRT for adrenal metastases published from 2008 to 2017 was performed, and outcomes in these studies were reviewed. Local control (LC) rates were fit to a statistically significant Poisson model using maximum likelihood estimation techniques.

RESULTS

One-year LC greater than 95% was achieved at an approximated biological equivalent dose with α/β = 10 Gy of 116.4 Gy.

CONCLUSIONS

While respecting normal tissue tolerances, tumor doses greater than or equal to a biological equivalent dose with α/β = 10 Gy of 116.4 Gy are recommended to achieve high LC. Further studies following unified reporting standards are needed for more robust prediction.

Stereotactic body radiation therapy (SBRT) of adrenal gland metastases in oligometastatic and oligoprogressive disease

BACKGROUND

Stereotactic body radiation therapy (SBRT) as a form of noninvasive treatment that is becoming increasingly used to manage cancers with adrenal gland metastases. There is a paucity of data on safety and efficacy of this modality. The aim of the study was to evaluate the safety and efficacy of adrenal gland SBRT in oligometastatic and oligoprogressive disease.

MATERIALS AND METHODS

In this retrospective study, we performed a single-institution analysis of 26 adrenal lesions from 23 patients with oligometastatic or oligoprogressive disease treated from 2013 to 2019 with the goal of achieving durable local control. Palliative cases were excluded. Radiation dosimetry data was collected. Kaplan Meier product estimator and Cox proportional hazards regression analysis were used for statistical analysis.

RESULTS

The median dose was 36 Gy in 3 fractions (range: 24-50 Gy and 3-6 fractions) with a median biologically effective dose (BED10) of 72 (range: 40-100). 1-year local control rate was 80% and median local control was not achieved due to a low number of failures. 1- and 2-year overall survival rates were 66% and 32%. Toxicity was mild with only one case of grade 2 nausea and no grade 3-5 toxicity. Higher neutrophil to lymphocyte ratio was associated with worse overall survival and a trend toward worse progression-free survival. In addition, worse performance status and lower BED10 were associated with worse survival. No such association could be shown for primary tumor location, histology, size or stage.

CONCLUSION

Adrenal SBRT for oligometastatic or oligoprogressive disease is a safe and effective form of treatment.

Radiation treatment for adult rare cancers: Oldest and newest indication

AIM

Aim of this analysis is to review the role of RT in the management of several rare tumors for adult patients.

METHODS

Collection data regarding RT and rare tumors was made by Pubmed.

RESULTS

For mucosal melanomas, RT is prescribed, being associated with lower local recurrence rate. For trachea tumors, RT was used as adjuvant or salvage treatment for unresectable disease. For pNET, RT can be a suitable option for post-surgical or unresectable/borderline. For bronchopulmonary neuroendocrine tumors the role of adjuvant treatments is uncertain. For hepatobiliary and ovarian malignancy, stereotactic body RT (SBRT) is a promising approach. For soft tissue sarcoma, perioperative treatments are indicated, and a growing role of SBRT in oligometastatic disease is recognized. For endocrine tumors, adjuvant RT has demonstrated benefits through reducing recurrence risk.

CONCLUSION

The radiotherapy is a frequent indication in adult rare cancers; thus the role of Radiation Oncologist must not be neglected.

Dosimetric evaluation of SBRT treatment plans of non-central lung tumours: clinical experience

Objectives:

Lung cancer is the most commonly diagnosed cancer in Canada and the leading cause of cancer-related mortality in both men and women in North America. Surgery is usually the primary treatment option for early-stage non-small cell lung cancer (NSCLC). However, for patients who may not be suitable candidates for surgery, stereotactic body radiation therapy (SBRT) is an alternative method of treatment. SBRT has proven to be an effective technique for treating NSCLC patients by focally administering high radiation dose to the tumour with acceptable risk of toxicity to surrounding healthy tissues. The goal of this comprehensive retrospective dosimetric study is to compare the dosimetric parameters between three-dimensional conformal radiation therapy (3DCRT) and volumetric-modulated arc therapy (VMAT) lung SBRT treatment plans for two prescription doses.

