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Kahl KH, Krauss PE, Neu M, Maurer CJ, Schill-Reiner S, Roushan Z, Laukmanis E, Dobner C, Janzen T, Balagiannis N, Sommer B, Stüben G, Shiban E. Intraoperative radiotherapy after neurosurgical resection of brain metastases as institutional standard treatment- update of the oncological outcome form a single center cohort after 117 procedures. J Neurooncol 2024; 169:187-193. [PMID: 38963657 PMCID: PMC11269407 DOI: 10.1007/s11060-024-04691-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 04/18/2024] [Indexed: 07/05/2024]
Abstract
PURPOSE Stereotactic radiotherapy (SRT) is the predominant method for the irradiation of resection cavities after resection of brain metastases (BM). Intraoperative radiotherapy (IORT) with 50 kV x-rays is an alternative way to irradiate the resection cavity focally. We have already reported the outcome of our first 40 IORT patients treated until 2020. Since then, IORT has become the predominant cavity treatment in our center due to patients´ choice. METHODS We retrospectively analyzed the outcomes of all patients who underwent resection of BM and IORT between 2013 and August 2023 at Augsburg University Medical Center (UKA). RESULTS We identified 105 patients with 117 resected BM treated with 50 kV x-ray IORT. Median diameter of the resected metastases was 3.1 cm (range 1.3 - 7.0 cm). Median applied dose was 20 Gy. All patients received standardized follow-up (FU) including three-monthly MRI of the brain. Mean FU was 14 months, with a median MRI FU for patients alive of nine months. Median overall survival (OS) of all treated patients was 18.2 months (estimated 1-year OS 57.7%). The observed local control (LC) rate of the resection cavity was 90.5% (estimated 1-year LC 84.2%). Distant brain control (DC) was 61.9% (estimated 1-year DC 47.9%). Only 16.2% of all patients needed WBI in the further course of disease. The observed radio necrosis rate was 2.6%. CONCLUSION After 117 procedures IORT still appears to be a safe and appealing way to perform cavity RT after neurosurgical resection of BM with low toxicity and excellent LC.
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Affiliation(s)
- Klaus-Henning Kahl
- Department of Radiotherapy and Radio- Oncology, University Medical Center Augsburg, Augsburg, Germany.
| | - Philipp E Krauss
- Department of Neurosurgery, University Medical Center Augsburg, Augsburg, Germany
| | - Maria Neu
- Department of Radiotherapy and Radio- Oncology, University Medical Center Augsburg, Augsburg, Germany
| | - Christoph J Maurer
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Medical Center Augsburg, Augsburg, Germany
| | - Sabine Schill-Reiner
- Department of Medical Physics and Radiation Protection, University Medical Center Augsburg, Augsburg, Germany
| | - Zoha Roushan
- Department of Medical Physics and Radiation Protection, University Medical Center Augsburg, Augsburg, Germany
| | - Eva Laukmanis
- Department of Medical Physics and Radiation Protection, University Medical Center Augsburg, Augsburg, Germany
| | - Christian Dobner
- Department of Medical Physics and Radiation Protection, University Medical Center Augsburg, Augsburg, Germany
| | - Tilman Janzen
- Department of Medical Physics and Radiation Protection, University Medical Center Augsburg, Augsburg, Germany
| | - Nikolaos Balagiannis
- Department of Radiotherapy and Radio- Oncology, University Medical Center Augsburg, Augsburg, Germany
| | - Björn Sommer
- Department of Neurosurgery, University Medical Center Augsburg, Augsburg, Germany
| | - Georg Stüben
- Department of Radiotherapy and Radio- Oncology, University Medical Center Augsburg, Augsburg, Germany
| | - Ehab Shiban
- Department of Neurosurgery, University Medical Center Augsburg, Augsburg, Germany
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Kanakarajan H, De Baene W, Gehring K, Eekers DBP, Hanssens P, Sitskoorn M. Factors associated with the local control of brain metastases: a systematic search and machine learning application. BMC Med Inform Decis Mak 2024; 24:177. [PMID: 38907265 PMCID: PMC11191176 DOI: 10.1186/s12911-024-02579-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/17/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Enhancing Local Control (LC) of brain metastases is pivotal for improving overall survival, which makes the prediction of local treatment failure a crucial aspect of treatment planning. Understanding the factors that influence LC of brain metastases is imperative for optimizing treatment strategies and subsequently extending overall survival. Machine learning algorithms may help to identify factors that predict outcomes. METHODS This paper systematically reviews these factors associated with LC to select candidate predictor features for a practical application of predictive modeling. A systematic literature search was conducted to identify studies in which the LC of brain metastases is assessed for adult patients. EMBASE, PubMed, Web-of-Science, and the Cochrane Database were searched up to December 24, 2020. All studies investigating the LC of brain metastases as one of the endpoints were included, regardless of primary tumor type or treatment type. We first grouped studies based on primary tumor types resulting in lung, breast, and melanoma groups. Studies that did not focus on a specific primary cancer type were grouped based on treatment types resulting in surgery, SRT, and whole-brain radiotherapy groups. For each group, significant factors associated with LC were identified and discussed. As a second project, we assessed the practical importance of selected features in predicting LC after Stereotactic Radiotherapy (SRT) with a Random Forest machine learning model. Accuracy and Area Under the Curve (AUC) of the Random Forest model, trained with the list of factors that were found to be associated with LC for the SRT treatment group, were reported. RESULTS The systematic literature search identified 6270 unique records. After screening titles and abstracts, 410 full texts were considered, and ultimately 159 studies were included for review. Most of the studies focused on the LC of the brain metastases for a specific primary tumor type or after a specific treatment type. Higher SRT radiation dose was found to be associated with better LC in lung cancer, breast cancer, and melanoma groups. Also, a higher dose was associated with better LC in the SRT group, while higher tumor volume was associated with worse LC in this group. The Random Forest model predicted the LC of brain metastases with an accuracy of 80% and an AUC of 0.84. CONCLUSION This paper thoroughly examines factors associated with LC in brain metastases and highlights the translational value of our findings for selecting variables to predict LC in a sample of patients who underwent SRT. The prediction model holds great promise for clinicians, offering a valuable tool to predict personalized treatment outcomes and foresee the impact of changes in treatment characteristics such as radiation dose.
