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Selingerova I, Holikova K, Chodur T, Hynkova L, Pospisil P, Bulik M, Belanova R, Siffelova K, Kolouskova I, Slavik M, Burkon P, Hrstka R, Jancalek R, Sana J, Slampa P, Kazda T. Challenges with hippocampal MR spectroscopy as a surrogate for pre-radiotherapy assessment of neurocognitive impairment in patients with brain metastasis. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2024; 168:206-215. [PMID: 38623639 DOI: 10.5507/bp.2024.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 03/22/2024] [Indexed: 04/17/2024] Open
Abstract
AIM Patients with multiple brain metastases (BM) benefit from hippocampal-avoiding whole brain radiotherapy (HA-WBRT), the challenging and less available form of WBRT. This study explores potential of pre-radiotherapy (pre-RT) hippocampal magnetic resonance spectroscopy (MRS) measuring hippocampal neuronal density as an imaging surrogate and predictive tool for assessing neurocognitive functions (NCF). METHODS 43 BM patients underwent pre-RT hippocampal MRS. N-acetyl aspartate (NAA) concentration, a marker for neuronal density (weighted by creatine (Cr) and choline (Cho) concentrations), and neurocognitive function (NCF) tests (HVLT and BVMT) performed by certified psychologists were evaluated. Clinical variables and NAA concentrations were correlated with pre-RT NCFs. RESULTS HVLT and BVMT subtests showed pre-RT deterioration except for BVMT recognition. Significantly better NCFs were observed in women in HVLT subsets. Significantly higher NAA/Cr + Cho was measured in women (median 0.63 vs. 0.55; P=0.048) in the left hippocampus (no difference in the right hippocampus). In men, a positive correlation (0.51, P=0.018) between total brain volume and HVLT-TR, between left hippocampal NAA/Cr + Cho and HVLT-R (0.45, P=0.063), and between right hippocampal NAA/Cr + Cho and BVMT-recognition (0.49, P=0.054) was observed. In women, a borderline significant negative correlation was observed between left hippocampal NAA/Cr + Cho and BVMT-TR (-0.43, P=0.076) and between right NAA/Cr + Cho and HVLT-DR (-0.42, P=0.051). CONCLUSION Borderline statistically significant correlations were observed with speculative interpretation underlying the challenges of hippocampal MRS as a surrogate for neurocognitive impairment. Further studies need to be done to ascertain the opportunities for imaging predictors of benefit from memory sparing radiotherapy.
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Affiliation(s)
- Iveta Selingerova
- Research Center for Applied Molecular Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Klara Holikova
- Department of Medical Imaging, St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomas Chodur
- Unit of Clinical Psychology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Ludmila Hynkova
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Petr Pospisil
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Martin Bulik
- Department of Medical Imaging, St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Renata Belanova
- Department of Radiology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Kamila Siffelova
- Unit of Clinical Psychology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Ivana Kolouskova
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Marek Slavik
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Petr Burkon
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Roman Hrstka
- Research Center for Applied Molecular Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Radim Jancalek
- Department of Neurosurgery, St. Anne's University Hospital Brno, Brno, Czech Republic
- Department of Neurosurgery, St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jiri Sana
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute and Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Pavel Slampa
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomas Kazda
- Research Center for Applied Molecular Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Mukwada G, Chamunyonga C, Rowshanfarzad P, Gill S, Ebert MA. Insights into the dosimetric and geometric characteristics of stereotactic radiosurgery for multiple brain metastases: A systematic review. PLoS One 2024; 19:e0307088. [PMID: 39121064 PMCID: PMC11315342 DOI: 10.1371/journal.pone.0307088] [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: 04/21/2024] [Accepted: 06/30/2024] [Indexed: 08/11/2024] Open
Abstract
BACKGROUND GammaKnife (GK) and CyberKnife (CK) have been the mainstay stereotactic radiosurgery (SRS) solution for multiple brain metastases (MBM) for several years. Recent technological advancement has seen an increase in single-isocentre C-arm linac-based SRS. This systematic review focuses on dosimetric and geometric insights into contemporary MBM SRS and thereby establish if linac-based SRS has matured to match the mainstay SRS delivery systems. METHODS The PubMed, Web of Science and Scopus databases were interrogated which yielded 891 relevant articles that narrowed to 20 articles after removing duplicates and applying the inclusion and exclusion criteria. Primary studies which reported the use of SRS for treatment of MBM SRS and reported the technical aspects including dosimetry were included. The review was limited to English language publications from January 2015 to August 2023. Only full-length papers were included in the final analysis. Opinion papers, commentary pieces, letters to the editor, abstracts, conference proceedings and editorials were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. The reporting of conformity indices (CI) and gradient indices, V12Gy, monitor units and the impact of translational and rotational shifts were extracted and analysed. RESULTS The single-isocentre technique for MBM dominated recent SRS studies and the most studied delivery platforms were Varian. The C-arm linac-based SRS plan quality and normal brain tissue sparing was comparable to GK and CK and in some cases better. The most used nominal beam energy was 6FFF, and optimised couch and collimator angles could reduce mean normal brain dose by 11.3%. Reduction in volume of the healthy brain receiving a certain dose was dependent on the number and size of the metastases and the relative geometric location. GK and CK required 4.5-8.4 times treatment time compared with linac-based SRS. Rotational shifts caused larger changes in CI in C-arm linac-based single-isocentre SRS. CONCLUSION C-arm linac-based SRS produced comparable MBM plan quality and the delivery is notably shorter compared to GK and CK SRS.
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Affiliation(s)
- Godfrey Mukwada
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Hospital Ave, Nedlands, Western Australia, Australia
- School of Physics, Mathematics and Computing, University of Western Australia, Crawley, Western Australia, Australia
| | - Crispen Chamunyonga
- School of Clinical Sciences, Discipline of Radiation Therapy, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Pejman Rowshanfarzad
- School of Physics, Mathematics and Computing, University of Western Australia, Crawley, Western Australia, Australia
- Centre for Advanced Technologies in Cancer Research (CATCR), Perth, Western Australia, Australia
| | - Suki Gill
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Hospital Ave, Nedlands, Western Australia, Australia
- School of Physics, Mathematics and Computing, University of Western Australia, Crawley, Western Australia, Australia
| | - Martin A. Ebert
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Hospital Ave, Nedlands, Western Australia, Australia
- School of Physics, Mathematics and Computing, University of Western Australia, Crawley, Western Australia, Australia
- Centre for Advanced Technologies in Cancer Research (CATCR), Perth, Western Australia, Australia
- School of Medicine and Population Health, University of Wisconsin, Madison, Wisconsin, United States of America
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Koide Y, Nagai N, Adachi S, Ito M, Kawamura M, Ito M, Ito F, Shindo Y, Aoyama T, Shimizu H, Hashimoto S, Tachibana H, Kodaira T. Impact of concurrent antibody-drug conjugates and radiotherapy on symptomatic radiation necrosis in breast cancer patients with brain metastases: a multicenter retrospective study. J Neurooncol 2024; 168:415-423. [PMID: 38644464 DOI: 10.1007/s11060-024-04681-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 04/15/2024] [Indexed: 04/23/2024]
Abstract
AIM We aimed to investigate the impact of concurrent antibody-drug conjugates (ADC) and radiotherapy on symptomatic radiation necrosis (SRN) in breast cancer patients with brain metastases (BM). METHODS This multicenter retrospective study uses four institutional data. Eligibility criteria were histologically proven breast cancer, diagnosed BM with gadolinium-enhanced MRI, a Karnofsky performance status of 60 or higher, and radiotherapy for all BM lesions between 2017 and 2022. Patients with leptomeningeal dissemination were excluded. Concurrent ADC was defined as using ADC within four weeks before or after radiotherapy. The cumulative incidence of SRN until December 2023 with death as a competing event was compared between the groups with and without concurrent ADC. Multivariable analysis was performed using the Fine-Gray model. RESULTS Among the 168 patients enrolled, 48 (29%) received ADC, and 19 (11%) had concurrent ADC. Of all, 36% were HER2-positive, 62% had symptomatic BM, and 33% had previous BM radiation histories. In a median follow-up of 31 months, 18 SRNs (11%) were registered (11 in grade 2 and 7 in grade 3). The groups with and without concurrent ADC had 5 SRNs in 19 patients and 13 SRNs in 149, and the two-year cumulative incidence of SRN was 27% vs. 7% (P = 0.014). Concurrent ADC was associated with a higher risk of SRN on multivariable analysis (subdistribution hazard ratio, 3.0 [95% confidence interval: 1.1-8.3], P = 0.030). CONCLUSIONS This study suggests that concurrent ADC and radiotherapy are associated with a higher risk of SRN in HER2-positive breast cancer patients.
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Affiliation(s)
- Yutaro Koide
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Japan.
| | - Naoya Nagai
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Japan
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Sou Adachi
- Department of Radiology, Aichi Medical University Hospital, Nagakute, Japan
| | - Masayuki Ito
- Department of Radiation Oncology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Mariko Kawamura
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Makoto Ito
- Department of Radiology, Aichi Medical University Hospital, Nagakute, Japan
| | - Fumitaka Ito
- Department of Radiation Oncology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yurika Shindo
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Japan
| | - Takahiro Aoyama
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Japan
| | - Hidetoshi Shimizu
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Japan
| | - Shingo Hashimoto
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Japan
| | - Hiroyuki Tachibana
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Japan
| | - Takeshi Kodaira
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Japan
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Leng JX, Carpenter DJ, Huang C, Qazi J, Arshad M, Mullikin TC, Reitman ZJ, Kirkpatrick JP, Floyd SR, Fecci PE, Chmura SJ, Hong JC, Salama JK. Determinants of Symptomatic Intracranial Progression After an Initial Stereotactic Radiosurgery Course. Adv Radiat Oncol 2024; 9:101475. [PMID: 38690297 PMCID: PMC11059392 DOI: 10.1016/j.adro.2024.101475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/04/2024] [Indexed: 05/02/2024] Open
Abstract
Purpose Clinical and imaging surveillance of patients with brain metastases is important after stereotactic radiosurgery (SRS) because many will experience intracranial progression (ITCP) requiring multidisciplinary management. The prognostic significance of neurologic symptoms at the time of ITCP is poorly understood. Methods and Materials This was a multi-institutional, retrospective cohort study from 2015 to 2020, including all patients with brain metastases completing an initial course of SRS. The primary outcome was overall survival (OS) by presence of neurologic symptoms at ITCP. OS, freedom from ITCP (FF-ITCP), and freedom from symptomatic ITCP (FF-SITCP) were assessed via Kaplan-Meier method. Cox proportional hazard models tested parameters impacting FF-ITCP and FF-SITCP. Results Among 1383 patients, median age was 63.4 years, 55% were female, and common primaries were non-small cell lung (49%), breast (15%), and melanoma (9%). At a median follow-up of 8.72 months, asymptomatic and symptomatic ITCP were observed in 504 (36%) and 194 (14%) patients, respectively. The majority of ITCP were distant ITCP (79.5%). OS was worse with SITCP (median, 10.2 vs 17.9 months, P < .001). SITCP was associated with clinical factors including total treatment volume (P = .012), melanoma histology (P = .001), prior whole brain radiation therapy (P = .003), number of brain metastases (P < .001), interval of 1 to 2 years from primary and brain metastasis diagnosis (P = .012), controlled extracranial disease (P = .042), and receipt of pre-SRS chemotherapy (P = .015). Patients who were younger and received post-SRS chemotherapy (P = .001), immunotherapy (P < .001), and targeted or small-molecule inhibitor therapy (P < .026) had better FF-SITCP. Conclusions In this cohort study of patients with brain metastases completing SRS, neurologic symptoms at ITCP is prognostic for OS. This data informs post-SRS surveillance in clinical practice as well as future prospective studies needed in the modern management of brain metastases.