Methods:

We retrospectively analysed and compared lung SBRT treatment plans of 263 patients treated with either a 3DCRT non-coplanar or with 2–3 VMAT arcs technique at 48 Gy in 4 fractions (48 Gy/4) or 50 Gy in 5 fractions (50 Gy/5) prescribed to the planning target volume (PTV), typically encompassing the 80% isodose volume. All patients were treated on either a Varian 21EX or TrueBeam linear accelerator using 6-MV or 10-MV photon beams.

Results:

The mean PTV V95% and V100% for treatment plans at 48 Gy/4 are 99·4 ± 0·6% and 96·0 ± 1·0%, respectively, for 3DCRT and 99·7 ± 0·4% and 96·4 ± 3·4%, respectively, for VMAT. The corresponding mean PTV V95% and V100% at 50 Gy/5 are 99·0 ± 1·4% and 95·5 ± 2·5% for 3DCRT and 99·5 ± 0·8% and 96·1 ± 1·6% for VMAT. The CIRI and HI5/95 for the PTV at 48 Gy/4 are 1·1 ± 0·1 and 1·2 ± 0·0 for 3DCRT and 1·0 ± 0·1 and 1·2 ± 0·0 for VMAT. The corresponding CIRI and HI5/95 at 50 Gy/5 are 1·1 ± 0·1 and 1·3 ± 0·1 for 3DCRT and 1·0 ± 0·1 and 1·2 ± 0·0 for VMAT. The mean R50% and D2cm at 48 Gy/4 are 5·0 ± 0·8 and 61·2 ± 7·0% for 3DCRT and 4·9 ± 0·8 and 57·8 ± 7·9% for VMAT. The corresponding R50% and D2cm at 50 Gy/5 are 4·7 ± 0·5 and 65·5 ± 9·4% for 3DCRT and 4·7 ± 0·7 and 60·0 ± 7·2% for VMAT.

Conclusion:

The use of 3DCRT or VMAT technique for lung SBRT is an efficient and reliable method for achieving dose conformity, rapid dose fall-off and minimising doses to the organs at risk. The VMAT technique resulted in improved dose conformity, rapid dose fall-off from the PTV compared to 3DCRT, although the magnitude may not be clinically significant.

Hypofractionated Radiotherapy for 35 Patients with Adrenal Metastases: A Single-Institution Experience

Objective

To investigate the clinical outcomes of hypofractionated radiotherapy for adrenal metastases.

Materials and Methods

We retrospectively reviewed patients diagnosed with adrenal metastases and treated with hypofractionated radiotherapy, who did not receive adrenalectomy or have disease progression after chemotherapy, from 2007 to 2019. The Kaplan–Meier method was used to estimate local control rate (LCR), progression-free survival (PFS), and overall survival (OS). Univariate analysis was performed using Log rank test.

Results

Thirty-five patients with 42 lesions were enrolled, and the lung was the most common primary site (80.0%). The median follow-up time was 46.4 months. The median volume of GTV and PTV was 23.2 cm³ (range: 3.5–97.8 cm³) and 38.3 cm³ (range: 10.2–135.6 cm³), respectively. The main dose regimens were 60 Gy delivered in 4–15 fractions, with the median dose of PTV being 60 Gy (range: 40–66.3 Gy) and the biologically effective dose (BED) being 84 Gy (range: 56–110 Gy). The 1-year and 2-year LCR, OS, and PFS were 92.7% and 88.1%, 76.9% and 45.4%, and 25.1% and 14.4%, respectively. Univariate analysis showed that chemotherapy, disease-free interval from primary disease diagnosis to adrenal metastases diagnosis, and age were significant factors for LCR, OS, and PFS, respectively (p=0.017, 0.049, and 0.004, respectively). No more than grade III toxicities were observed.

Conclusion

As a non-invasive approach, hypofractionated radiotherapy is safe and effective for metastatic adrenal lesions, without serious complications.