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Affiliation(s)
- Hemalatha Kanakarajan
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands.
| | - Wouter De Baene
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
| | - Karin Gehring
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Daniëlle B P Eekers
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Patrick Hanssens
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Margriet Sitskoorn
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands.
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Samanci Y, Ali Tepebasili M, Deniz Ardor G, Haluk Duzkalir A, Orbay Askeroglu M, Peker S. Efficacy of hypofractionated Gamma Knife radiosurgery in treating surgical beds of metastatic brain tumors. J Clin Neurosci 2024; 121:105-113. [PMID: 38387112 DOI: 10.1016/j.jocn.2024.02.020] [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: 01/11/2024] [Revised: 02/01/2024] [Accepted: 02/17/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVE Surgery alone for metastatic brain tumors (METs) often results in local recurrence due to microscopic residual tumor tissue. While stereotactic radiosurgery (SRS) is commonly used post-surgery, hypofractionation may be required for large surgical beds. This study evaluated the efficacy and safety of hypofractionated Gamma Knife radiosurgery (hf-GKRS) for the first time as a post-operative adjuvant therapy. METHODS This retrospective study involved 24 patients (28 surgical beds) who underwent hf-GKRS within four weeks after surgery. The study primarily focused on local control (LC) rate and analyzed distant intracranial failure (DICF), intracranial progression-free survival (PFS), leptomeningeal disease (LMD), overall survival (OS), and radiation necrosis (RN). RESULTS During a median follow-up of 9 months, LC was achieved in 89.3 % of surgical beds. LC estimates at 6, 12, and 24 months were 96.4 %, 82.7 %, and 82.7 %, respectively. DICF was observed in 45.8 % of patients, and LMD was identified in two patients (8.3 %). At the end of the follow-up, 58.3 % of patients were alive, and the median OS was 20 months. RN occurred in only one surgical bed (3.6 %). No grade 5 toxicity was observed. The univariate analysis identified a longer interval to GKRS (HR 11.842, p = 0.042) and a larger treatment volume (HR 1.103, p = 0.037) as significant factors for local failure. CONCLUSIONS hf-GKRS shows potential as an effective and safe adjuvant treatment for surgical beds. It offers an alternative to SRS, SRT, or WBRT, particularly for larger volumes or tumors near critical structures. Further research is needed to confirm these results and optimize treatment approaches.
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Affiliation(s)
- Yavuz Samanci
- Koc University School of Medicine, Department of Neurosurgery, Istanbul, Turkey
| | | | - Gokce Deniz Ardor
- Koc University Hospital, Department of Neurosurgery, Gamma Knife Center, Istanbul, Turkey
| | - Ali Haluk Duzkalir
- Koc University Hospital, Department of Neurosurgery, Gamma Knife Center, Istanbul, Turkey
| | - M Orbay Askeroglu
- Koc University Hospital, Department of Neurosurgery, Gamma Knife Center, Istanbul, Turkey
| | - Selcuk Peker
- Koc University School of Medicine, Department of Neurosurgery, Istanbul, Turkey.
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Kübler J, Wester-Ebbinghaus M, Wenz F, Stieler F, Bathen B, Mai SK, Wolff R, Hänggi D, Blanck O, Giordano FA. Postoperative stereotactic radiosurgery and hypofractionated radiotherapy for brain metastases using Gamma Knife and CyberKnife: a dual-center analysis. J Neurosurg Sci 2024; 68:22-30. [PMID: 32031357 DOI: 10.23736/s0390-5616.20.04830-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
BACKGROUND Postoperative stereotactic radiosurgery (SRS) and hypofractionated stereotactic radiotherapy (hFSRT) to tumor cavities is emerging as a new standard of care after resection of brain metastases. Both Gamma Knife (GK) and CyberKnife (CK) are modalities commonly used for stereotactic radiotherapy, but fractional schemes are not consistent. The objective of this study was to evaluate outcomes in patients receiving postoperative stereotactic radiotherapy of resected brain metastases (BM) using different fractionation schedules and modalities in two large centers. METHODS Patients with newly diagnosed BM who underwent postoperative SRS or hFSRT with either GK or CK at two large cancer centers were retrospectively evaluated. We analyzed local control (LC), regional control (RC) and overall survival (OS). RESULTS From April 14th to May 18th, 2020, 79 patients with 81 resection cavities were treated. Forty-seven patients (59.5%) received GK and 32 patients (40.5%) received CK treatment. Fifty-four cavities (66.7%) were treated with hFSRT and 27 (33.3%) with SRS. The most common hFSRT and SRS scheme was 3x10 Gy and 1x16 Gy, respectively. Median OS was 11.7 months with survival rates of 44.7% at 1 year and 18.5% at 2 years. LC was 83.3% after 1 year. Median time to regional progression was 12.0 months with RC rates of 61.1% at 6 months and 41.0% at 12 months. There was no difference in OS, LC or RC between GK and CK treatments or SRS and hFSRT. CONCLUSIONS Both SRS and hFSRT provide high local control rates in resected BM regardless of the applied modality.