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Affiliation(s)
- Jim X. Leng
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - David J. Carpenter
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
- Department of Radiation Oncology, Wellstar Paulding Hospital, Hiram, Georgia
| | - Christina Huang
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Jamiluddin Qazi
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Muzamil Arshad
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Trey C. Mullikin
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Zachary J. Reitman
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - John P. Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Scott R. Floyd
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Peter E. Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Steven J. Chmura
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Julian C. Hong
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, California
- Joint Program in Computational Precision Health, University of California, San Francisco, California and University of California, Berkeley, California
| | - Joseph K. Salama
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
- Radiation Oncology Clinical Service, Durham VA Health Care System, Durham, North Carolina
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5
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Ene CI, Abi Faraj C, Beckham TH, Weinberg JS, Andersen CR, Haider AS, Rao G, Ferguson SD, Alvarez-Brenkenridge CA, Kim BYS, Heimberger AB, McCutcheon IE, Prabhu SS, Wang CM, Ghia AJ, McGovern SL, Chung C, McAleer MF, Tom MC, Perni S, Swanson TA, Yeboa DN, Briere TM, Huse JT, Fuller GN, Lang FF, Li J, Suki D, Sawaya RE. Response of treatment-naive brain metastases to stereotactic radiosurgery. Nat Commun 2024; 15:3728. [PMID: 38697991 PMCID: PMC11066027 DOI: 10.1038/s41467-024-47998-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 04/15/2024] [Indexed: 05/05/2024] Open
Abstract
With improvements in survival for patients with metastatic cancer, long-term local control of brain metastases has become an increasingly important clinical priority. While consensus guidelines recommend surgery followed by stereotactic radiosurgery (SRS) for lesions >3 cm, smaller lesions (≤3 cm) treated with SRS alone elicit variable responses. To determine factors influencing this variable response to SRS, we analyzed outcomes of brain metastases ≤3 cm diameter in patients with no prior systemic therapy treated with frame-based single-fraction SRS. Following SRS, 259 out of 1733 (15%) treated lesions demonstrated MRI findings concerning for local treatment failure (LTF), of which 202 /1733 (12%) demonstrated LTF and 54/1733 (3%) had an adverse radiation effect. Multivariate analysis demonstrated tumor size (>1.5 cm) and melanoma histology were associated with higher LTF rates. Our results demonstrate that brain metastases ≤3 cm are not uniformly responsive to SRS and suggest that prospective studies to evaluate the effect of SRS alone or in combination with surgery on brain metastases ≤3 cm matched by tumor size and histology are warranted. These studies will help establish multi-disciplinary treatment guidelines that improve local control while minimizing radiation necrosis during treatment of brain metastasis ≤3 cm.
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Affiliation(s)
- Chibawanye I Ene
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA.
| | - Christina Abi Faraj
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Thomas H Beckham
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey S Weinberg
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Clark R Andersen
- Department of Biostatistics, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Ali S Haider
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Ganesh Rao
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Sherise D Ferguson
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | | | - Betty Y S Kim
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Amy B Heimberger
- Department of Neurological Surgery, Malnati Brain Tumor Institute of the Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ian E McCutcheon
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Sujit S Prabhu
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Chenyang Michael Wang
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Amol J Ghia
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Caroline Chung
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Martin C Tom
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Subha Perni
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Todd A Swanson
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Debra N Yeboa
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Tina M Briere
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Jason T Huse
- Department of Pathology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Gregory N Fuller
- Department of Pathology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Frederick F Lang
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Dima Suki
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Raymond E Sawaya
- Faculty of Medicine and Medical Affairs, American University of Beirut, Beirut, Lebanon
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Crooks J, Dominic O, Shepard M, Yu A, Liang Y, Karlovits SM, Wegner RE. Cost of Treatment for Brain Metastases Using Data From a National Health Insurance. Adv Radiat Oncol 2024; 9:101438. [PMID: 38567144 PMCID: PMC10985802 DOI: 10.1016/j.adro.2024.101438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/29/2023] [Indexed: 04/04/2024] Open
Abstract
Purpose In the United States, brain metastases (BMs) affect 10% to 20% of patients with cancer, presenting a significant health care challenge and necessitating intricate, high-cost treatments. Few studies have explored the comprehensive care cost for BMs, and none have used real insurance claims data. Partnering with a northeastern health care insurer, we investigated the true costs of various brain-directed radiation methods, aiming to shed light on treatment expenses, modalities, and their efficacy. Methods and Materials We analyzed medical claims from Highmark Health-insured patients in Pennsylvania, Delware, West Virginia, and New York diagnosed with BMs (ICD-10 code C79.31) and treated with radiation from January 1, 2020 to July 1, 2022. Costs for radiation techniques were grouped by specific current procedural terminology claim codes. We subdivided costs into technical and physician components and separated hospital from freestanding costs for some modalities. Results From January 1, 2020 to July 1, 2022, 1048 Highmark Health members underwent treatment for BMs. Females (n = 592) significantly outnumbered males (n = 456), with an average age of 64.4 years. Each member had, on average, 5.309 claims costing $2015 per claim. Total cost totaled $10,697,749. Per-treatment analysis showed that hippocampal avoidance intensity modulated radiation therapy was the costliest treatment at $47,748, followed by stereotactic radiation therapy at $37,230, linear accelerator stereotactic radiosurgery (SRS) at $30,737, Gamma Knife SRS at $30,711, and whole-brain radiation therapy at $5225. Conclusions Whole-brain radiation therapy was the least costly radiation technique. Similar per-treatment prices for Gamma Knife and linear accelerator SRS support their use in treating BMs. Stereotactic radiation therapy in general was costlier on a per-use basis than SRS, prompting further scrutiny on its frequent use. Hippocampal avoidance intensity modulated radiation therapy was the costliest radiation therapy on a per-use basis by a moderate amount, prompting further discussion about its comparative cost effectiveness against other radiation modalities. This study underscores the importance of multiple considerations in treating BMs, such as tumor control, survival, side effects, and costs.
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Affiliation(s)
- Joseph Crooks
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Oralia Dominic
- Medical Policy Research Department, Highmark Health, Pittsburgh, Pennsylvania
| | - Matthew Shepard
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Alexander Yu
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Yun Liang
- Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Stephen M. Karlovits
- Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Rodney E. Wegner
- Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania
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7
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Nadal E, Vilariño N, Simó M, Navarro V, Bruna J. Reply to E.J. Lehrer et al and J.B. De Vis et al. J Clin Oncol 2024; 42:859-861. [PMID: 38079584 DOI: 10.1200/jco.23.02248] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 10/16/2023] [Indexed: 02/29/2024] Open
Affiliation(s)
- Ernest Nadal
- Ernest Nadal, MD, PhD, and Noelia Vilariño, MD, Preclinical and Experimental Research in Thoracic Tumors (PRETT), Oncobell, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet, Barcelona, Spain, Department of Medical Oncology, Catalan Institute of Oncology (ICO), L'Hospitalet, Barcelona, Spain; Marta Simó, MD, PhD, Neuro-Oncology Unit, Department of Neurology, Hospital de Bellvitge, L'Hospitalet, Barcelona, Spain; Valentí Navarro, BS, Department of Medical Oncology, Catalan Institute of Oncology (ICO), L'Hospitalet, Barcelona, Spain; and Jordi Bruna, MD, PhD, Neuro-Oncology Unit, Department of Neurology, Hospital de Bellvitge, L'Hospitalet, Barcelona, Spain
| | - Noelia Vilariño
- Ernest Nadal, MD, PhD, and Noelia Vilariño, MD, Preclinical and Experimental Research in Thoracic Tumors (PRETT), Oncobell, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet, Barcelona, Spain, Department of Medical Oncology, Catalan Institute of Oncology (ICO), L'Hospitalet, Barcelona, Spain; Marta Simó, MD, PhD, Neuro-Oncology Unit, Department of Neurology, Hospital de Bellvitge, L'Hospitalet, Barcelona, Spain; Valentí Navarro, BS, Department of Medical Oncology, Catalan Institute of Oncology (ICO), L'Hospitalet, Barcelona, Spain; and Jordi Bruna, MD, PhD, Neuro-Oncology Unit, Department of Neurology, Hospital de Bellvitge, L'Hospitalet, Barcelona, Spain
| | - Marta Simó
- Ernest Nadal, MD, PhD, and Noelia Vilariño, MD, Preclinical and Experimental Research in Thoracic Tumors (PRETT), Oncobell, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet, Barcelona, Spain, Department of Medical Oncology, Catalan Institute of Oncology (ICO), L'Hospitalet, Barcelona, Spain; Marta Simó, MD, PhD, Neuro-Oncology Unit, Department of Neurology, Hospital de Bellvitge, L'Hospitalet, Barcelona, Spain; Valentí Navarro, BS, Department of Medical Oncology, Catalan Institute of Oncology (ICO), L'Hospitalet, Barcelona, Spain; and Jordi Bruna, MD, PhD, Neuro-Oncology Unit, Department of Neurology, Hospital de Bellvitge, L'Hospitalet, Barcelona, Spain
| | - Valentí Navarro
- Ernest Nadal, MD, PhD, and Noelia Vilariño, MD, Preclinical and Experimental Research in Thoracic Tumors (PRETT), Oncobell, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet, Barcelona, Spain, Department of Medical Oncology, Catalan Institute of Oncology (ICO), L'Hospitalet, Barcelona, Spain; Marta Simó, MD, PhD, Neuro-Oncology Unit, Department of Neurology, Hospital de Bellvitge, L'Hospitalet, Barcelona, Spain; Valentí Navarro, BS, Department of Medical Oncology, Catalan Institute of Oncology (ICO), L'Hospitalet, Barcelona, Spain; and Jordi Bruna, MD, PhD, Neuro-Oncology Unit, Department of Neurology, Hospital de Bellvitge, L'Hospitalet, Barcelona, Spain
| | - Jordi Bruna
- Ernest Nadal, MD, PhD, and Noelia Vilariño, MD, Preclinical and Experimental Research in Thoracic Tumors (PRETT), Oncobell, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet, Barcelona, Spain, Department of Medical Oncology, Catalan Institute of Oncology (ICO), L'Hospitalet, Barcelona, Spain; Marta Simó, MD, PhD, Neuro-Oncology Unit, Department of Neurology, Hospital de Bellvitge, L'Hospitalet, Barcelona, Spain; Valentí Navarro, BS, Department of Medical Oncology, Catalan Institute of Oncology (ICO), L'Hospitalet, Barcelona, Spain; and Jordi Bruna, MD, PhD, Neuro-Oncology Unit, Department of Neurology, Hospital de Bellvitge, L'Hospitalet, Barcelona, Spain
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8
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Yao J, Morrison MA, Lupo JM. Editorial for "Relationship Between Microstructural Alterations and Cognitive Decline After Whole-Brain Radiation Therapy for Brain Metastases: An Exploratory Whole-Brain MR Analysis Based on Neurite Orientation Dispersion and Density Imaging". J Magn Reson Imaging 2024; 59:253-254. [PMID: 37194681 DOI: 10.1002/jmri.28780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 05/18/2023] Open
Affiliation(s)
- Jingwen Yao
- Department of Radiological Sciences, UCLA, Los Angeles, California, USA
| | - Melanie A Morrison
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
- Department of Bioengineering at UCB and Department of Bioengineering and Therapeutic Sciences at UCSF, UCSF/UC Berkeley Graduate Program in Bioengineering, San Francisco, Berkeley, California, USA
| | - Janine M Lupo
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
- Department of Bioengineering at UCB and Department of Bioengineering and Therapeutic Sciences at UCSF, UCSF/UC Berkeley Graduate Program in Bioengineering, San Francisco, Berkeley, California, USA
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9
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Vellayappan B, Lim-Fat MJ, Kotecha R, De Salles A, Fariselli L, Levivier M, Ma L, Paddick I, Pollock BE, Regis J, Sheehan JP, Suh JH, Yomo S, Sahgal A. A Systematic Review Informing the Management of Symptomatic Brain Radiation Necrosis After Stereotactic Radiosurgery and International Stereotactic Radiosurgery Society Recommendations. Int J Radiat Oncol Biol Phys 2024; 118:14-28. [PMID: 37482137 DOI: 10.1016/j.ijrobp.2023.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 07/02/2023] [Accepted: 07/14/2023] [Indexed: 07/25/2023]
Abstract
Radiation necrosis (RN) secondary to stereotactic radiosurgery is a significant cause of morbidity. The optimal management of corticosteroid-refractory brain RN remains unclear. Our objective was to summarize the literature specific to efficacy and toxicity of treatment paradigms for patients with symptomatic corticosteroid-refractory RN and to provide consensus guidelines for grading and management of RN on behalf of the International Stereotactic Radiosurgery Society. A systematic review of articles pertaining to treatment of RN with bevacizumab, laser interstitial thermal therapy (LITT), surgical resection, or hyperbaric oxygen therapy was performed. The primary composite outcome was clinical and/or radiologic stability/improvement (ie, proportion of patients achieving improvement or stability with the given intervention). Proportions of patients achieving the primary outcome were pooled using random weighted-effects analysis but not directly compared between interventions. Twenty-one articles were included, of which only 2 were prospective studies. Thirteen reports were relevant for bevacizumab, 5 for LITT, 5 for surgical resection and 1 for hyperbaric oxygen therapy. Weighted effects analysis revealed that bevacizumab had a pooled symptom improvement/stability rate of 86% (95% CI 77%-92%), pooled T2 imaging improvement/stability rate of 93% (95% CI 87%-98%), and pooled T1 postcontrast improvement/stability rate of 94% (95% CI 87%-98%). Subgroup analysis showed a statistically significant improvement favoring treatment with low-dose (below median, ≤7.5 mg/kg every 3 weeks) versus high-dose bevacizumab with regards to symptom improvement/stability rate (P = .02) but not for radiologic T1 or T2 changes. The pooled T1 postcontrast improvement/stability rate for LITT was 88% (95% CI 82%-93%), and pooled symptom improvement/stability rate for surgery was 89% (95% CI 81%-96%). Toxicity was inconsistently reported but was generally low for all treatment paradigms. Corticosteroid-refractory RN that does not require urgent surgical intervention, with sufficient noninvasive diagnostic testing that favors RN, can be treated medically with bevacizumab in carefully selected patients as a strong recommendation. The role of LITT is evolving as a less invasive image guided surgical modality; however, the overall evidence for each modality is of low quality. Prospective head-to-head comparisons are needed to evaluate the relative efficacy and toxicity profile among treatment approaches.