THE NOVEL USE OF STEREOTACTIC RADIOTHERAPY FOR REMNANT ADRENAL TISSUE IN NELSON SYNDROME

Objective

Recurrent Cushing disease (CD) is a rare complication that occurs in patients who have undergone bilateral adrenalectomy (BLA). We report a case of recurrent CD in a patient with Nelson syndrome and adrenalectomy due to remnant adrenal tissue, and a novel treatment strategy using stereotactic body radiation therapy (SBRT) to the adrenal glands.

Methods

We report a case of recurrent CD in a woman with Nelson syndrome and adrenalectomy and describe her clinical course and management. We also include a literature review of CD management and adrenal radiation.

Results

The patient had persistent pituitary CD despite pituitary surgery and radiosurgery and underwent BLA. She developed recurrent CD due to a remnant adrenal gland post adrenalectomy. She then underwent SBRT to both adrenal beds to treat the remnant adrenal tissue. Her serum cortisol dropped rapidly after adrenal radiation and she experienced minimal side effects. She has been in remission for over 2 years.

Conclusion

This is the first reported case of recurrent CD in a patient post adrenalectomy that was successfully treated with SBRT to the remnant adrenal tissue.

Adrenal SBRT: a multi-institutional review of treatment outcomes and toxicity

The adrenal glands are a common site of metastatic disease. Definitive treatment for oligometastatic disease using ablative radiotherapy is becoming common in modern radiation oncology practice. However, most data on the treatment of adrenal metastases are limited to single institution reports. Furthermore, delivering ablative radiotherapy doses to intra-abdominal lesions can be challenging due to the proximity of the gastrointestinal tract. We report the outcomes of a multi-institutional cohort of patients treated with definitive radiotherapy for adrenal metastases, primarily using 10 fraction regimens. Retrospective review of institutional databases revealed 29 lesions in 27 patients were treated from 2005 to 2018 at two institutions. Outcome data, including local control, disease-free, and overall survival were abstracted from the medical record system. Toxicity was graded using CTCAE v5.0. Detailed radiotherapy data was abstracted from the treatment planning systems. The median dose was 50 Gy in 10 fractions. Actuarial 1 and 2 year local control was 86% and 76% respectively. The median overall and disease-free survival were 22.8 and 5.6 months respectively. There were no associations identified between local failure and GTV and PTV physical or biologic effective dose. Two patients developed late Grade 3 gastrointestinal toxicity. High dose radiotherapy to adrenal metastases is a feasible treatment with excellent local control and a reasonable safety profile. For lesions in close proximity to gastrointestinal structures, moderately hypofractionated 10 fraction regimens may be a reasonable compromise between local control and toxicity.

Adrenal oligometastasis cured with stereotactic ablative radiotherapy

Stereotactic ablative radiotherapy (SABR) has emerged as an effective, noninvasive alternative to surgery in patients with oligometastatic disease. Historically, select patients with adrenal oligometastases have been treated with adrenalectomies which can offer durable local control and reasonable survival rates. SABR is a promising noninvasive treatment alternative to surgery capable of delivering ablative doses of radiation to the tumor with the goal of achieving durable local control of adrenal metastases. We report on a case of a patient who underwent initial surgical resection for a locally advanced lung adenocarcinoma and subsequently developed an early, biopsy-proven, oligometastatic recurrence in the adrenal gland. He underwent chemotherapy and SABR using CyberKnife to the adrenal metastasis and is in remission 7 years after treatment with no late toxicity. Fractionated SABR is an attractive noninvasive alternative to surgery for adrenal metastases. This case demonstrates that select patients with adrenal oligometastases, can achieve long-term remission and even cure following SABR.

Stereotactic body radiotherapy for adrenal oligometastasis in lung cancer patients

OBJECTIVE

To report our experience on stereotactic body radiotherapy (SBRT) in adrenal metastases from lung cancer.

METHODS

37 oligometastatic lung cancer patients with 38 adrenal metastases submitted to SBRT were retrospectively analyzed. SBRT was delivered by volumetric modulated arc therapy (VMAT) or helical tomotherapy (HT). Primary study end point was local recurrence-free survival (LR-FS) and secondary end points were distant-progression free survival (d-PFS) and overall survival (OS).