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Affiliation(s)
- Jens Kübler
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Michael Wester-Ebbinghaus
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Florian Stieler
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Bastian Bathen
- Saphir Radiosurgery Center Frankfurt, Frankfurt am Main, Germany
- Department of Radiation Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Sabine K Mai
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Robert Wolff
- Saphir Radiosurgery Center Frankfurt, Frankfurt am Main, Germany
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Oliver Blanck
- Saphir Radiosurgery Center Frankfurt, Frankfurt am Main, Germany
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany -
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Upadhyay R, Ayan AS, Jain S, Klamer BG, Perlow HK, Zoller W, Blakaj DM, Beyer S, Grecula J, Arnett A, Thomas E, Chakravarti A, Raval RR, Palmer JD. Dose-Volume Tolerance of the Brain and Predictors of Radiation Necrosis After 3-Fraction Radiosurgery for Brain Metastases: A Large Single-Institutional Analysis. Int J Radiat Oncol Biol Phys 2024; 118:275-284. [PMID: 37574170 DOI: 10.1016/j.ijrobp.2023.07.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/26/2023] [Accepted: 07/29/2023] [Indexed: 08/15/2023]
Abstract
PURPOSE Stereotactic radiosurgery (SRS) is the current standard of care in patients with brain metastases and controlled extracranial disease. Radiation necrosis (RN) is the dose-limiting side effect of SRS, but the dose constraints especially for fractionated SRS remain poorly defined. We assessed the risk of RN after 3-fraction SRS with a goal to identify specific dose-volume constraints associated with grade 3 or higher RN (G3RN). METHODS AND MATERIALS A single-institutional retrospective review of patients treated with 3-fraction SRS was performed. The primary endpoint was G3RN, which was defined as severe symptoms with evidence of necrosis on magnetic resonance imaging with perfusion and/or biopsy confirmation. Tissue volume around each target lesion was contoured, and volumetric doses per lesion were recorded. Logistic regression models were used to estimate the relationship between RN and each volumetric dose, and normal tissue complication probability modeling was performed using a modified Lyman-Kutcher-Burman model. RESULTS From 2015 to 2021, 434 patients underwent 539 courses of linear accelerator-based SRS; 2518 lesions were treated. Median SRS dose was 24 Gy. Median follow-up after SRS was 7.9 months, and the median overall survival was 9 months. A total of 93 patients (17.2%) and 123 lesions (4.9%) developed any RN. Forty-two patients (7.8%) and 57 lesions (2.3%) developed G3RN. On logistic regression, V20 and V23 were best predictors of any grade RN and G3RN, respectively, with cutoff values of 4 cc, 10 cc, and 20 cc associated with <5%, <7.5%, and <10% risk of any RN, respectively, and V23 < 15 cc associated with <5% risk of G3RN. With constrained optimization of the normal tissue complication probability Lyman-Kutcher-Burman model for G3RN, we obtained a TD50 (uniform dose resulting in a 50% complication risk) of 31.4 Gy (95% CI, 27.8-35.1 Gy). CONCLUSIONS In patients receiving 3-fraction SRS, G3RN was seen in 7.8% of patients, and 2.3% of the lesions were treated. V20 and V23 were the most robust dosimetric parameters associated with RN. Further studies evaluating the outcomes and RN in patients treated with fractionated SRS compared with single-fraction SRS are warranted.
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Affiliation(s)
- Rituraj Upadhyay
- Department of Radiation Oncology, Ohio State University James Cancer Center, Columbus, Ohio
| | - Ahmet S Ayan
- Division of Radiation Physics, Department of Radiation Oncology, Ohio State University James Cancer Center, Columbus, Ohio
| | - Sagarika Jain
- Division of Radiation Physics, Department of Radiation Oncology, Ohio State University James Cancer Center, Columbus, Ohio
| | - Brett G Klamer
- Center for Biostatistics, Ohio State University, Columbus, Ohio
| | - Haley K Perlow
- Department of Radiation Oncology, Ohio State University James Cancer Center, Columbus, Ohio
| | - Wesley Zoller
- Department of Radiation Oncology, Ohio State University James Cancer Center, Columbus, Ohio
| | - Dukagjin M Blakaj
- Department of Radiation Oncology, Ohio State University James Cancer Center, Columbus, Ohio
| | - Sasha Beyer
- Department of Radiation Oncology, Ohio State University James Cancer Center, Columbus, Ohio
| | - John Grecula
- Department of Radiation Oncology, Ohio State University James Cancer Center, Columbus, Ohio
| | - Andrea Arnett
- Department of Radiation Oncology, Ohio State University James Cancer Center, Columbus, Ohio
| | - Evan Thomas
- Department of Radiation Oncology, Ohio State University James Cancer Center, Columbus, Ohio
| | - Arnab Chakravarti
- Department of Radiation Oncology, Ohio State University James Cancer Center, Columbus, Ohio
| | - Raju R Raval
- Department of Radiation Oncology, Ohio State University James Cancer Center, Columbus, Ohio
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University James Cancer Center, Columbus, Ohio.
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Chambrelant I, Jarnet D, Bou-Gharios J, Le Fèvre C, Kuntz L, Antoni D, Jenny C, Noël G. Stereotactic Radiation Therapy of Single Brain Metastases: A Literature Review of Dosimetric Studies. Cancers (Basel) 2023; 15:3937. [PMID: 37568753 PMCID: PMC10416831 DOI: 10.3390/cancers15153937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/29/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023] Open
Abstract
Stereotactic radiotherapy (SRT) plays a major role in treating brain metastases (BMs) and can be delivered using various equipment and techniques. This review aims to identify the dosimetric factors of each technique to determine whether one should be preferred over another for single BMs treatment. A systematic literature review on articles published between January 2015 and January 2022 was conducted using the MEDLINE and ScienceDirect databases, following the PRISMA methodology, using the keywords "dosimetric comparison" and "brain metastases". The included articles compared two or more SRT techniques for treating single BM and considered at least two parameters among: conformity (CI), homogeneity (HI) and gradient (GI) indexes, delivery treatment time, and dose-volume of normal brain tissue. Eleven studies were analyzed. The heterogeneous lesions along with the different definitions of dosimetric indexes rendered the studied comparison almost unattainable. Gamma Knife (GK) and volumetric modulated arc therapy (VMAT) provide better CI and GI and ensure the sparing of healthy tissue. To conclude, it is crucial to optimize dosimetric indexes to minimize radiation exposure to healthy tissue, particularly in cases of reirradiation. Consequently, there is a need for future well-designed studies to establish guidelines for selecting the appropriate SRT technique based on the treated BMs' characteristics.