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Affiliation(s)
- Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore.
| | - Mary Jane Lim-Fat
- Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Antonio De Salles
- Department of Neurosurgery, University of California, Los Angeles, California; HCor Neuroscience, São Paulo, Brazil
| | - Laura Fariselli
- Department of Neurosurgery, Unit of Radiotherapy, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Marc Levivier
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of Southern California, Los Angeles, California
| | - Ian Paddick
- Division Physics, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jean Regis
- Department of Functional Neurosurgery, Aix Marseille University, Timone University Hospital, Marseille, France
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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10
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Royal-Preyra B. The Impact of Immune Checkpoint Inhibition on the Risk of Radiation Necrosis Following Stereotactic Radiotherapy for Metastatic Brain Cancer. Cureus 2023; 15:e51381. [PMID: 38161546 PMCID: PMC10757743 DOI: 10.7759/cureus.51381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2023] [Indexed: 01/03/2024] Open
Abstract
Purpose/objective Forty percent of cancer patients develop brain metastases (BM) and are often treated with stereotactic radiation (SRS/SRT). Checkpoint inhibitor (CI) use is suspected of increasing the risk of radiation necrosis (RN). Our aim is to determine whether treatment with CI is associated with an increased risk of RN in BM patients treated with SRS/SRT. Methods We retrospectively identified the medical records of BM patients treated with SRS/SRT between 1/2017 and 12/2021 using an institutional database. RN was defined by MRI imaging read by neuroradiologists and/or surgical pathology. V12GY of patients with and without RN was compared using the Mann-Whitney test. The chi-square test was used to see if RN was associated with CI use, histology, particular CI agent used, > 1 course SRS/SRT, SRS/SRT dose, chemotherapy, whole brain radiotherapy (WBRT), age, or sex. Results Two hundred and fifty-nine patients treated with 455 courses of SRS/SRT were analyzed. The most common primary histologies were lung 56% (N=146), breast 14% (N= 37), melanoma 9% (N=24), and renal cancer 7% (N=18). A total of 53.8% (N = no. of patients) were treated with CI. The overall rate of any RN was 21.8% (N=27) in the CI group compared to 14.8% (N=141) in the non-CI group (p=0.174). Mean V12Gy was 15.525 cc and 9.419 cc in patients with and without RN (p=0.02768). Mean number of SRS/SRT courses was 2 and 1.53 for patients with and without RN, and >1 course of SRS/SRT was a predictor of RN (p <0.01). Other features analyzed were not significant. Conclusion RN was higher in the BM patients treated with SRS/SRT receiving CI compared to non-CI patients (21.8%, N=27, versus 14.6%, N= 16), but failed to reach statistical significance. V12Gy and > 1 course of SRS/SRT was associated with RN. Caution should be taken in treating patients with SRS/SRT and CI there might be an increased risk of RN.
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Affiliation(s)
- Ben Royal-Preyra
- Radiation Oncology, Centre Hospitalier Affilié Universitaire Regional, Trois-Rivières, CAN
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11
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Yerramilli D, Johnstone CA. Radiation Therapy at the End of-Life: Quality of Life and Financial Toxicity Considerations. Semin Radiat Oncol 2023; 33:203-210. [PMID: 36990637 DOI: 10.1016/j.semradonc.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
In patients with advanced cancer, radiation therapy is considered at various time points in the patient's clinical course from diagnosis to death. As some patients are living longer with metastatic cancer on novel therapeutics, radiation oncologists are increasingly using radiation therapy as an ablative therapy in appropriately selected patients. However, most patients with metastatic cancer still eventually die of their disease. For those without effective targeted therapy options or those who are not candidates for immunotherapy, the time frame from diagnosis to death is still relatively short. Given this evolving landscape, prognostication has become increasingly challenging. Thus, radiation oncologists must be diligent about defining the goals of therapy and considering all treatment options from ablative radiation to medical management and hospice care. The risks and benefits of radiation therapy vary based on an individual patient's prognosis, goals of care, and the ability of radiation to help with their cancer symptoms without undue toxicity over the course of their expected lifetime. When considering recommending a course of radiation, physicians must broaden their understanding of risks and benefits to include not only physical symptoms, but also various psychosocial burdens. These include financial burdens to the patient, to their caregiver and to the healthcare system. The burden of time spent at the end-of-life receiving radiation therapy must also be considered. Thus, the consideration of radiation therapy at the end-of-life can be complex and requires careful attention to the whole patient and their goals of care.
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12
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Muacevic A, Adler JR. GammaTile: Comprehensive Review of a Novel Radioactive Intraoperative Seed-Loading Device for the Treatment of Brain Tumors. Cureus 2022; 14:e29970. [PMID: 36225241 PMCID: PMC9541893 DOI: 10.7759/cureus.29970] [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] [Accepted: 10/05/2022] [Indexed: 11/05/2022] Open
Abstract
GammaTile is a Food and Drug Administration (FDA)-licensed device consisting of four cesium-131 (Cs-131) radiation-emitting seeds in the collagen tile about the postage stamp size. The tiles are utilized to line the brain cavity immediately after tumor resection. GammaTile therapy is a surgically targeted radiation therapy (STaRT) that helps provide instant, dose-intense treatment after the completion of resection. The objective of this study is to explore the safety and efficacy of GammaTile surgically targeted radiation therapy for brain tumors. This study also reviews the differences between GammaTile surgically targeted radiation therapy (STaRT) and other traditional treatment options for brain tumors. The electronic database searches utilized in this study include PubMed, Google Scholar, and ScienceDirect. A total of 4,150 articles were identified based on the search strategy. Out of these articles, 900 articles were retrieved. A total of 650 articles were excluded for various reasons, thus retrieving 250 citations. We applied the exclusion and inclusion criteria to these retrieved articles by screening their full text and excluding 180 articles. Therefore, 70 citations were retrieved and included in this comprehensive literature review, as outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram. Based on the findings of this study, GammaTile surgically targeted radiation therapy (STaRT) is safe and effective for treating brain tumors. Similarly, the findings have also shown that the efficacy of GammaTile therapy can be enhanced by combining it with other standard-of-care treatment options/external beam radiation therapy (EBRT). Also, the results show that patients diagnosed with recurrent glioblastoma (GBM) exhibit poor median overall survival because of the possibility of the tumor returning. Therefore, combining STaRT with other standard-of-care treatment options/EBRT can improve the patient's overall survival (OS). GammaTile therapy enhances access to care, guarantees 100% compliance, and eliminates patients' need to travel regularly to hospitals for radiation treatments. Its implementation requires collaboration from various specialties, such as radiation oncology, medical physics, and neurosurgery.
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13
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Alvi MA, Asher AL, Michalopoulos GD, Grills IS, Warnick RE, McInerney J, Chiang VL, Attia A, Timmerman R, Chang E, Kavanagh BD, Andrews DW, Walter K, Bydon M, Sheehan JP. Factors associated with progression and mortality among patients undergoing stereotactic radiosurgery for intracranial metastasis: results from a national real-world registry. J Neurosurg 2022; 137:985-998. [PMID: 35171833 DOI: 10.3171/2021.10.jns211410] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 10/14/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) has been increasingly employed in recent years to treat intracranial metastatic lesions. However, there is still a need for optimization of treatment paradigms to provide better local control and prevent progressive intracranial disease. In the current study, the authors utilized a national collaborative registry to investigate the outcomes of patients with intracranial metastatic disease who underwent SRS and to determine factors associated with lesion treatment response, overall progression, and mortality. METHODS The NeuroPoint Alliance SRS registry was queried for all patients with intracranial metastatic lesions undergoing single- or multifraction SRS at participating institutions between 2016 and 2020. The main outcomes of interest included lesion response (lesion-level analysis), progression using Response Assessment for Neuro-Oncology criteria, and mortality (patient-level analysis). Kaplan-Meier analysis was used to report time to progression and overall survival, and multivariable Cox proportional hazards analysis was used to investigate factors associated with lesion response, progression, and mortality. RESULTS A total of 501 patients (1447 intracranial metastatic lesions) who underwent SRS and had available follow-up were included in the current analyses. The most common primary tumor was lung cancer (49.5%, n = 248), followed by breast (15.4%, n = 77) and melanoma (12.2%, n = 61). Most patients had a single lesion (44.9%, n = 225), 29.3% (n = 147) had 2 or 3 lesions, and 25.7% (n = 129) had > 3 lesions. The mean sum of baseline measurements of the lesions according to Response Evaluation Criteria in Solid Tumors (RECIST) was 35.54 mm (SD 25.94). At follow-up, 671 lesions (46.4%) had a complete response, 631 (43.6%) had a partial response (≥ 30% decrease in longest diameter) or were stable (< 30% decrease but < 20% increase), and 145 (10%) showed progression (> 20% increase in longest diameter). On multivariable Cox proportional hazards analysis, melanoma-associated lesions (HR 0.48, 95% CI 0.34-0.67; p < 0.001) and larger lesion size (HR 0.94, 95% CI 0.93-0.96; p < 0.001) showed lower odds of lesion regression, while a higher biologically effective dose was associated with higher odds (HR 1.001, 95% CI 1.0001-1.00023; p < 0.001). A total of 237 patients (47.3%) had overall progression (local failure or intracranial progressive disease), with a median time to progression of 10.03 months after the index SRS. Factors found to be associated with increased hazards of progression included male sex (HR 1.48, 95% CI 1.108-1.99; p = 0.008), while administration of immunotherapy (before or after SRS) was found to be associated with lower hazards of overall progression (HR 0.62, 95% CI 0.460-0.85; p = 0.003). A total of 121 patients (23.95%) died during the follow-up period, with a median survival of 19.4 months from the time of initial SRS. A higher recursive partitioning analysis score (HR 21.3485, 95% CI 1.53202-3.6285; p < 0.001) was found to be associated with higher hazards of mortality, while single-fraction treatment compared with hypofractionated treatment (HR 0.082, 95% CI 0.011-0.61; p = 0.015), administration of immunotherapy (HR 0.385, 95% CI 0.233-0.64; p < 0.001), and presence of single compared with > 3 lesions (HR 0.427, 95% CI 0.187-0.98; p = 0.044) were found to be associated with lower risk of mortality. CONCLUSIONS The comparability of results between this study and those of previously published clinical trials affirms the value of multicenter databases with real-world data collected without predetermined research purpose.