RESULTS

Median age was 67 years and primary tumor was non-small-cell lung cancer in 27 (73%) and small-cell lung cancer in 10 (27%) patients. Adrenal metastases were in the left side in 66% cases. Median prescribed dose was 30 Gy in 5 fractions for a median biologically equivalent dose (α/β ratio 10  Gy, BED10) of 48 Gy. Most patients (62%) were submitted to SBRT alone, while the others (38%) received chemo-, immune- or target- therapies. Median follow-up was 10.5 months, median OS 16 months and median d-PFS 3 months. 27 (70%) patients obtained a local control with a median LR-FS of 32 months. LR-FS was significantly related to BED10 with a better LC with BED10 ≥72 Gy, 1- and 2 year LR-FS rates were 54.1±11.6% and 45±12.7% vs 100 and 100% for BED ≤59.5 Gy and BED ≥72 Gy, respectively (p = 0.05). There was no severe toxicity.

CONCLUSION

SBRT was effective and safe in lung cancer adrenal metastases. A dose-response relationship was found between BED10 >72 Gy and better local control. No significant toxicity was registered thanks to the respect of dose constraints and suspension of chemo- and target-therapies.

ADVANCES IN KNOWLEDGE

SBRT with a BED10 >72 Gy is an effective treatment for adrenal oligometastatic lung cancer patients.

Single-Fraction Stereotactic Body Radiation Therapy: A Paradigm During the Coronavirus Disease 2019 (COVID-19) Pandemic and Beyond?

PURPOSE

Owing to the coronavirus disease 2019 (COVID-19) pandemic, radiation oncology departments have adopted various strategies to deliver radiation therapy safely and efficiently while minimizing the risk of severe acute respiratory syndrome coronavirus-2 transmission among patients and health care providers. One practical strategy is to deliver stereotactic body radiation therapy (SBRT) in a single fraction, which has been well established for treating bone metastases, although it has been infrequently used for other extracranial sites.

METHODS AND MATERIALS

A PubMed search of published articles in English related to single-fraction SBRT was performed. A critical review was performed of the articles that described clinical outcomes of single-fraction SBRT for treatment of primary extracranial cancers and oligometastatic extraspinal disease.

RESULTS

Single-fraction SBRT for peripheral early-stage non-small cell lung cancer is supported by randomized data and is strongly endorsed during the COVID-19 pandemic by the European Society for Radiotherapy and Oncology-American Society for Radiation Oncology practice guidelines. Prospective and retrospective studies supporting a single-fraction regimen are limited, although outcomes are promising for renal cell carcinoma, liver metastases, and adrenal metastases. Data are immature for primary prostate cancer and demonstrate excess late toxicity in primary pancreatic cancer.

CONCLUSIONS

Single-fraction SBRT should be strongly considered for peripheral early-stage non-small cell lung cancer during the COVID-19 pandemic to mitigate the potentially severe consequences of severe acute respiratory syndrome coronavirus-2 transmission. Although single-fraction SBRT is promising for the definitive treatment of other primary or oligometastatic cancers, multi-fraction SBRT should be the preferred regimen owing to the need for additional prospective evaluation to determine long-term efficacy and safety.

Single-institutional outcome-analysis of low-dose stereotactic body radiation therapy (SBRT) of adrenal gland metastases

BACKGROUND

Adrenal gland metastases are a common diagnostic finding in various tumor diseases. Due to the increased use of imaging methods, they are diagnosed more frequently, especially in asymptomatic patients. SBRT has emerged as a new, alternative treatment option in the field of radiation oncology. In the past, it was often used for treating inoperable lung, liver, prostate, and brain tumors. Meanwhile, it is also an established keystone in the treatment of oligometastatic diseases. This retrospective study aims to evaluate the effect of low-dose SBRT in patients with adrenal metastases.

METHODS

We analyzed a group of 31 patients with 34 adrenal gland lesions treated with low-dose SBRT between July 2006 and July 2019. Treatment-planning was performed through contrast-enhanced CT, followed by image-guided stereotactic radiotherapy using cone-beam CT. The applied cumulative median dose was 35 Gy; the median single dose was 7 Gy. We focused on local control (LC), progression-free survival (PFS), overall survival (OS), as well as acute and late toxicity.