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Affiliation(s)
- Isabelle Chambrelant
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), UNICANCER, Paul Strauss Comprehensive Cancer Center, 67200 Strasbourg, France; (I.C.); (C.L.F.); (L.K.); (D.A.)
| | - Delphine Jarnet
- Department of Medical Physics, Institut de Cancérologie Strasbourg Europe (ICANS), UNICANCER, Paul Strauss Comprehensive Cancer Center, 67200 Strasbourg, France;
| | - Jolie Bou-Gharios
- Radiobiology Laboratory, Institut de Cancérologie Strasbourg Europe (ICANS), Paul Strauss Comprehensive Cancer Center, 67200 Strasbourg, France;
| | - Clara Le Fèvre
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), UNICANCER, Paul Strauss Comprehensive Cancer Center, 67200 Strasbourg, France; (I.C.); (C.L.F.); (L.K.); (D.A.)
| | - Laure Kuntz
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), UNICANCER, Paul Strauss Comprehensive Cancer Center, 67200 Strasbourg, France; (I.C.); (C.L.F.); (L.K.); (D.A.)
| | - Delphine Antoni
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), UNICANCER, Paul Strauss Comprehensive Cancer Center, 67200 Strasbourg, France; (I.C.); (C.L.F.); (L.K.); (D.A.)
| | - Catherine Jenny
- Department of Medical Physics, AP-HP, Sorbonne Université, CEDEX 13, 75651 Paris, France;
| | - Georges Noël
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), UNICANCER, Paul Strauss Comprehensive Cancer Center, 67200 Strasbourg, France; (I.C.); (C.L.F.); (L.K.); (D.A.)
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7
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Layer JP, Hamed M, Potthoff AL, Dejonckheere CS, Layer K, Sarria GR, Scafa D, Koch D, Köksal M, Kugel F, Grimmer M, Holz JA, Zeyen T, Friker LL, Borger V, Schmeel FC, Weller J, Hölzel M, Schäfer N, Garbe S, Forstbauer H, Giordano FA, Herrlinger U, Vatter H, Schneider M, Schmeel LC. Outcome assessment of intraoperative radiotherapy for brain metastases: results of a prospective observational study with comparative matched-pair analysis. J Neurooncol 2023; 164:107-116. [PMID: 37477822 PMCID: PMC10462513 DOI: 10.1007/s11060-023-04380-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/20/2023] [Indexed: 07/22/2023]
Abstract
PURPOSE Intraoperative radiation therapy (IORT) is an emerging alternative to adjuvant stereotactic external beam radiation therapy (EBRT) following resection of brain metastases (BM). Advantages of IORT include an instant prevention of tumor regrowth, optimized dose-sparing of adjacent healthy brain tissue and immediate completion of BM treatment, allowing an earlier admission to subsequent systemic treatments. However, prospective outcome data are limited. We sought to assess long-term outcome of IORT in comparison to EBRT. METHODS A total of 35 consecutive patients, prospectively recruited within a study registry, who received IORT following BM resection at a single neuro-oncological center were evaluated for radiation necrosis (RN) incidence rates, local control rates (LCR), distant brain progression (DBP) and overall survival (OS) as long-term outcome parameters. The 1 year-estimated OS and survival rates were compared in a balanced comparative matched-pair analysis to those of our institutional database, encompassing 388 consecutive patients who underwent adjuvant EBRT after BM resection. RESULTS The median IORT dose was 30 Gy prescribed to the applicator surface. A 2.9% RN rate was observed. The estimated 1 year-LCR was 97.1% and the 1 year-DBP-free survival 73.5%. Median time to DBP was 6.4 (range 1.7-24) months in the subgroup of patients experiencing intracerebral progression. The median OS was 17.5 (0.5-not reached) months with a 1 year-survival rate of 61.3%, which did not not significantly differ from the comparative cohort (p = 0.55 and p = 0.82, respectively). CONCLUSION IORT is a safe and effective fast-track approach following BM resection, with comparable long-term outcomes as adjuvant EBRT.
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Affiliation(s)
- Julian P Layer
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
- Institute of Experimental Oncology, University Hospital Bonn, Bonn, Germany.
| | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | | | - Cas S Dejonckheere
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Katharina Layer
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Davide Scafa
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - David Koch
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Mümtaz Köksal
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Fabian Kugel
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Molina Grimmer
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Jasmin A Holz
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Thomas Zeyen
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Lea L Friker
- Institute of Experimental Oncology, University Hospital Bonn, Bonn, Germany
- Institute of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - F Carsten Schmeel
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Johannes Weller
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Michael Hölzel
- Institute of Experimental Oncology, University Hospital Bonn, Bonn, Germany
| | - Niklas Schäfer
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Stephan Garbe
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | | | - Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, Mannheim, Germany
- DKFZ-Hector Cancer Institute of the University Medical Center Mannheim, Mannheim, Germany
- Mannheim Institute of Intelligent Systems in Medicine (MIISM), Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ulrich Herrlinger
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | | | - L Christopher Schmeel
- Department of Radiation Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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8
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Waltenberger M, Bernhardt D, Diehl C, Gempt J, Meyer B, Straube C, Wiestler B, Wilkens JJ, Zimmer C, Combs SE. Hypofractionated stereotactic radiotherapy (HFSRT) versus single fraction stereotactic radiosurgery (SRS) to the resection cavity of brain metastases after surgical resection (SATURNUS): study protocol for a randomized phase III trial. BMC Cancer 2023; 23:709. [PMID: 37516835 PMCID: PMC10385881 DOI: 10.1186/s12885-023-11202-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 07/19/2023] [Indexed: 07/31/2023] Open
Abstract
BACKGROUND The brain is a common site for cancer metastases. In case of large and/or symptomatic brain metastases, neurosurgical resection is performed. Adjuvant radiotherapy is a standard procedure to minimize the risk of local recurrence and is increasingly performed as local stereotactic radiotherapy to the resection cavity. Both hypofractionated stereotactic radiotherapy (HFSRT) and single fraction stereotactic radiosurgery (SRS) can be applied in this case. Although adjuvant stereotactic radiotherapy to the resection cavity is widely used in clinical routine and recommended in international guidelines, the optimal fractionation scheme still remains unclear. The SATURNUS trial prospectively compares adjuvant HFSRT with SRS and seeks to detect the superiority of HFSRT over SRS in terms of local tumor control. METHODS In this single center two-armed randomized phase III trial, adjuvant radiotherapy to the resection cavity of brain metastases with HFSRT (6 - 7 × 5 Gy prescribed to the surrounding isodose) is compared to SRS (1 × 12-20 Gy prescribed to the surrounding isodose). Patients are randomized 1:1 into the two different treatment arms. The primary endpoint of the trial is local control at the resected site at 12 months. The trial is based on the hypothesis that HFSRT is superior to SRS in terms of local tumor control. DISCUSSION Although adjuvant stereotactic radiotherapy after resection of brain metastases is considered standard of care treatment, there is a need for further prospective research to determine the optimal fractionation scheme. To the best of our knowledge, the SATURNUS study is the only randomized phase III study comparing different regimes of postoperative stereotactic radiotherapy to the resection cavity adequately powered to detect the superiority of HFSRT regarding local control. TRIAL REGISTRATION The study was retrospectively registered with ClinicalTrials.gov, number NCT05160818, on December 16, 2021. The trial registry record is available on https://clinicaltrials.gov/study/NCT05160818 . The presented protocol refers to version V1.3 from March 21, 2021.