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Affiliation(s)
- Mohammed Ali Alvi
- 1Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Anthony L Asher
- 3Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Giorgos D Michalopoulos
- 1Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Inga S Grills
- 4Department of Neurological Surgery, Beaumont Health System, Royal Oak, Michigan
| | - Ronald E Warnick
- 5Department of Neurosurgery, The Jewish Hospital, Cincinnati, Ohio
| | - James McInerney
- 6Department of Neurosurgery, Penn State Health, Hershey, Pennsylvania
| | - Veronica L Chiang
- 7Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Albert Attia
- 8Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert Timmerman
- 9Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Eric Chang
- 10Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Brian D Kavanagh
- 11Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - David W Andrews
- 12Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Kevin Walter
- 13Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York; and
| | - Mohamad Bydon
- 1Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jason P Sheehan
- 14Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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14
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Yan M, Holden L, Wang M, Soliman H, Myrehaug S, Tseng CL, Detsky J, Ruschin M, Tjong M, Atenafu EG, Das S, Lipsman N, Heyn C, Sahgal A, Husain Z. Gamma knife icon based hypofractionated stereotactic radiosurgery (GKI-HSRS) for brain metastases: impact of dose and volume. J Neurooncol 2022; 159:705-712. [PMID: 35999435 DOI: 10.1007/s11060-022-04115-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/09/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Gamma Knife Icon-based hypofractionated stereotactic radiosurgery (GKI-HSRS) is a novel technical paradigm in the treatment of brain metastases that allows for both the dosimetric benefits of the GKI stereotactic radiosurgery (SRS) platform as well as the biologic benefits of fractionation. We report mature local control and adverse radiation effect (ARE) outcomes following 5 fraction GKI-HSRS for intact brain metastases. METHODS Patients with intact brain metastases treated with 5-fraction GKI-HSRS were retrospectively reviewed. Survival, local control, and adverse radiation effect rates were determined. Univariable and multivariable regression (MVA) were performed on potential predictive factors. RESULTS Two hundred and ninety-nine metastases in 146 patients were identified. The median clinical follow-up was 10.7 months (range 0.5-47.6). The median total dose and prescription isodose was 27.5 Gy (range, 20-27.5) in 5 daily fractions and 52% (range, 45-93), respectively. The median overall survival (OS) was 12.7 months, and the 1-year local failure rate was 15.2%. MVA identified a total dose of 27.5 Gy vs. ≤ 25 Gy (hazard ratio [HR] 0.59, p = 0.042), and prior chemotherapy exposure (HR 1.99, p = 0.015), as significant predictors of LC. The 1-year ARE rate was 10.8% and the symptomatic ARE rate was 1.8%. MVA identified a gross tumor volume of ≥ 4.5 cc (HR 7.29, p < 0.001) as a significant predictor of symptomatic ARE. CONCLUSION Moderate total doses in 5 daily fractions of GKI-HSRS were associated with high rates of LC and a low incidence of symptomatic ARE.
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Affiliation(s)
- Michael Yan
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Lori Holden
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Michael Wang
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Mark Ruschin
- Department of Medical Physics, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Michael Tjong
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada
| | - Sunit Das
- Department of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Nir Lipsman
- Department of Neurosurgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - Chinthaka Heyn
- Department of Radiology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada. .,Sunnybrook Health Sciences Center, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
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15
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Radiation therapy for melanoma brain metastases: a systematic review. Radiol Oncol 2022; 56:267-284. [PMID: 35962952 PMCID: PMC9400437 DOI: 10.2478/raon-2022-0032] [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: 05/25/2022] [Accepted: 06/17/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Radiation therapy (RT) for melanoma brain metastases, delivered either as whole brain radiation therapy (WBRT) or as stereotactic radiosurgery (SRS), is an established component of treatment for this condition. However, evidence allowing comparison of the outcomes, advantages and disadvantages of the two RT modalities is scant, with very few randomised controlled trials having been conducted. This has led to considerable uncertainty and inconsistent guideline recommendations. The present systematic review identified 112 studies reporting outcomes for patients with melanoma brain metastases treated with RT. Three were randomised controlled trials but only one was of sufficient size to be considered informative. Most of the evidence was from non-randomised studies, either specific treatment series or disease cohorts. Criteria for determining treatment choice were reported in only 32 studies and the quality of these studies was variable. From the time of diagnosis of brain metastasis, the median survival after WBRT alone was 3.5 months (IQR 2.4-4.0 months) and for SRS alone it was 7.5 months (IQR 6.7-9.0 months). Overall patient survival increased over time (pre-1989 to 2015) but this was not apparent within specific treatment groups. CONCLUSIONS These survival estimates provide a baseline for determining the incremental benefits of recently introduced systemic treatments using targeted therapy or immunotherapy for melanoma brain metastases.
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16
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Imber BS, Young RJ, Beal K, Reiner AS, Giantini-Larsen AM, Yang JT, Aramburu-Nunez D, Cohen GN, Brennan C, Tabar V, Moss NS. Salvage resection plus cesium-131 brachytherapy durably controls post-SRS recurrent brain metastases. J Neurooncol 2022; 159:609-618. [PMID: 35896906 PMCID: PMC9328626 DOI: 10.1007/s11060-022-04101-9] [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: 06/14/2022] [Accepted: 07/16/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Salvage of recurrent previously irradiated brain metastases (rBrM) is a significant challenge. Resection without adjuvant re-irradiation is associated with a high local failure rate, while reirradiation only partially reduces failure but is associated with greater radiation necrosis risk. Salvage resection plus Cs131 brachytherapy may offer dosimetric and biologic advantages including improved local control versus observation, with reduced normal brain dose versus re-irradiation, however data are limited. METHODS A prospective registry of consecutive patients with post-stereotactic radiosurgery (SRS) rBrM undergoing resection plus implantation of collagen-matrix embedded Cs131 seeds (GammaTile, GT Medical Technologies) prescribed to 60 Gy at 5 mm from the cavity was analyzed. RESULTS Twenty patients underwent 24 operations with Cs131 implantation in 25 tumor cavities. Median maximum preoperative diameter was 3.0 cm (range 1.1-6.3). Gross- or near-total resection was achieved in 80% of lesions. A median of 16 Cs131 seeds (range 6-30), with a median air-kerma strength of 3.5 U/seed were implanted. There was one postoperative wound dehiscence. With median follow-up of 1.6 years for survivors, two tumors recurred (one in-field, one marginal) resulting in 8.4% 1-year progression incidence (95%CI = 0.0-19.9). Radiographic seed settling was identified in 7/25 cavities (28%) 1.9-11.7 months post-implantation, with 1 case of distant migration (4%), without clinical sequelae. There were 8 cases of radiation necrosis, of which 4 were symptomatic. CONCLUSIONS With > 1.5 years of follow-up, intraoperative brachytherapy with commercially available Cs131 implants was associated with favorable local control and toxicity profiles. Weak correlation between preoperative tumor geometry and implanted tiles highlights a need to optimize planning criteria.
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Affiliation(s)
- Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert J Young
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Radiology, Neuroradiology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anne S Reiner
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | - Jonathan T Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Aramburu-Nunez
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gil'ad N Cohen
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cameron Brennan
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Viviane Tabar
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nelson S Moss
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA. .,Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Kumar S, Wang X, Pittell H, Calip GS, Weiss SE, Meyer JE, Royce TJ. Real world use of radiation for newly diagnosed brain metastases in ALK-positive lung cancer receiving a first line ALK inhibitor. Int J Radiat Oncol Biol Phys 2022; 114:627-634. [PMID: 35870711 DOI: 10.1016/j.ijrobp.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/06/2022] [Accepted: 07/13/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Management paradigms now allow systemic targeted drugs before central nervous system (CNS)-directed radiotherapy (RT) in selected asymptomatic patients with non-small cell lung cancer (NSCLC) with brain metastases (BM). We aim to quantify how novel targeted agents with improved CNS activity, such as second-generation ALK inhibitors (e.g. alectinib), might impact the role of CNS-directed RT. METHODS AND MATERIALS This retrospective, observational, real world patterns of care study used a nationwide electronic health record-derived de-identified longitudinal database. A random sample of patients with ALK+ advanced NSCLC and BM on first-line ALK-inhibitor monotherapy between January 1, 2014 and August 31, 2019 were included. Using an index date of the first instance of BM, the outcome was brain-directed local treatment within four months. Trends over time were reported and tested using multivariable modified Poisson regression with robust error variance, including an indicator of in or after 2017 (when alectinib was approved). RESULTS Of 352 patients, 146 had BM. 104 received CNS-directed local therapy and 42 did not. The majority (89.4%) were treated with RT alone. Of those receiving RT, stereotactic radiosurgery (SRS) monotherapy was the most common (53%) followed by whole brain radiotherapy (WBRT) alone (39%). On multivariable analysis, those patients who had their first BM in or after 2017 had a decreased rate of receiving local BM treatment versus those prior to 2017 with an adjusted incidence rate ratio (aIRR) 0.63 (95% confidence interval [CI]: 0.41-0.95; p=0.026). We found no change in the proportion of BM treated with WBRT in or after 2017 vs before (aIRR = 0.70; 95% CI: 0.24-2.06; p = 0.517). CONCLUSIONS We found decreasing use of CNS-directed RT in patients with NSCLC with new BM on first-line ALK inhibitors. Clinical outcomes for these patients require continued investigation as physicians may be increasingly comfortable deferring upfront local therapy for BM in lieu of novel targeted agents with improved CNS activity.
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Affiliation(s)
- Sameera Kumar
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | | | | | - Gregory S Calip
- Flatiron Health, New York, NY; Center for Pharmacoepidemiology & Pharmacoeconomic Research, University of Illinois Chicago, Chicago, IL
| | - Stephanie E Weiss
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Joshua E Meyer
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Trevor J Royce
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA; Department of Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, NC.
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18
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Fabian A, Domschikowski J, Letsch A, Schmalz C, Freitag-Wolf S, Dunst J, Krug D. Clinical endpoints in trials of palliative radiotherapy: A systematic meta-research analysis. Radiother Oncol 2022; 174:123-131. [PMID: 35868602 DOI: 10.1016/j.radonc.2022.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE Up to 50% of radiotherapy courses are delivered in palliative intent for various indications. Despite the large number of treated patients, we know little about the choice of endpoints in trials of palliative radiotherapy. Our primary aim was, therefore, to analyze primary endpoints in trials of palliative radiotherapy. METHODS We conducted a pre-registered (https://doi.org/10.17605/OSF.IO/GMCAF) meta-research analysis searching Pubmed/MEDLINE, EMBASE, CENTRAL, and "ClinicalTrials.gov" for clinical trials of palliative radiotherapy published 1990-2020. Endpoints were categorized in "patient-centered endpoints", including overall survival and patient-reported outcomes, and "tumor-centered endpoints" such as local control. The remainder were "other endpoints" including toxicity or observer-rated symptoms. We applied descriptive statistics to summarize data and logistic regression to assess if year of publication predicted the choice of primary endpoints. RESULTS Of 7379 records screened, 292 were eligible. Trials were characterized by small sample sizes and use of external beam radiotherapy for metastases or thoracic primaries. Median patient age was 64 and median ECOG was 1. Only 64.4%(145/225) of published trials clearly stated their primary endpoint. Published trials employed a "patient-centered primary endpoint" in 45.5%(66/145) and a "tumor-centered primary endpoint" in 17.3%(25/145) of the cases. There was no statistically significant trend in time for the use of "patient-centered primary endpoints". Registered ongoing trials used a "patient-centered primary endpoint" in 32.8%(22/67) and a "tumor-centered primary endpoint" in 26.9%(18/67) of the cases. CONCLUSION Although "patient-centered primary endpoints" appear relatively prevalent in published trials of palliative radiotherapy, their use is still suboptimal and appears to be lower in currently ongoing trials.