RESULTS

Seven adrenal gland metastases (20.6%) experienced local failure, 80.6% of the patients faced a distant progression. Fourteen patients were still alive. Median follow-up for all patients was 9.8 months and for patients alive 14.4 months. No treatment-related side-effects >grade 2 occurred. Of all, 48.4% suffered from acute gastrointestinal disorders; 32.3% reported acute fatigue, throbbing pain in the renal area, and mild adrenal insufficiency. Altogether, 19.4% of the patients faced late-toxicities, which were as follows: Grade 1: 12.9% gastrointestinal disorders, 3.2% fatigue, Grade 2: 9.7% fatigue, 6.5% headache, 3.2% loss of weight. The 1-year OS and probability of LF were 64 and 25.9%, respectively.

CONCLUSION

Low-dose SBRT has proven as an effective and safe method with promising outcomes for treating adrenal metastases. There appeared no high-grade toxicities >grade 2, and 79.4% of treated metastases were progression-free. Thus, SBRT should be considered as a therapy option for adrenal metastases as an individual therapeutic concept in the interdisciplinary discussion as an alternative to surgical or systemic treatment.

Clinical efficacy of Stereotactic Body Radiation Therapy (SBRT) for adrenal gland metastases: A multi-center retrospective study from China

To evaluate the efficacy and safety of CyberKnife Stereotactic Body Radiation Therapy (SBRT) in the treatment of adrenal gland metastases (AGM), we designed a large-scale multicenter retrospective study to report the safety and efficacy of SBRT for inoperable AGM. In this study, 75 (61 males, 14 females) patients with 84 AGM and Karnofsky performance score ≥70 were treated by SBRT from October 2006 to January 2017. Of these, the purpose of treatment were controlling all known metastatic sites for 21 patients while 54 for palliation of bulky adrenal metastases. The efficacy and safety of SBRT were evaluated during follow-up. Potential factors predictive of local control (LC) and overall survival (OS) were identified by univariate and multivariate analysis. Median follow-up time was 12.7 months (range 1.8–96.4). The complete response (CR), partial response (PR), stable disease (SD) and progressive disease (PD) rates were 23.8%, 23.8%, 31.0% and 21.4%, respectively. The 0.5, 1, and 2-year LC rates were 93.6%, 83.8%, and 62.1%, respectively; OS rates on the same follow-up intervals were 93.7%, 62.5%, and 49.6%, respectively, and the corresponding PFS rates were 48.5%, 33.9%, and 16.0%, respectively. The treatment was well tolerated with 2 patients reporting grade-3 diarrhea and fatigue, respectively. Multivariate analysis showed that simultaneous treatment of SBRT for other metastatic lesions, the number of AGM, initiation of systemic therapy, and the maximum diameter of AGM were predictive of LC rates. Moreover, patients with AGM < 5 cm had a superior OS compared with those with AGM ≥ 5 cm (28.0 months vs. 17.6 months, P = 0.032). SBRT is an effective therapeutic option for treatment of AGM with high LC rates with minimal toxicity.

The Prognostic Role of Pretreatment Neutrophil to Lymphocyte Ratio (NLR) in Malignant Adrenal Lesions Treated With Stereotactic Body Radiation Therapy (SBRT)

OBJECTIVE

The objective of this study was to evaluate a single institution's experience with stereotactic body radiotherapy (SBRT) in treating malignant adrenal lesions, as well as the prognostic value of systemic inflammation biomarkers.

MATERIALS AND METHODS

From November 2007 to February 2018, 27 patients with malignant adrenal lesions received 31 SBRT treatments. Outcomes, measured from the date of SBRT, included overall survival (OS), local control (LC), and freedom from progression. Cox proportional hazard model was utilized to identify potential prognostic factors. Tumor response was assessed with PET Response Evaluation Criteria In Solid Tumors (PERCIST)/Response Evaluation Criteria in Solid Tumors (RECIST) criteria. Acute toxicity was evaluated with the National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.03 criteria.