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Affiliation(s)
- Maria Waltenberger
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany.
| | - Denise Bernhardt
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Christian Diehl
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany
| | | | - Benedikt Wiestler
- Institute of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany
| | - Jan J Wilkens
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany
| | - Claus Zimmer
- Institute of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum, Ingolstädter Landstraße 1, 85764, Neuherberg, Germany
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9
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Diehl CD, Giordano FA, Grosu AL, Ille S, Kahl KH, Onken J, Rieken S, Sarria GR, Shiban E, Wagner A, Beck J, Brehmer S, Ganslandt O, Hamed M, Meyer B, Münter M, Raabe A, Rohde V, Schaller K, Schilling D, Schneider M, Sperk E, Thomé C, Vajkoczy P, Vatter H, Combs SE. Opportunities and Alternatives of Modern Radiation Oncology and Surgery for the Management of Resectable Brain Metastases. Cancers (Basel) 2023; 15:3670. [PMID: 37509330 PMCID: PMC10377800 DOI: 10.3390/cancers15143670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Postsurgical radiotherapy (RT) has been early proven to prevent local tumor recurrence, initially performed with whole brain RT (WBRT). Subsequent to disadvantageous cognitive sequalae for the patient and the broad distribution of modern linear accelerators, focal irradiation of the tumor has omitted WBRT in most cases. In many studies, the effectiveness of local RT of the resection cavity, either as single-fraction stereotactic radiosurgery (SRS) or hypo-fractionated stereotactic RT (hFSRT), has been demonstrated to be effective and safe. However, whereas prospective high-level incidence is still lacking on which dose and fractionation scheme is the best choice for the patient, further ablative techniques have come into play. Neoadjuvant SRS (N-SRS) prior to resection combines straightforward target delineation with an accelerated post-surgical phase, allowing an earlier start of systemic treatment or rehabilitation as indicated. In addition, low-energy intraoperative RT (IORT) on the surgical bed has been introduced as another alternative to external beam RT, offering sterilization of the cavity surface with steep dose gradients towards the healthy brain. This consensus paper summarizes current local treatment strategies for resectable brain metastases regarding available data and patient-centered decision-making.
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Affiliation(s)
- Christian D Diehl
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 80336 München, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Anca-L Grosu
- Department of Radiation Oncology, University Medical Center, Medical Faculty, 79106 Freiburg, Germany
| | - Sebastian Ille
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Klaus-Henning Kahl
- Department of Radiation Oncology, University Medical Center Augsburg, 86156 Augsburg, Germany
| | - Julia Onken
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
- Berlin Institute of Health, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- German Cancer Consortium (DKTK), Partner Site Berlin, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, 37075 Göttingen, Germany
- Comprehensive Cancer Center Niedersachsen (CCC-N), 37075 Göttingen, Germany
| | - Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Ehab Shiban
- Department of Neurosurgery, University Medical Center Augsburg, 86156 Augsburg, Germany
| | - Arthur Wagner
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Jürgen Beck
- Department of Neurosurgery, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Stefanie Brehmer
- Department of Neurosurgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Oliver Ganslandt
- Neurosurgical Clinic, Klinikum Stuttgart, 70174 Stuttgart, Germany
| | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Marc Münter
- Department of Radiation Oncology, Klinikum Stuttgart Katharinenhospital, 70174 Stuttgart, Germany
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Veit Rohde
- Department of Neurosurgery, Universitätsmedizin Göttingen, 37075 Göttingen, Germany
| | - Karl Schaller
- Department of Neurosurgery, University of Geneva Medical Center & Faculty of Medicine, 1211 Geneva, Switzerland
| | - Daniela Schilling
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Elena Sperk
- Mannheim Cancer Center, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 80336 München, Germany
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10
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Calderon B, Vazquez L, Belkacemi M, Pourel N. Stereotactic radiotherapy for brain metastases: predictive factors of radionecrosis. Eur J Med Res 2023; 28:233. [PMID: 37443046 DOI: 10.1186/s40001-023-01178-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
PURPOSE Stereotactic radiotherapy (SRT) is a highly effective approach and represents the current standard of treatment for patients with limited number of brain metastasis (BM). SRT is generally well tolerated but can sometimes lead to radionecrosis (RN). The aim of this study was to identify predictive factors of radionecrosis related to SRT for brain metastasis. METHODS This retrospective observational cohort study included patients who underwent SRT in the Institut Sainte Catherine between January 1st, 2017 and December 31st, 2020 for the treatment of brain metastasis from any cancer. Individual data and particularly signs of radionecrosis (clinical, imaging, anatomopathological) were collected from electronic medical records. Radionecrosis was defined as the occurrence on MRI of contrast-enhancing necrotic lesions, surrounded by edema, occurring at least 6 months after SRT and localized within fields of irradiation. RESULTS 123 patients were included; median age was 66 years. 17 patients (11.8%) developed radionecrosis after a median follow up of 418.5 days [63;1498]. Predictive factors of radionecrosis in multivariate analysis were age under 66 years with a sensitivity of 77% and a specificity of 56%. No other factor as the presence of comorbidities, the number of irradiated metastases, the PTV volume or the volume of irradiated healthy brain were predictive of radionecrosis. CONCLUSION Age at treatment initiation and tumor location seems to be correlated with radionecrosis in patients with brain metastasis treated with SRT. These elements could be useful to adapted radiation therapy.