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Affiliation(s)
- Alexander Fabian
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany.
| | - Justus Domschikowski
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany
| | - Anne Letsch
- Department of Hematology and Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany
| | - Claudia Schmalz
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany
| | - Sandra Freitag-Wolf
- Institute of Medical Informatics and Statistics, Christian-Albrechts-University Kiel, 24118 Kiel, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany
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19
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Chee LYS, Sia J, Milne RL, Foroudi F, Millar JL, Ong WL. Variations in whole brain radiation therapy fractionation for brain metastases in Victoria. J Med Imaging Radiat Oncol 2022; 66:1106-1114. [PMID: 35726760 PMCID: PMC10084193 DOI: 10.1111/1754-9485.13447] [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: 03/31/2022] [Accepted: 06/05/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We aim to evaluate the use of different whole brain radiation therapy (WBRT) fractionation schedules for brain metastases (BM) in Victoria, and the factors associated with it. METHODS This is a population-based cohort of patients who received radiation therapy for BM between 2012 and 2017, as captured in the Victorian Radiotherapy Minimum Dataset. We excluded patients with primary brain tumour and those who had 'prophylactic' intent treatment. The Cochran-Armitage test was used to evaluate changing trend in WBRT fractionation. Multivariate multinomial logistic regressions were used to evaluate factors associated with WBRT fractionation. RESULTS Of the 3111 patients who had WBRT, 1048 (45%), 1291 (42%) and 312 (13%) had ≤5, 6-10 and >10 fractions WBRT respectively. There was progressive increase in ≤5 fractions WBRT use over time, from 37% in 2012 to 50% in 2017 (P-trend < 0.001). In multivariate analyses, increasing age, patients with gastrointestinal cancer, patients living in remote/regional areas and more recent treatment were associated with the use of shorter WBRT fractionation (≤5 fractions), while patients who had WBRT plus stereotactic radiosurgery, and those treated in private institutions were associated with the use of prolonged WBRT fractionation (≥6 fractions). Three hundred eighty-nine (13%) patients died within 30 days of WBRT, of which 241 (64%), 119 (32%) and 17 (5%) had ≤5, 6-10 and > 10 fractions WBRT respectively. CONCLUSION We observed large variations in WBRT fractionation that are associated with patient, tumour, treatment and institutional factors. It is important to continuously monitor and benchmark our practice in order to reduce potentially unwarranted variations.
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Affiliation(s)
- Lessandra Yan Shan Chee
- Alfred Health Radiation Oncology, Melbourne, Victoria, Australia.,Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Joseph Sia
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Roger L Milne
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia.,Centre for Epidemiology and Biostatistics, School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.,Precision Medicine, School of Clinical Sciences, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Farshad Foroudi
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness and Research Centre, Austin Health, Melbourne, Victoria, Australia
| | - Jeremy L Millar
- Alfred Health Radiation Oncology, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Wee Loon Ong
- Alfred Health Radiation Oncology, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia.,School of Clinical Medicine, University of Cambridge, Cambridge, UK
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20
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Memantine in the Prevention of Radiation-Induced Brain Damage: A Narrative Review. Cancers (Basel) 2022; 14:cancers14112736. [PMID: 35681716 PMCID: PMC9179311 DOI: 10.3390/cancers14112736] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/25/2022] [Accepted: 05/30/2022] [Indexed: 12/03/2022] Open
Abstract
Simple Summary Decline in cognitive function is a major problem for patients undergoing whole-brain radiotherapy (WBRT). Scientific interest has increased due to the high dropout rate of patients in the first months after WBRT and the early onset of cognitive decline. Therefore, the study of antiglutamatergic pharmacological prophylaxis and hippocampal-sparing WBRT techniques has been deepened based on the knowledge of the mechanisms of hyperglutamatergic neurotoxicity and the role of some hippocampal areas in cognitive decline. In order to provide a summary of the evidence in this field, and to foster future research in this setting, this literature review presents current evidence on the prevention of radiation-induced cognitive decline and particularly on the role of memantine. Abstract Preserving cognitive functions is a priority for most patients with brain metastases. Knowing the mechanisms of hyperglutamatergic neurotoxicity and the role of some hippocampal areas in cognitive decline (CD) led to testing both the antiglutamatergic pharmacological prophylaxis and hippocampal-sparing whole-brain radiotherapy (WBRT) techniques. These studies showed a relative reduction in CD four to six months after WBRT. However, the failure to achieve statistical significance in one study that tested memantine alone (RTOG 0614) led to widespread skepticism about this drug in the WBRT setting. Moreover, interest grew in the reasons for the strong patient dropout rates in the first few months after WBRT and for early CD onset. In fact, the latter can only partially be explained by subclinical tumor progression. An emerging interpretation of the (not only) cognitive impairment during and immediately after WBRT is the dysfunction of the limbic and hypothalamic system with its immune and hormonal consequences. This new understanding of WBRT-induced toxicity may represent the basis for further innovative trials. These studies should aim to: (i) evaluate in greater detail the cognitive effects and, more generally, the quality of life impairment during and immediately after WBRT; (ii) study the mechanisms producing these early effects; (iii) test in clinical studies, the modern and advanced WBRT techniques based on both hippocampal-sparing and hypothalamic-pituitary-sparing, currently evaluated only in planning studies; (iv) test new timings of antiglutamatergic drugs administration aimed at preventing not only late toxicity but also acute effects.
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21
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Bolem N, Soon YY, Ravi S, Dinesh N, Teo K, Nga VDW, Lwin S, Yeo TT, Vellayappan B. Is there any survival benefit from post-operative radiation in brain metastases? A systematic review and meta-analysis of randomized controlled trials. J Clin Neurosci 2022; 99:327-335. [PMID: 35339853 DOI: 10.1016/j.jocn.2022.03.024] [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: 11/20/2021] [Revised: 02/25/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The benefits of adding upfront post-operative radiation, either whole-brain (WBRT) or cavity, after resection of brain metastases have been debated, particularly due to the long-term sequalae post radiation. We sought to compare the efficacy and safety between post-operative radiation versus resection alone. METHODS We searched various biomedical databases from 1983 to 2018, for eligible randomized controlled trials (RCT). Outcomes studied were local recurrence (LR), overall survival (OS) and serious (Grade 3 + ) adverse events. We used the random effects model to pool outcomes. Methodological quality of each study was assessed using the Cochrane Risk of Bias tool. We employed the GRADE approach to assess the certainty of evidence. RESULTS We included 5 RCTs comprising of 673 patients. The pooled odds ratio (OR) for LR is 0.26 (95% confidence interval (CI) 0.19-0.37, P < 0.001, GRADE certainty high), strongly supporting the use of post-operative radiation. Meta-regression analysis done comparing cavity and WBRT, did not show any difference in LR. The pooled hazard ratio (HR) for overall survival (OS) is 1.1 (95% CI 0.90-1.34, P = 0.37, GRADE certainty high). The treatment-related toxicities could not be pooled; the 2 studies which reported this did not find differences between the approaches. The risk of bias across the included studies was low. CONCLUSION Our analysis confirms that upfront post-operative radiation significantly reduces the risk of LR. However, the lack of improvement in OS suggests that local control alone may not impact survival. Balancing local control, and neuro-cognitive effects of WBRT, cavity radiation seems to be a safe and effective option.
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Affiliation(s)
- Nagarjun Bolem
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Yu Yang Soon
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore
| | - Sreyes Ravi
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore
| | - Nivedh Dinesh
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Kejia Teo
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Vincent Diong Weng Nga
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Sein Lwin
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore.
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22
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Kirkpatrick JP. Answering the Big Clinical Questions in Brain Metastasis Management. Front Oncol 2022; 11:834122. [PMID: 35118002 PMCID: PMC8805701 DOI: 10.3389/fonc.2021.834122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/27/2021] [Indexed: 11/30/2022] Open
Abstract
Management of brain metastases is challenging, both because of the historically guarded prognosis and evolving, more efficacious treatment paradigms for metastatic cancer. This perspective addresses several of the important difficult questions that practitioners treating patients with brain tumors face in the clinic. Successfully answering these questions requires knowledge of the clinical evidence, thoughtful discussion of the patient’s goals of care and collaboration in a multi-disciplinary setting.
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Affiliation(s)
- John P. Kirkpatrick
- Department of Radiation Oncology, Duke Cancer Institute, Durham, NC, United States
- Department of Neurosurgery, Duke Cancer Institute, Durham, NC, United States
- *Correspondence: John P. Kirkpatrick,
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23
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Adeberg S, Sauer C, Lambert L, Regnery S, Windisch P, Zaoui K, Freudlsperger C, Moratin J, Farnia B, Nikendei C, Krauss J, Ehrenthal JC, El Shafie R, Hörner-Rieber J, König L, Akbaba S, Lang K, Held T, Rieken S, Debus J, Friederich HC, Maatouk I. Screening and Psycho-Oncological Support for Patients With Head and Neck Cancer and Brain Malignancies Before Radiotherapy With Mask Fixation: Results of a Feasibility Study. Front Psychol 2021; 12:760024. [PMID: 34975651 PMCID: PMC8716729 DOI: 10.3389/fpsyg.2021.760024] [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] [Received: 08/17/2021] [Accepted: 11/08/2021] [Indexed: 11/13/2022] Open
Abstract
This single-center, single-arm trial investigates the feasibility of a psycho-oncological care program, which aims to reduce psychological distress and improve compliance with radiotherapy with mask fixation in patients with head and neck cancer or brain malignancies. The care program comprised (1) a screening/needs assessment and (2) the provision of a psycho-oncological intervention using imaginative stabilization techniques for distressed patients (distress due to anxiety ≥5) or in a case of subjective interest in the psycho-oncological intervention. Another allocation path to the intervention was directly through the radiation oncologist in charge who classified the patient as: in need of support to tolerate the immobilization device. Of a total of 1,020 screened patients, 257 (25.2%) patients indicated a distress ≥5 and 141 (13.8%) patients reported panic attacks. 25% of the patients reported a subjective interest in psycho-oncological support. A total of 35 patients received the psycho-oncological intervention, of which 74% were assigned by radiation oncologists. In this small patient cohort, no significant pre-post effects in terms of depression, anxiety, distress, and quality of life (mental and physical component scores) could be detected. Our results indicate a good feasibility (interdisciplinary workflow and cooperation, allocation by physicians in charge) of the psycho-oncological care program for this cohort of patients before radiotherapy with mask fixation. The screening results underline the high psychological distress and demand for psycho-oncological support. However, since the utilization of our intervention was low, future studies should reduce the barriers and improve compliance to psycho-oncological services by these patients.Clinical Trial Registration: https://www.drks.de/drks_web/setLocale_EN.do #DRKS00013493
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Affiliation(s)
- Sebastian Adeberg
- National Center for Tumor Diseases (NCT), University Hospital Heidelberg (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Radiation Oncology, University Hospital Heidelberg (UKHD), Heidelberg, Germany
- Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), UKHD and DKFZ, Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christina Sauer
- National Center for Tumor Diseases (NCT), University Hospital Heidelberg (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg (UKHD), Heidelberg University, Heidelberg, Germany
| | - Lena Lambert
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg (UKHD), Heidelberg University, Heidelberg, Germany
| | - Sebastian Regnery
- National Center for Tumor Diseases (NCT), University Hospital Heidelberg (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Radiation Oncology, University Hospital Heidelberg (UKHD), Heidelberg, Germany
- Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), UKHD and DKFZ, Heidelberg, Germany
| | - Paul Windisch
- Department of Radiation Oncology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Karim Zaoui
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Freudlsperger
- Department of Oral and Maxillofacial Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Julius Moratin
- Department of Oral and Maxillofacial Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Benjamin Farnia
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, United States
| | - Christoph Nikendei
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg (UKHD), Heidelberg University, Heidelberg, Germany
| | - Juergen Krauss
- National Center for Tumor Diseases (NCT), University Hospital Heidelberg (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Rami El Shafie
- National Center for Tumor Diseases (NCT), University Hospital Heidelberg (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Radiation Oncology, University Hospital Heidelberg (UKHD), Heidelberg, Germany
- Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), UKHD and DKFZ, Heidelberg, Germany
| | - Juliane Hörner-Rieber
- National Center for Tumor Diseases (NCT), University Hospital Heidelberg (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Radiation Oncology, University Hospital Heidelberg (UKHD), Heidelberg, Germany
- Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), UKHD and DKFZ, Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Laila König
- National Center for Tumor Diseases (NCT), University Hospital Heidelberg (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Radiation Oncology, University Hospital Heidelberg (UKHD), Heidelberg, Germany
- Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), UKHD and DKFZ, Heidelberg, Germany
| | - Sati Akbaba
- National Center for Tumor Diseases (NCT), University Hospital Heidelberg (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Radiation Oncology, University Hospital Heidelberg (UKHD), Heidelberg, Germany
- Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), UKHD and DKFZ, Heidelberg, Germany
| | - Kristin Lang
- National Center for Tumor Diseases (NCT), University Hospital Heidelberg (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Radiation Oncology, University Hospital Heidelberg (UKHD), Heidelberg, Germany
- Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), UKHD and DKFZ, Heidelberg, Germany
| | - Thomas Held
- National Center for Tumor Diseases (NCT), University Hospital Heidelberg (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Radiation Oncology, University Hospital Heidelberg (UKHD), Heidelberg, Germany
- Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), UKHD and DKFZ, Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Goettingen University Hospital, Goettingen, Germany
| | - Juergen Debus
- National Center for Tumor Diseases (NCT), University Hospital Heidelberg (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Radiation Oncology, University Hospital Heidelberg (UKHD), Heidelberg, Germany
- Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), UKHD and DKFZ, Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg (UKHD), Heidelberg University, Heidelberg, Germany
| | - Hans-Christoph Friederich
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg (UKHD), Heidelberg University, Heidelberg, Germany
| | - Imad Maatouk
- National Center for Tumor Diseases (NCT), University Hospital Heidelberg (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg (UKHD), Heidelberg University, Heidelberg, Germany
- Section of Psychosomatic Medicine, Psychotherapy and Psychooncology, Department of Internal Medicine II, Julius-Maximilian University Würzburg, Würzburg, Germany
- *Correspondence: Imad Maatouk,
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24
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Khan M, Zhao Z, Li X, Liao G. Anti-PD1 Therapy Plus Whole-Brain Radiation Therapy May Prolong PFS in Selected Non-Small Cell Lung Cancer Patients with Brain Metastases: A Retrospective Study. Int J Gen Med 2021; 14:8903-8918. [PMID: 34858054 PMCID: PMC8631977 DOI: 10.2147/ijgm.s333890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/06/2021] [Indexed: 12/17/2022] Open
Abstract
Background Whole-brain radiotherapy (WBRT) remains an essential modality of treatment for brain metastases (BMs) derived from non-small cell lung cancer (NSCLC) patients and anti-PD-1 therapy has demonstrated intracranial responses in these patients. We aimed to evaluate if the combination of the two treatments could yield additive efficacy. Methods A retrospective review of our institution’s database was carried out to identify NSCLC patients with BMs who had been treated with anti-PD1 therapy and/or WBRT between 2015 and 2020. Patient characteristics, main outcomes, including progression-free survival (PFS) and overall survival (OS), and factors affecting these outcomes were analyzed. SPSS 24 was used for statistical analysis. Appropriate statistical tests were employed according to the type of data. Results Overall, 21 NSCLC BM patients were identified that had received WBRT. Of these, ten had been additionally treated with anti-PD1 therapy within 30 days of WBRT initiation. Median PFS was 3 (95% CI 0.8–5.1) months with WBRT alone versus 11 (95% CI 6.3–15.6) months with combined treatment. Risk of disease progression was 71% lower with the combined approach (HR 0.29, 95% CI 0.11–0.80; p=0.016). A trend toward improved OS was also observed with the combined approach (HR 0.33, 95% CI 0.08–1.12; p=0.107). Concurrent treatment (p=0.028) and male sex (p=0.052) were associated with improved PFS, while OS was associated only with age (p=0.02). Conclusion Concurrent WBRT and anti-PD1 therapy may delay progression and improve survival in BM patients with confirmed EGFR- and ALK-negative NSCLC histology. Prospective studies are warranted to validate and elucidate on the additive effect of the two modalities.