RESULTS

Median follow-up for all patients was 8 months. The complete response, partial response, stable disease, and progressive disease rates were 59%, 9%, 32%, and 0%, respectively. One-year LC, OS, and freedom from progression were 77.7%, 38.0%, and 10.0%, respectively. There was a trend toward significance upon multivariate analysis for pretreatment neutrophil to lymphocyte ratio >4.1 to predict inferior OS (adjusted hazard ratio=3.29, P=0.09, 1-year OS: 11% vs. 80%). There were 3 cases (10%) complicated by grade 2 acute toxicity, including nausea and fatigue. There was 1 grade 5 toxicity, as 1 case was complicated by a fatal gastric ulcer occurring 3 months after SBRT to the left adrenal gland (112.5 BED10).

CONCLUSIONS

These results support the limited existing literature, demonstrating that SBRT provides adequate LC for adrenal lesions with minimal toxicity. Pretreatment neutrophil to lymphocyte ratio may serve as a prognostic factor in these patients.

Stereotactic body radiotherapy (SBRT) for adrenal metastases of oligometastatic or oligoprogressive tumor patients

INTRODUCTION

Local ablative treatment strategies are frequently offered to patients diagnosed with oligometastatic disease. Stereotactic body radiotherapy (SBRT), as ablative treatment option, is well established for lung and liver metastases, whereas for isolated adrenal gland metastases the level of evidence is scarce.

MATERIAL AND METHODS

This single-institution analysis of oligometastatic or oligoprogressive disease was limited to patients who received SBRT to adrenal metastasis between 2012 and 2019. Patient, tumor, treatment characteristics, and dosimetric parameters were analyzed for evaluation of their effect on survival outcomes.

RESULTS

During the period of review 28 patients received ablative SBRT to their adrenal gland metastases. Most common primary tumors were non-small cell lung cancers (46%) with most patients diagnosed with a single adrenal gland metastasis (61%), which occurred after a median time of 14 months. SBRT was delivered to a median biological effective dose at α/β of 10 (BED₁₀) of 75 Gy (range: 58-151 Gy). Median gross tumor volume (GTV) and median planning target volume (PTV) were 42 and 111 mL, respectively. The homogeneity and conformity indices were 1.17 (range: 1.04-1.64) and 0.5 (range: 0.4.0.99), respectively, with the conformity index being affected by dose restrictions to organs at risk (OARs) in 50% of the patients. Overall response rate based on RECIST criteria was 86% (CR = 29%, PR = 57%) with 2-year local control (LC) of 84.8%, 2-year progression-free survival (PFS) of 26.3%, and 1-and 2-year overall survival (OS) of 46.6 and 32.0%, respectively. During follow up, only two local recurrences occurred. A trend for superior LC was seen if BED₁₀ was ≥75Gy (p = 0.101) or if the PTV was < 100 ml (p = 0.072). SBRT was tolerated well with only mild toxicity.

CONCLUSION

SBRT for adrenal metastases resulted in promising LC with low toxicity. Treatment response appeared to be superior, if SBRT was applied with higher BED. As the close proximity of OARs often limits the application of sufficiently high doses, further dose escalations strategies and techniques should be investigated in future.

Stereotactic Body Radiation Therapy of Adrenal Metastases: A Pooled Meta-Analysis and Systematic Review of 39 Studies with 1006 Patients

PURPOSE

To perform a systematic review and pooled meta-analysis of adrenal metastasis stereotactic body radiation therapy (SBRT) outcomes, treatment characteristics, and toxicity to define the efficacy and propose guidelines for intervention.

METHODS AND MATERIALS

We performed a comprehensive literature search of the Embase and PubMed databases of studies reporting outcome or toxicity data for photon-based SBRT of adrenal metastases in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We then conducted a meta-analysis to estimate pooled overall response, local control (LC), and overall survival and analyzed these outcomes in the context of dosimetric parameters and toxicity using metaregression.