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Affiliation(s)
- Benoît Calderon
- Institut Sainte Catherine, 250 Chemin Des Baigne-Pieds, 84000, Avignon, France
| | - Léa Vazquez
- Institut Sainte Catherine, 250 Chemin Des Baigne-Pieds, 84000, Avignon, France.
| | | | - Nicolas Pourel
- Institut Sainte Catherine, 250 Chemin Des Baigne-Pieds, 84000, Avignon, France
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11
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Beddok A, Loi M, Rivin Del Campo E, Dumas JL, Orthuon A, Créhange G, Huguet F. [Limits of dose constraint definition for organs at risk specific to stereotactic radiotherapy]. Cancer Radiother 2023:S1278-3218(23)00067-7. [PMID: 37208260 DOI: 10.1016/j.canrad.2023.01.006] [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: 11/23/2022] [Revised: 01/24/2023] [Accepted: 01/30/2023] [Indexed: 05/21/2023]
Abstract
Stereotactic radiotherapy is a very hypofractionated radiotherapy (>7.5Gy per fraction), and therefore is more likely to induce late toxicities than conventional normofractionated irradiations. The present study examines four frequent and potentially serious late toxicities: brain radionecrosis, radiation pneumonitis, radiation myelitis, and radiation-induced pelvic toxicities. The critical review focuses on the toxicity scales, the definition of the dose constrained volume, the dosimetric parameters, and the non-dosimetric risk factors. The most commonly used toxicity scales remain: RTOG/EORTC or common terminology criteria for adverse events (CTCAE). The definition of organ-at-risk volume requiring protection is often controversial, which limits the comparability of studies and the possibility of accurate dose constraints. Nevertheless, for the brain, whatever the indication (arteriovenous malformation, benign tumor, metastasis of solid tumors...), the association between the volume of brain receiving 12Gy (V12Gy) and the risk of cerebral radionecrosis is well established for both single and multi-fraction stereotactic irradiation. For the lung, the average dose received by both lungs and the V20 seem to correlate well with the risk of radiation-induced pneumonitis. For the spinal cord, the maximum dose is the most consensual parameter. Clinical trial protocols are useful for nonconsensual dose constraints. Non-dosimetric risk factors should be considered when validating the treatment plan.
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Affiliation(s)
- A Beddok
- Institut Curie, université PSL, université Paris Saclay, Inserm, Lito U1288, 75005 Orsay, France; Service de radiothérapie oncologique, institut Curie, université PSL, Paris, France.
| | - M Loi
- Radiotherapy Department, University of Florence, Florence, Italie
| | - E Rivin Del Campo
- Service de radiothérapie oncologique, hôpital Tenon, AP-HP, Sorbonne Université, 75020 Paris, France; Faculté de médecine, Sorbonne Université, 75013 Paris, France
| | - J-L Dumas
- Service de radiothérapie oncologique, institut Curie, université PSL, Paris, France
| | - A Orthuon
- Service de radiothérapie oncologique, hôpital Tenon, AP-HP, Sorbonne Université, 75020 Paris, France
| | - G Créhange
- Institut Curie, université PSL, université Paris Saclay, Inserm, Lito U1288, 75005 Orsay, France; Service de radiothérapie oncologique, institut Curie, université PSL, Paris, France
| | - F Huguet
- Service de radiothérapie oncologique, hôpital Tenon, AP-HP, Sorbonne Université, 75020 Paris, France; Faculté de médecine, Sorbonne Université, 75013 Paris, France
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12
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Layer JP, Layer K, Sarria GR, Röhner F, Dejonckheere CS, Friker LL, Zeyen T, Koch D, Scafa D, Leitzen C, Köksal M, Schmeel FC, Schäfer N, Landsberg J, Hölzel M, Herrlinger U, Schneider M, Giordano FA, Schmeel LC. Five-Fraction Stereotactic Radiotherapy for Brain Metastases-A Retrospective Analysis. Curr Oncol 2023; 30:1300-1313. [PMID: 36826062 PMCID: PMC9955428 DOI: 10.3390/curroncol30020101] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/10/2023] [Accepted: 01/15/2023] [Indexed: 01/18/2023] Open
Abstract
PURPOSE To determine the safety and outcome profile of five-fraction stereotactic radiotherapy (FSRT) for brain metastases (BM), either as a definitive or adjuvant treatment. METHODS We assessed clinical data of patients receiving five fractions of 7 Gy each (cumulative physical dose of 35 Gy) to BM or surgical cavities. The primary endpoints were toxicity and radiation necrosis (RN) rates. Secondary endpoints were 1-year cumulative local control rate (LCR) and estimated overall survival (OS). RESULTS A total of 36 eligible patients receiving FSRT to a total of 49 targets were identified and included. The median follow up was 9 (1.1-56.2) months. The median age was 64.5 (34-92) years, the median ECOG score was 1, and the median Diagnostic-Specific Graded Prognostic Assessment (DS-GPA) score was 2. Treatment was well tolerated and there were no grade 3 adverse events or higher. The overall RN rate was 14.3% and the median time to RN was 12.9 (1.8-23.8) months. RN occurrence was associated with immunotherapy, young age (≤45 years), and large PTV. The cumulative 1-year local control rate was 83.1% and the estimated median local progression free-survival was 18.8 months. The estimated median overall survival was 11 (1.1-56.2) months and significantly superior in those patients presenting with RN. CONCLUSIONS FSRT with 5 × 7 Gy represents a feasible, safe, and efficient fast track approach of intensified FSRT with acceptable LC and comparable RN rates for both the adjuvant and definitive RT settings.