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Affiliation(s)
- Muhammad Khan
- Department of Oncology, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, People's Republic of China.,Department of Oncology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, People's Republic of China
| | - Zhihong Zhao
- Department of Nephrology, Shenzhen People's Hospital, Second Clinical Medicine Centre, Jinan University, Shenzhen, People's Republic of China
| | - Xianming Li
- Department of Oncology, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, People's Republic of China
| | - Guixiang Liao
- Department of Oncology, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, People's Republic of China
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25
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Liao G, Qian Y, Arooj S, Zhao Z, Yan M, Li Z, Yang H, Zheng T, Li G, Li X, Khan M. Radiation Plus Anti-PD-1 Therapy for NSCLC Brain Metastases: A Retrospective Study. Front Oncol 2021; 11:742971. [PMID: 34745964 PMCID: PMC8567143 DOI: 10.3389/fonc.2021.742971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/28/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Radiation therapy (RT) is the mainstay of brain metastases (BMs), and anti-PD-1 blockade has led to intracranial responses in non-small cell lung carcinoma (NSCLC) patients with BMs. OBJECTIVE This study aimed to evaluate the efficacy and safety of adding anti-PD-1 blockade to RT in the management of NSCLC patients with BM in terms of survival outcome. MATERIALS AND METHODS We retrospectively reviewed 70 NSCLC patients with BMs who were treated with whole brain radiation therapy (WBRT) between January 2016 and January 2021. Of the 70 patients, 29 additionally received anti-PD-1 therapy within 30 days of WBRT initiation. Baseline characteristics of the patients and efficacy outcomes such as progression-free survival (PFS) and overall survival (OS) were statistically compared using SPSS v26. Results were obtained using the Chi-square test/Fisher exact test, t-test, Kaplan-Meier, and Cox regression survival analyses. RESULTS The median survival for the entire cohort was 24 months (95% CI, 19.5-28.5). The median survival times for WBRT alone and WBRT plus anti-PD-1 therapy cohorts were 20 months (95% CI, 11.6-28.3) and 27 months (95% CI, 19.5-28.5), respectively (p=0.035). There was no statistical difference in PFS for the treatment cohorts (median PFS for WBRT alone: 7 months vs. 12 months for WBRT plus anti-PD-1, p=0.247). In EGFR wild-type subgroup (n=31), both PFS (p=0.037) and OS (p=0.012) were significantly improved. Only the treatment group (WBRT plus anti-PD-1) was a significant predictor of OS on univariate and multivariate analyses (p=0.040). There were no significant differences in adverse events among the treatment groups. CONCLUSIONS NSCLC patients with BM receiving additional anti-PD-1 therapy may derive better OS than WBRT alone without any increase in adverse events. Prospective well-designed studies are warranted to validate and elucidate the additive effects of the two modalities in this group of patients.
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Affiliation(s)
- Guixiang Liao
- Department of Oncology, Shenzhen People’s Hospital, The First Affiliated Hospital Of Southern University Of Science And Technology, Shenzhen, China
| | - Yuting Qian
- Department of Radiation Oncology, Shenzhen People's Hospital, The Second College of Jinan University, Shenzhen, China
| | - Sumbal Arooj
- Department of Oncology, Shenzhen People’s Hospital, The First Affiliated Hospital Of Southern University Of Science And Technology, Shenzhen, China
- Department of Biochemistry and Molecular Biology, University of Sialkot, Sialkot, Pakistan
| | - Zhihong Zhao
- Department of Nephrology, Shenzhen People’s Hospital, Second Clinical Medicine Centre, Jinan University, Shenzhen, China
| | - Maosheng Yan
- Department of Oncology, Shenzhen People’s Hospital, The First Affiliated Hospital Of Southern University Of Science And Technology, Shenzhen, China
| | - Zihuang Li
- Department of Oncology, Shenzhen People’s Hospital, The First Affiliated Hospital Of Southern University Of Science And Technology, Shenzhen, China
| | - Hongli Yang
- Department of Oncology, Shenzhen People’s Hospital, The First Affiliated Hospital Of Southern University Of Science And Technology, Shenzhen, China
| | - Tao Zheng
- Department of Oncology, Shenzhen People’s Hospital, The First Affiliated Hospital Of Southern University Of Science And Technology, Shenzhen, China
| | - Gang Li
- Department of Chemoradiation Oncology, The First Affiliated Hospital Of Wenzhou Medical University, Wenzhou, China
| | - Xianming Li
- Department of Oncology, Shenzhen People’s Hospital, The First Affiliated Hospital Of Southern University Of Science And Technology, Shenzhen, China
| | - Muhammad Khan
- Department of Oncology, Shenzhen People’s Hospital, The First Affiliated Hospital Of Southern University Of Science And Technology, Shenzhen, China
- Department of Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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Koo J, Roh TH, Lee SR, Heo J, Oh YT, Kim SH. Whole-Brain Radiotherapy vs. Localized Radiotherapy after Resection of Brain Metastases in the Era of Targeted Therapy: A Retrospective Study. Cancers (Basel) 2021; 13:cancers13184711. [PMID: 34572938 PMCID: PMC8472558 DOI: 10.3390/cancers13184711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/10/2021] [Accepted: 09/17/2021] [Indexed: 11/30/2022] Open
Abstract
Simple Summary The paradigm shift from cytotoxic chemotherapy to molecular targeted therapy dramatically improved the survival and quality of life of cancer patients. In radio-oncological aspects, there also was a paradigm shift from whole-brain radiotherapy to localized radiotherapy including stereotactic radiosurgery. This retrospective study analyzed 124 consecutive patients who had undergone surgical resection of brain metastases. We found targeted therapies to improve overall survival and distant control with decreased incidence of leptomeningeal metastasis. Our data suggest that localized radiotherapy is sufficient after resection of brain metastases when systemic targeted therapy is available. Abstract Whether targeted therapy (TT) and radiotherapy impact survival after resection of brain metastases (BM) is unknown. The purpose of this study was to analyze the factors affecting overall survival (OS), local control (LC), distant control (DC), and leptomeningeal metastases (LMM) in patients who had undergone resection of BM. We retrospectively analyzed 124 consecutive patients who had undergone resection of BM between 2004 and 2020. Patient information about age, sex, Karnofsky Performance Scale (KPS), origin of cancer, synchronicity, tumor size, status of primary cancer, use of TT, extent of resection, and postoperative radiotherapy was collected. Radiation therapy was categorized into whole-brain radiotherapy (WBRT), localized radiotherapy (local brain radiotherapy or stereotactic radiosurgery (LBRT/SRS)), and no radiation. We identified factors that affect OS, LC, DC, and LMM. In multivariable analysis, significant factors for OS were higher KPS score (≥90) (HR 0.53, p = 0.011), use of TT (HR 0.43, p = 0.001), controlled primary disease (HR 0.63, p = 0.047), and single BM (HR 0.55, p = 0.016). Significant factors for LC were gross total resection (HR 0.29, p = 0.014) and origin of cancer (p = 0.041). Both WBRT and LBRT/SRS showed superior LC than no radiation (HR 0.32, p = 0.034 and HR 0.38, p = 0.018, respectively). Significant factors for DC were use of TT (HR 0.54, p = 0.022) and single BM (HR 0.47, p = 0.004). Reduced incidence of LMM was associated with use of TT (HR 0.42, p = 0.038), synchronicity (HR 0.25, p = 0.028), and controlled primary cancer (HR 0.44, p = 0.047). TT was associated with prolonged OS, improved DC, and reduced LMM in resected BM patients. WBRT and LBRT/SRS showed similar benefits on LC. Considering the extended survival of cancer patients and the long-term effect of WBRT on cognitive function, LBRT/SRS appears to be a good option after resection of BM.
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Affiliation(s)
- Jaho Koo
- Gamma Knife Center, Brain Tumor Center, Department of Neurosurgery, Ajou University Hospital, Ajou University School of Medicine, Suwon 16499, Korea; (J.K.); (S.R.L.); (S.-H.K.)
| | - Tae Hoon Roh
- Gamma Knife Center, Brain Tumor Center, Department of Neurosurgery, Ajou University Hospital, Ajou University School of Medicine, Suwon 16499, Korea; (J.K.); (S.R.L.); (S.-H.K.)
- Correspondence:
| | - Sang Ryul Lee
- Gamma Knife Center, Brain Tumor Center, Department of Neurosurgery, Ajou University Hospital, Ajou University School of Medicine, Suwon 16499, Korea; (J.K.); (S.R.L.); (S.-H.K.)
| | - Jaesung Heo
- Brain Tumor Center, Department of Radiation Oncology, Ajou University Hospital, Ajou University School of Medicine, Suwon 16499, Korea; (J.H.); (Y.-T.O.)
| | - Young-Taek Oh
- Brain Tumor Center, Department of Radiation Oncology, Ajou University Hospital, Ajou University School of Medicine, Suwon 16499, Korea; (J.H.); (Y.-T.O.)
| | - Se-Hyuk Kim
- Gamma Knife Center, Brain Tumor Center, Department of Neurosurgery, Ajou University Hospital, Ajou University School of Medicine, Suwon 16499, Korea; (J.K.); (S.R.L.); (S.-H.K.)