RESULTS

Thirty-nine studies published between 2009 and 2019 reporting outcomes on 1006 patients were included. The median follow-up was 12 months, and the median biological equivalent dose (BED10, alpha/beta = 10) was 67 Gy. The pooled overall response was 54.6% (95% confidence interval [CI], 46.5%-62.5%). The pooled 1- and 2-year rates of LC were 82% (95% CI, 74%-88%) and 63% (95% CI, 50%-74%), respectively, and the pooled 1- and 2-year overall survival rates were 66% (95% CI, 57%-74%) and 42% (95% CI, 31%-53%), respectively. There was a strong positive association between SBRT dose and 1- and 2-year LC (P < .0001, P = .0002) and an association with 2-year OS (P = .03). Based on a metaregression of dose and LC, BED10 of 60 Gy, 80 Gy, and 100 Gy predicted 1-year LC of 70.5%, 84.8%, and 92.9% and 2-year LC of 47.8%, 70.1%, and 85.6%, respectively. The overall rate of grade 3 or higher toxicity was 1.8%.

CONCLUSIONS

SBRT of adrenal metastases provides good 1-year LC with an excellent safety profile, and dose escalation may be associated with improved LC. Prospective studies are needed to validate these findings and determine whether there are subsets of patients for whom adrenal metastasis-directed SBRT may confer a survival advantage.

Surgical outcomes of stage IV non-small cell lung cancer: a single-center experience

Background

Increasing evidence has shown the effectiveness of surgery for stage IV non-small cell lung cancer (NSCLC). Present study aims to summarize the experience of our institution in dealing with advanced NSCLC in the context of multimodality therapy including lung surgery.

Methods

Patients underwent surgical resection for stage IV NSCLC diagnosed before or during surgery from January 2014 to June 2017 at Tangdu Hospital were included in this study.

Results

There were 88 stage IV NSCLC patients enrolled in this study. Among them, 35 patients with pleural metastases, 18 with brain oligometastases, 25 with extra-brain oligometastases and 10 with multiple metastatic sites or organs. For primary lung tumor, almost all (86/88) were resected with R0. For metastatic lesions, 53 patients received curative local treatment and 9 patients with partial treatment. There were 62 patients received adjuvant treatment, 10 patients received no adjuvant treatment and 16 patients with missing data of adjuvant treatment. The median overall survival of patients was 31.72 months. The estimated 3-year OS was 42.2%. Patients with pleural metastases and brain oligometastases got better outcomes than the ones with extra-brain oligometastases and multiple metastases (P<0.001). Patients with adjuvant epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) treatment had significantly better OS compared with those with adjuvant chemotherapy treatment (P=0.015). Besides, age <60 and cT1-2 were also associated with better survival.

Conclusions

Surgery may be a considerable choice for stage IV NSCLC in the context of multimodality therapy.

Breath-hold versus mid-ventilation in SBRT of adrenal metastases

PURPOSE

To improve local control in radiotherapy of adrenal metastases precise dose delivery without increasing toxicity is vital. Decreasing the Clinical Target Volume (CTV) - Planning Target Volume (PTV) margins by reducing breathing movement can achieve this. Few data were published concerning the effect of a breath-hold technique. This study investigates the potential of Active Breathing Control (ABC) to limit adrenal breathing movement and reduce CTV-PTV margins.

METHODS

We compared adrenal gland movement in free-breathing, making use of the Mid-ventilation (MidV) technique, and with ABC. The coordinates of the adrenal glands obtained on ten phases of a free breathing 4D-CT and on several repeat inspiration ABC CT-scans were measured. Separate coordinates, the random margin component and the margin vector norm were computed and compared between the two techniques.

RESULTS

We compared the two techniques in 11 patients (21 adrenal glands) and found the largest movement in the Z-direction, with values of 8.7 ± 4.2 mm for MidV and 2.4 ± 1.5 mm for ABC. In 71% of the cases ABC resulted in a smaller margin component than MidV, although non-significant (p ≥ 0.4).

CONCLUSION

Movement of the adrenal gland is largest in the Z-direction. The mean difference in the margin vector norm between both techniques was small with large variations over the patient group, the clinical effect of these differences is unknown. Applying an individualised motion management strategy could be beneficial. If a peak-to-peak amplitude above 15 mm in the Z-direction is observed in the MidV scan we advise to examine if a breath-hold technique could reduce margins.