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Affiliation(s)
- Julian P. Layer
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
- Institute of Experimental Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Katharina Layer
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Gustavo R. Sarria
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Fred Röhner
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Cas S. Dejonckheere
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Lea L. Friker
- Institute of Experimental Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
- Institute of Neuropathology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Thomas Zeyen
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany
| | - David Koch
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Davide Scafa
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Christina Leitzen
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Mümtaz Köksal
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | | | - Niklas Schäfer
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany
| | - Jennifer Landsberg
- Department of Dermatology, University Hospital Bonn, 53127 Bonn, Germany
| | - Michael Hölzel
- Institute of Experimental Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Ulrich Herrlinger
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Frank A. Giordano
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, 68167 Mannheim, Germany
| | - Leonard Christopher Schmeel
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
- Correspondence:
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13
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Devan SP, Luo G, Jiang X, Xie J, Dean D, Johnson LS, Morales-Paliza M, Harmsen H, Xu J, Kirschner AN. Rodent Model of Brain Radionecrosis using Clinical LINAC-based Stereotactic Radiosurgery. Adv Radiat Oncol 2022; 7:101014. [PMID: 36060637 PMCID: PMC9436710 DOI: 10.1016/j.adro.2022.101014] [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: 12/21/2021] [Accepted: 06/21/2022] [Indexed: 11/18/2022] Open
Abstract
Purpose Methods and Materials Results Conclusions
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Affiliation(s)
- Sean P. Devan
- Chemical and Physical Biology Program, Vanderbilt University, Nashville, Tennessee
- Vanderbilt University Institute of Imaging Science
| | | | - Xiaoyu Jiang
- Vanderbilt University Institute of Imaging Science
- Radiology and Radiologic Sciences
| | - Jingping Xie
- Vanderbilt University Institute of Imaging Science
| | | | | | | | - Hannah Harmsen
- Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Junzhong Xu
- Vanderbilt University Institute of Imaging Science
- Radiology and Radiologic Sciences
| | - Austin N. Kirschner
- Departments of Radiation Oncology
- Corresponding author: Austin N. Kirschner, MD, PhD
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Kahl KH, Balagiannis N, Höck M, Schill S, Roushan Z, Shiban E, Müller H, Grossert U, Konietzko I, Sommer B, Maurer CJ, Berlis A, Heidecke V, Janzen T, Stüben G. Intraoperative radiotherapy with low-energy x-rays after neurosurgical resection of brain metastases-an Augsburg University Medical Center experience. Strahlenther Onkol 2021; 197:1124-1130. [PMID: 34415358 PMCID: PMC8604815 DOI: 10.1007/s00066-021-01831-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/18/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE External-beam radiotherapy (EBRT) is the predominant method for localized brain radiotherapy (LBRT) after resection of brain metastases (BM). Intraoperative radiotherapy (IORT) with 50-kV x‑rays is an alternative way to focally irradiate the resection cavity after BM surgery, with the option of shortening the overall treatment time and limiting normal tissue irradiation. METHODS We retrospectively analyzed the outcomes of all patients who underwent neurosurgical resection of BM and 50-kV x‑ray IORT between 2013 and 2020 at Augsburg University Medical Center. RESULTS We identified 40 patients with 44 resected BM treated with 50-kV x‑ray IORT. Median diameter of the resected metastases was 2.8 cm (range 1.5-5.9 cm). Median applied dose was 20 Gy. All patients received standardized follow-up (FU) including 3‑monthly MRI of the brain. Mean FU was 14.4 months, with a median MRI FU for alive patients of 12.2 months. Median overall survival (OS) of all treated patients was 26.4 months (estimated 1‑year OS 61.6%). The observed local control (LC) rate of the resection cavity was 88.6% (estimated 1‑year LC 84.3%). Distant brain control (DC) was 47.5% (estimated 1‑year DC 33.5%). Only 25% of all patients needed WBI in the further course of disease. The observed radionecrosis rate was 2.5%. CONCLUSION IORT with 50-kV x‑rays is a safe and appealing way to apply LBRT after neurosurgical resection of BM, with low toxicity and excellent LC. Close MRI FU is paramount to detect distant brain failure (DBF) early.
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Affiliation(s)
- Klaus-Henning Kahl
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Augsburg, Stenglinstraße 2, 86156 Augsburg, Germany
| | - Nikolaos Balagiannis
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Augsburg, Stenglinstraße 2, 86156 Augsburg, Germany
| | - Michael Höck
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Augsburg, Stenglinstraße 2, 86156 Augsburg, Germany
| | - Sabine Schill
- Medizinische Physik und Strahlenschutz, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Zoha Roushan
- Medizinische Physik und Strahlenschutz, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Ehab Shiban
- Klinik für Neurochirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Heiko Müller
- Klinik für Neurochirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Ute Grossert
- Klinik für Neurochirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Ina Konietzko
- Klinik für Neurochirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Björn Sommer
- Klinik für Neurochirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Christoph J. Maurer
- Klinik für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Ansgar Berlis
- Klinik für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Volkmar Heidecke
- Klinik für Neurochirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Tilman Janzen
- Medizinische Physik und Strahlenschutz, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Georg Stüben
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Augsburg, Stenglinstraße 2, 86156 Augsburg, Germany
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15
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Intraoperative radiotherapy for glioblastoma: A systematic review of techniques and outcomes. J Clin Neurosci 2021; 93:36-41. [PMID: 34656258 DOI: 10.1016/j.jocn.2021.08.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/12/2021] [Accepted: 08/21/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Despite multimodality treatment, the prognosis of glioblastoma (GBM) has remained poor. Intraoperative radiation therapy (IORT) offers additional local control by directly applying a radiation source to the resection margin, where most recurrences occur. METHODS We performed a systematic review on the oncologic outcomes and toxicities of IORT for GBM in the era of modern external beam radiation therapy (EBRT) and chemotherapy with temozolamide. RESULTS Four studies representing 123 patients were included. Majority (81%) were newly diagnosed, and gross total resection was reported in 13-80% of cases. IORT modalities included electrons from a linear accelerator (LINAC) and photons from a 50-kV x-ray device. Median doses were from 12.5 to 20 Gy for electron-based studies and 10-25 Gy for photon-based studies. Adjuvant treatment consisted of 46-60 Gy post-operative EBRT in electron-based studies and the Stupp protocol in photon-based studies. Complications included radiation necrosis (2.8-33%), infection, hematoma, perilesional edema, and wound dehiscence. Median time to local recurrence was 9.9-16 months and the reported overall progression-free survival was 11.2-12.2 months. Median overall survival was 13-14.2 months for the electron-based studies and 13.8-18 months for the photon-based studies. CONCLUSION IORT resulted in improved local control and comparable overall survival rates with the Stupp protocol. Although photon-based IORT had better results than electron IORT, this may be due to improvements in other forms of adjuvant treatment rather than the IORT modality itself. The overall effect of IORT on GBM treatment is still inconclusive due to the small number of patients and heterogeneous reporting of data.