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Vellayappan BA, McGranahan T, Graber J, Taylor L, Venur V, Ellenbogen R, Sloan AE, Redmond KJ, Foote M, Chao ST, Suh JH, Chang EL, Sahgal A, Lo SS. Radiation Necrosis from Stereotactic Radiosurgery-How Do We Mitigate? Curr Treat Options Oncol 2021; 22:57. [PMID: 34097171 DOI: 10.1007/s11864-021-00854-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2021] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT Intracranial stereotactic radiosurgery (SRS) is an effective and convenient treatment for many brain conditions. Data regarding safety come mostly from retrospective single institutional studies and a small number of prospective studies. Variations in target delineation, treatment delivery, imaging follow-up protocols and dose prescription limit the interpretation of this data. There has been much clinical focus on radiation necrosis (RN) in particular, as it is being increasingly recognized on follow-up imaging. Symptomatic RN may be treated with medical therapy (such as corticosteroids and bevacizumab) with surgical resection being reserved for refractory patients. Nevertheless, RN remains a challenging condition to manage, and therefore upfront patient selection for SRS remains critical to provide complication-free control. Mitigation strategies need to be considered in situations where the baseline risk of RN is expected to be high-such as large target volume or re-irradiation. These may involve reduction in the prescribed dose or hypofractionated stereotactic radiation therapy (HSRT). Recently published guidelines and international meta-analysis report the benefit of HSRT in larger lesions, without compromising control rates. However, careful attention to planning parameters and SRS techniques still need to be adhered, even with HSRT. In cases where the risk is deemed to be high despite mitigation, a combination approach of surgery with or without post-operative radiation should be considered.
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Affiliation(s)
- Balamurugan A Vellayappan
- Department of Radiation oncology, National University Cancer Institute, 1E Kent Ridge Road, Level 7 Tower block, Singapore, 119228, Singapore.
| | - Tresa McGranahan
- Department of Neurology, Alvord Brain Tumor Center, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Jerome Graber
- Department of Neurology, Alvord Brain Tumor Center, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Lynne Taylor
- Department of Neurology, Alvord Brain Tumor Center, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Vyshak Venur
- Department of Neurology, Alvord Brain Tumor Center, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Richard Ellenbogen
- Department of Neurology, Alvord Brain Tumor Center, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Andrew E Sloan
- Department of Neurological Surgery, Seidman Cancer Center and University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH, USA
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, MD, USA
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Samuel T Chao
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John H Suh
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eric L Chang
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
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Feasibility and potential advantages using VMAT in SRS metastasis treatments. ACTA ACUST UNITED AC 2021; 26:119-127. [PMID: 34046222 DOI: 10.5603/rpor.a2021.0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 12/18/2020] [Indexed: 11/25/2022]
Abstract
Background Utilization of stereotactic radiosurgery (SRS) for brain metastases (BM) has become the technique of choice as opposed to whole brain radiation therapy (WBRT). The aim of this work is to evaluate the feasibility and potential benefits in terms of normal tissue (NT) and dose escalation of volumetric modulated arc therapy (VMAT) in SRS metastasis treatment. A VMAT optimization procedure has therefore been developed for internal dose scaling which minimizes planner dependence. Materials and methods Five patient-plans incorporating treatment with frame-based SRS with dynamic conformal arc technique (DA) were re-planned for VMAT. The lesions selected were between 4-6 cm3. The same geometry used in the DA plans was maintained for the VMAT cases. A VMAT planning procedure was performed attempting to scale the dose in inner auxiliary volumes, and to explore the potential for dose scaling with this technique. Comparison of dose-volume histogram (DVH) parameters were obtained. Results VMAT allows a superior NT sparing plus conformity and dose scaling using the auxiliary volumes. The VMAT results were significantly superior in NT sparing, improving both the V10 and V12 values in all cases, with a 2-3 cm3 saving. In addition, VMAT improves the dose coverage D95 by about 0.5 Gy. The objective of dose escalation was achieved with VMAT with an increment of the Dmean and the Dmedian of about 2 Gy. Conclusions This work shows a benefit of VMAT in SRS treatment with significant NT sparing. A VMAT optimization procedure, based on auxiliary inner volumes, has been developed, enabling internal dose escalation.
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Khan M, Zheng T, Zhao Z, Arooj S, Liao G. Efficacy of BRAF Inhibitors in Combination With Stereotactic Radiosurgery for the Treatment of Melanoma Brain Metastases: A Systematic Review and Meta-Analysis. Front Oncol 2021; 10:586029. [PMID: 33692938 PMCID: PMC7937920 DOI: 10.3389/fonc.2020.586029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/30/2020] [Indexed: 12/30/2022] Open
Abstract
Background BRAF inhibitors have improved the outcome for patients with BRAF mutant metastatic melanoma and have shown intracranial responses in melanoma brain metastases. Stereotactic radiosurgery (SRS) is being used as a local treatment for melanoma brain metastasis (MBM) with better local control and survival. We searched for studies comparing the combination of two treatments with SRS alone to detect any clinical evidence of synergism. Materials and Methods PubMed, EMBASE, Medline, and Cochrane library were searched until May 2020 for studies with desired comparative outcomes. Outcomes of interest that were obtained for meta-analysis included survival as the primary, and local control as the secondary outcome. Results A total of eight studies involving 976 patients with MBM were selected. Survival was significantly improved for patients receiving BRAF inhibitor plus SRS in comparison to SRS alone as assessed from the time of SRS induction (SRS survival: hazard ratio [HR] 0.67 [0.58–0.79], p <0.00001), from the time of brain metastasis diagnosis (BM survival: HR 0.65 [0.54, 0.78], p < 0.00001), or from the time of primary diagnosis (PD survival: HR 0.74 [0.57–0.95], p = 0.02). Dual therapy was also associated with improved local control, indicating an additive effect of the two treatments (HR 0.53 [0.31–0.93], p=0.03). Intracranial hemorrhage was higher in patients receiving BRAF inhibitors plus SRS than in those receiving SRS alone (OR, 3.16 [1.43–6.96], p = 0.004). Conclusions BRAF inhibitors in conjunction with SRS as local treatment appear to be efficacious. Local brain control and survival improved in patients with MBM receiving dual therapy. Safety assessment would need to be elucidated further as the incidence of intracranial hemorrhage was increased.
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Affiliation(s)
- Muhammad Khan
- Department of Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China.,Department of Oncology, First affiliated Hospital of Anhui Medical University, Hefei, China
| | - Tao Zheng
- Department of Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Zhihong Zhao
- Department of Nephrology, Shenzhen People's Hospital, Second Clinical Medicine Centre, Jinan University, Shenzhen, China
| | - Sumbal Arooj
- Department of Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China.,Department of Biochemistry, University of Sialkot, Sialkot, Pakistan
| | - Guixiang Liao
- Department of Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
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Khan M, Zhao Z, Arooj S, Liao G. Bevacizumab for radiation necrosis following radiotherapy of brain metastatic disease: a systematic review & meta-analysis. BMC Cancer 2021; 21:167. [PMID: 33593308 PMCID: PMC7885379 DOI: 10.1186/s12885-021-07889-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 01/19/2021] [Indexed: 01/10/2023] Open
Abstract
Background Radiotherapy is the mainstay of brain metastasis (BM) management. Radiation necrosis (RN) is a serious complication of radiotherapy. Bevacizumab (BV), an anti-vascular endothelial growth factor monoclonal antibody, has been increasingly used for RN treatment. We systematically reviewed the medical literature for studies reporting the efficacy and safety of bevacizumab for treatment of RN in BM patients. Materials and methods PubMed, Medline, EMBASE, and Cochrane library were searched with various search keywords such as “bevacizumab” OR “anti-VEGF monoclonal antibody” AND “radiation necrosis” OR “radiation-induced brain necrosis” OR “RN” OR “RBN” AND “Brain metastases” OR “BM” until 1st Aug 2020. Studies reporting the efficacy and safety of BV treatment for BM patients with RN were retrieved. Study selection and data extraction were carried out by independent investigators. Open Meta Analyst software was used as a random effects model for meta-analysis to obtain mean reduction rates. Results Two prospective, seven retrospective, and three case report studies involving 89 patients with RN treated with BV were included in this systematic review and meta-analysis. In total, 83 (93%) patients had a recorded radiographic response to BV therapy, and six (6.7%) had experienced progressive disease. Seven studies (n = 73) reported mean volume reductions on gadolinium-enhanced T1 (mean: 47.03%, +/− 24.4) and T2-weighted fluid-attenuated inversion recovery (FLAIR) MRI images (mean: 61.9%, +/− 23.3). Pooling together the T1 and T2 MRI reduction rates by random effects model revealed a mean of 48.58 (95% CI: 38.32–58.85) for T1 reduction rate and 62.017 (95% CI: 52.235–71.799) for T2W imaging studies. Eighty-five patients presented with neurological symptoms. After BV treatment, nine (10%) had stable symptoms, 39 (48%) had improved, and 34 (40%) patients had complete resolution of their symptoms. Individual patient data was available for 54 patients. Dexamethasone discontinuation or reduction in dosage was observed in 30 (97%) of 31 patients who had recorded dosage before and after BV treatment. Side effects were mild. Conclusions Bevacizumab presents a promising treatment strategy for patients with RN and brain metastatic disease. Radiographic response and clinical improvement was observed without any serious adverse events. Further class I evidence would be required to establish a bevacizumab recommendation in this group of patients.
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Affiliation(s)
- Muhammad Khan
- Department of Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, 518020, People's Republic of China.,Department of Oncology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, People's Republic of China
| | - Zhihong Zhao
- Department of Nephrology, Shenzhen People's Hospital, Second Clinical Medicine Centre, Jinan University, Shenzhen, People's Republic of China
| | - Sumbal Arooj
- Department of Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, 518020, People's Republic of China.,Department of Biochemistry, University of Sialkot, Sialkot, Pakistan
| | - Guixiang Liao
- Department of Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, 518020, People's Republic of China.
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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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Holub K, Louvel G. Efficacy of salvage stereotactic radiotherapy (SRT) for locally recurrent brain metastases after initial SRT and characteristics of target population. Clin Transl Oncol 2021; 23:1463-1473. [PMID: 33464481 DOI: 10.1007/s12094-020-02544-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/15/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Due to a steadily growing use of stereotactic radiotherapy (SRT) for treatment of brain metastases (BMs), the in-field failure after an initial stereotaxy is an increasingly frequent problem. Repeat stereotactic radiotherapy (re-SRT) shows encouraging results in terms of local control. However, the evidence on prognostic factors limiting the overall survival (OS) of re-treated patients is scarce. Here, we sought to analyze the patients' and treatment characteristics influencing the survival outcomes after re-SRT. METHODS Data of all patients with local failure of initial SRT treated from 2012 to 2019 were retrospectively reviewed and cases treated with salvage SRT were analyzed. We analyzed the impact of patients' and treatment characteristics on overall survival after re-SRT by Kaplan-Meier method and Cox regression models. Local and distant brain control, cause of death, and radionecrosis rate were also assessed. RESULTS Forty-seven patients with 55 BMs treated with re-SRT were evaluated. Median OS after re-SRT was 9.2 months and the overall local control was 83.6%. Nine BMs (16.4%) presented local relapse (LR), 12 (21.8%) radionecrosis, while 21 patients (44.7%) developed new BMs. Only absence of extracranial metastases at BMs diagnosis (HR 0.42, CI 95%; 0.18-0.97), extracranial disease progression (HR 2.39, CI 95%; 1.06-5.38) and distant brain failure (HR 3.94, CI 95%; 1.68-9.24) after re-SRT were significantly associated with patients' survival. Extracranial progression following re-SRT was an independent prognosticator of worse OS. CONCLUSION Re-SRT after LR presented excellent local control with acceptable RN rate and improved patients' survival, limited mainly by extracranial and distant brain progression.
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Affiliation(s)
- K Holub
- Radiotherapy Department, Gustave Roussy Cancer Campus, Villejuif, France.
| | - G Louvel
- Radiotherapy Department, Gustave Roussy Cancer Campus, Villejuif, France.
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Batumalai V, Descallar J, Delaney GP, Gabriel G, Wong K, Shafiq J, Vinod SK, Barton MB. Patterns of palliative radiotherapy fractionation for brain metastases patients in New South Wales, Australia. Radiother Oncol 2020; 156:174-180. [PMID: 33359268 DOI: 10.1016/j.radonc.2020.12.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/10/2020] [Accepted: 12/12/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE There is a paucity of studies examining variation in the use of palliative radiation therapy (RT) fractionation for brain metastases. The aim of this study is to assess variation in palliative RT fractionation given for brain metastases in New South Wales (NSW), Australia, and identify factors associated with variation. MATERIALS AND METHODS This is a population-based cohort of patients who received whole brain RT (WBRT) for brain metastases (2009-2014), as captured in the NSW Central Cancer Registry. A logistic regression model was used to identify factors associated with fractionation type. RESULTS Of the 2,698 patients that received WBRT, 1,389 courses (51%) were < 6 fractions, 1,050 courses (39%) were 6-10 fractions, and 259 courses (10%) were > 10 fractions. Older patients were more likely to be treated with shorter courses (P < 0.0001). Patients with primary lung cancers were more likely to receive shorter courses compared with other primary cancers (P < 0.0001). Patients without surgical excision were more likely to receive < 6 fractions compared to those who underwent surgical excision. Shorter courses were more likely to be delivered to patients with the most disadvantaged socioeconomic status (SES) compared with patients with the least disadvantaged SES (P < 0.0001). There were significant fluctuations in the proportion of courses using lower number of fractions over time from 2009 to 2014, but no apparent trend (P = 0.02). There was wide variation in the proportion of shorter courses across residence local health districts, ranging from 24% to 69% for < 6 fractions, 21% to 72% for 6-10 fractions, and 4% to 20% for > 10 fractions (P < 0.0001). CONCLUSION This study has identified significant unwarranted variations in fractionation for WBRT in NSW. Accelerating the uptake of shorter fractionation regimens, if warranted through evidence, should be prioritised to enhance evidence-based care.
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Affiliation(s)
- V Batumalai
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia; Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, Australia.
| | - J Descallar
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia
| | - G P Delaney
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia; Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, Australia
| | - G Gabriel
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia
| | - K Wong
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia; Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, Australia
| | - J Shafiq
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia
| | - S K Vinod
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia; Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, Australia
| | - M B Barton
- Collaboration for Cancer Outcomes, Research and Evaluation, Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia; Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, Australia
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Chan M, Ferguson D, Ni Mhurchu E, Yuan R, Gondara L, McKenzie M, Olson R, Thiessen B, Lalani N, Ma R, Nichol A. Patients with pretreatment leukoencephalopathy and older patients have more cognitive decline after whole brain radiotherapy. Radiat Oncol 2020; 15:271. [PMID: 33239056 PMCID: PMC7687765 DOI: 10.1186/s13014-020-01717-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/13/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose To investigate predictors of cognitive decline after whole brain radiotherapy (WBRT) for brain metastases. Methods A secondary analysis of a phase 2 clinical trial was conducted in patients who received stereotactic radiosurgery for 1–10 brain metastases and WBRT (NCT01046123). The Montreal Cognitive Assessment (MoCA) was performed at baseline and every 3 months after WBRT. Baseline T2-weighted fluid attenuation inversion recovery magnetic resonance imaging was independently assessed by two neuroradiologists for the presence of white matter hyperintensities (WMH) using the Fazekas visual rating scale. WMH were also manually segmented for volumetric analysis. Univariable and multivariable logistic regression were used to test the association between baseline variables and MoCA score decline.
Results Forty-six patients survived ≥ 3 months after treatment. Age (OR 1.12 (1.04–1.21), p < 0.01), baseline WMH volume (OR 1.20, 95% CI 1.06–1.52, p = 0.02) and baseline Fazekas score ≥ 3/6 (OR 6.4, 95% CI 1.7–24.7, p < 0.01) were predictive of MoCA score decline. In multivariable analysis, age was the only significant predictor of MoCA decline. However, all three patients with pre-treatment leukoencephalopathy (Fazekas score = 6/6) had notable adverse outcomes due to cognitive impairment: one required full-time home nursing support and two were institutionalized. Conclusion A greater decline in cognition after WBRT was observed in older patients and patients with a higher baseline WMH burden. Although this study is small and hypothesis-generating, we propose that radiation oncologists should exercise caution in prescribing WBRT if leukoencephalopathy is present on pre-treatment imaging. Trial Registration: clinicaltrials.gov identifier NCT01046123. First posted January 11, 2010. https://clinicaltrials.gov/ct2/show/NCT01046123
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Affiliation(s)
- Matthew Chan
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Vancouver, 600 West 10th Ave, Vancouver, BC, V5Z 4E6, Canada
| | - David Ferguson
- Department of Radiology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Elaine Ni Mhurchu
- Department of Radiology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Ren Yuan
- Department of Radiology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Lovedeep Gondara
- Department of Population Oncology, BC Cancer - Vancouver Centre, Vancouver, BC, Canada
| | - Michael McKenzie
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Vancouver, 600 West 10th Ave, Vancouver, BC, V5Z 4E6, Canada
| | - Robert Olson
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Prince George, Prince George, BC, Canada
| | - Brian Thiessen
- Department of Medical Oncology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Nafisha Lalani
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Vancouver, 600 West 10th Ave, Vancouver, BC, V5Z 4E6, Canada
| | - Roy Ma
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Vancouver, 600 West 10th Ave, Vancouver, BC, V5Z 4E6, Canada
| | - Alan Nichol
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada. .,Department of Radiation Oncology, BC Cancer - Vancouver, 600 West 10th Ave, Vancouver, BC, V5Z 4E6, Canada.
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Khan M, Zhao Z, Arooj S, Zheng T, Liao G. Lapatinib Plus Local Radiation Therapy for Brain Metastases From HER-2 Positive Breast Cancer Patients and Role of Trastuzumab: A Systematic Review and Meta-Analysis. Front Oncol 2020; 10:576926. [PMID: 33240815 PMCID: PMC7677410 DOI: 10.3389/fonc.2020.576926] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 09/30/2020] [Indexed: 01/11/2023] Open
Abstract
Background Intracranial activity of lapatinib has been demonstrated in several studies in patients with human epidermal growth factor receptor-2 positive breast cancers (HER-2+ BC). Stereotactic radiosurgery (SRS) has been increasingly used as the local therapy for brain metastases in breast cancer patients. Increased objective response rate was observed for lapatinib plus whole brain radiotherapy (WBRT) is such patients with high toxicity. Objective We seek to obtain clinical evidence of synergistic efficacy of lapatinib in combination with radiation therapy, in particular, SRS. Materials and methods We carried out a comprehensive research using the following databases: PubMed; Medline; EMBASE; Cochrane library. These databases were searched until 10 June 2020. PRISMA guidelines were followed step by step for carrying out this systematic review and meta-analysis. Review Manager v 5.4 software was used for statistical evaluation of data. Results Overall 6 studies with 843 HER-2 positive breast cancer patients (442 HER-2 amplified disease, 399 luminal B disease) were included in this systematic review and meta-analysis. A total 279 patients had received lapatinib in addition to HER-2 antibody (trastuzumab) plus/minus chemoradiotherapy, while 610 patients had received trastuzumab-based management or only chemoradiotherapy. Lapatinib-based management of BM was associated with significant increase in overall survival (HR 0.63 [0.52, 0.77], p < 0.00001). Combination of the two (trastuzumab plus lapatinib) was associated with increased survival advantage compared to each agent alone (0.55 [0.32, 0.92], p = 0.02). SRS in combination with lapatinib was associated with increased local control (HR 0.47 [0.33, 0.66], p = 0.0001). Ever use of lapatinib with SRS was associated an increased survival as reported in two studies (Shireen et al.: 27.3 vs. 19.5 months, p = 0.03; Kim et al.: 33.3 vs. 23.6 months, p = 0.009). Kim et al. also revealed significant increase in intracranial activity with concurrent lapatinib reporting 57% complete response compared to 38% (p < 0.001) and lower progressive disease rate of 11 vs. 19% (p < 0.001). Risk of radiation necrosis was decreased with lapatinib use. Conclusions Lapatinib has shown intracranial activity and yielded better survival for HER-2+ BC patients with BMs. SRS in combination with ever use of lapatinib had better local control and were associated with better survival. Radiation necrosis risk was reduced with the use of lapatinib.
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Affiliation(s)
- Muhammad Khan
- Department of Radiation Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China.,Department of Oncology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhihong Zhao
- Department of Nephrology, Shenzhen People's Hospital, Second Clinical Medicine Centre, Jinan University, Shenzhen, China
| | - Sumbal Arooj
- Department of Radiation Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China.,Department of Biochemistry, University of Sialkot, Sialkot, Pakistan
| | - Tao Zheng
- Department of Radiation Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Guixiang Liao
- Department of Radiation Oncology, Shenzhen People's Hospital, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
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Putz F, Weissmann T, Oft D, Schmidt MA, Roesch J, Siavooshhaghighi H, Filimonova I, Schmitter C, Mengling V, Bert C, Frey B, Lettmaier S, Distel LV, Semrau S, Fietkau R. FSRT vs. SRS in Brain Metastases-Differences in Local Control and Radiation Necrosis-A Volumetric Study. Front Oncol 2020; 10:559193. [PMID: 33102223 PMCID: PMC7554610 DOI: 10.3389/fonc.2020.559193] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/12/2020] [Indexed: 12/13/2022] Open
Abstract
Background: While the role of stereotactic radiotherapy for brain metastases is increasing, evidence on the comparative efficacy and safety of fractionated stereotactic radiotherapy (FSRT) and single-session radiosurgery (SRS) is scarce. Methods: Longitudinal volumetric analysis was performed in a consecutive cohort of 120 patients and 190 brain metastases (>0.065 cm3 in volume / > ~5 mm in diameter) treated exclusively with FSRT (n = 98) and SRS (n = 92), respectively. A total of 972 tumor segmentations was used, averaging 5.1 time points per metastasis. Progression was defined using a volumetric extension of the RANO-BM criteria. Local control and radionecrosis were compared for lesions treated with FSRT and SRS, respectively. Results: Metastases treated with FSRT were significantly larger at baseline (mean, 4.66 vs. 0.40 cm3, p < 0.001). Biologically effective dose (BED) for metastases (α/β = 12, linear-quadratic-cubic model) was significantly associated with local control, whereas BED for normal brain (α/β = 2, linear-quadratic model) was significantly associated with radionecrosis. Median time to local progression was 22.9 months in the FSRT group compared to 14.5 months in the SRS group (p = 0.022). Overall radionecrosis rate at 12 months was 3.4% for FSRT and 14.8% for SRS (p = 0.010). Radionecrosis °IV requiring resection with histologic proof of radiation necrosis also was significantly reduced in the FSRT group (FSRT 0.0% vs. SRS 3.9%, p = 0.041). In multivariate analysis, FSRT was associated with reduced risk of progression (HR 0.47, p = 0.015) and reduced risk of radionecrosis (HR 0.18, p = 0.045). Conclusions: This volumetric study provides initial evidence that the improvements in therapeutic ratio expected for FSRT in larger brain metastases, might equally extend into the domain of smaller metastases, traditionally less considered for fractionated treatment. FSRT might constitute an important tool to further increase local control and reduce radionecrosis risk in stereotactic radiotherapy for brain metastases, that should be assessed in randomized intervention trials.
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Affiliation(s)
- Florian Putz
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas Weissmann
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Dominik Oft
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Manuel Alexander Schmidt
- Department of Neuroradiology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Johannes Roesch
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Hadi Siavooshhaghighi
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Irina Filimonova
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Charlotte Schmitter
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Veit Mengling
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Benjamin Frey
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sebastian Lettmaier
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Luitpold Valentin Distel
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sabine Semrau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Chilukuri S, Burela N. Memantine for Prevention of Brain Irradiation-Induced Cognitive Toxicity: A Tale of an Underappreciated and Underused Intervention. JCO Glob Oncol 2020; 6:1384-1388. [PMID: 32926643 PMCID: PMC7529526 DOI: 10.1200/go.20.00342] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Srinivas Chilukuri
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, India
| | - Nagarjuna Burela
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, India
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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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