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Gallo J, Garimall S, Shanker M, Castelli J, Watkins T, Olson S, Huo M, Foote MC, Pinkham MB. Outcomes Following Hypofractionated Stereotactic Radiotherapy to the Cavity After Surgery for Melanoma Brain Metastases. Clin Oncol (R Coll Radiol) 2021; 34:179-186. [PMID: 34642065 DOI: 10.1016/j.clon.2021.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 09/05/2021] [Accepted: 09/21/2021] [Indexed: 11/18/2022]
Abstract
AIMS Hypofractionated stereotactic radiotherapy (HSRT) to the cavity after surgical resection of brain metastases improves local control. Most reported cohorts include few patients with melanoma, a population known to have high rates of recurrence and neurological death. We aimed to assess outcomes in patients with melanoma brain metastases who received HSRT after surgery at two Australian institutions. MATERIALS AND METHODS A retrospective analysis was carried out including patients treated between January 2012 and May 2020. HSRT was recommended for patients with melanoma brain metastases at high risk of local recurrence after surgery. Treatment was delivered using appropriately commissioned linear accelerators. Routine follow-up included surveillance magnetic resonance imaging brain every 3 months for at least 2 years. Primary outcomes were overall survival, local control, incidence of radiological radionecrosis and symptomatic radionecrosis. RESULTS There were 63 cavities identified in 57 patients. The most common HSRT dose prescriptions were 24 Gy in three fractions and 27.5 Gy in five fractions. The median follow-up was 32 months in survivors. Local control was 90% at 1 year, 83% at 2 years and 76% at 3 years. Subtotal brain metastases resection (hazard ratio 12.5; 95% confidence interval 1.4-111; P = 0.0238) was associated with more local recurrence. Overall survival was 64% at 1 year, 45% at 2 years and 40% at 3 years. There were 10 radiological radionecrosis events (16% of cavities) during the study period, with 5% at 1 year and 8% at 2 years after HSRT. The median time to onset of radiological radionecrosis was 21 months (range 6-56). Of these events, three became symptomatic (5%) during the study period at a median time to onset of 26 months (range 21-32). CONCLUSION Cavity HSRT is associated with high rates of local control in patients with melanoma brain metastases. Subtotal resection strongly predicts for local recurrence after HSRT. Symptomatic radionecrosis occurred in 5% of cavities but increased to 8% of longer-term survivors.
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Affiliation(s)
- J Gallo
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
| | - S Garimall
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - M Shanker
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Princess Alexandra Hospital Research Foundation, Woolloongabba, Queensland, Australia
| | - J Castelli
- Icon Cancer Centre, Greenslopes Private Hospital, Greenslopes, Queensland, Australia
| | - T Watkins
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - S Olson
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - M Huo
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - M C Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Icon Cancer Centre, Greenslopes Private Hospital, Greenslopes, Queensland, Australia
| | - M B Pinkham
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Icon Cancer Centre, Greenslopes Private Hospital, Greenslopes, Queensland, Australia
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Rogers S, Stauffer A, Lomax N, Alonso S, Eberle B, Gomez Ordoñez S, Lazeroms T, Kessler E, Brendel M, Schwyzer L, Riesterer O. Five fraction stereotactic radiotherapy after brain metastasectomy: a single-institution experience and literature review. J Neurooncol 2021; 155:35-43. [PMID: 34546498 DOI: 10.1007/s11060-021-03840-5] [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: 07/31/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The outcomes of five fraction stereotactic radiotherapy (hfSRT) following brain metastasectomy were evaluated and compared with published series. METHODS 30 Gy in 5 fractions HfSRT prescribed to the surgical cavity was reduced to 25 Gy if the volume of 'brain-GTV' receiving 20 Gy exceeded 20 cm3. Endpoints were local recurrence, nodular leptomeningeal recurrence, new brain metastases and radionecrosis. The literature was searched for reports of clinical and dosimetric outcomes following postoperative hfSRT in 3-5 fractions. RESULTS 39 patients with 40 surgical cavities were analyzed. Cavity local control rate at 1 year was 33/40 (82.5%). 3 local failures followed 30 Gy/5 fractions and 4 with 25 Gy/5 fractions. The incidence of leptomeningeal disease (LMD) was 7/40 (17.5%). No grade 3-4 toxicities, particularly no radionecrosis, were reported. The incidence of distant brain metastases was 15/40 (37.5%). The median overall survival was 15 months. Across 13 published series, the weighted mean local control was 83.1% (adjusted for sample size), the mean incidence of LMD was 14.9% (7-34%) and the mean rate of radionecrosis was 10.3% (0-20.6%). CONCLUSION Postoperative hfSRT can be delivered with 25-30 Gy in 5 fractions with efficacy in excess of 82% and no significant toxicity when the dose to 'brain-GTV' does not exceed 20 cm3.
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Affiliation(s)
- S Rogers
- Radiation Oncology Center KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland.
| | - A Stauffer
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - N Lomax
- Radiation Oncology Center KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - S Alonso
- Radiation Oncology Center KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - B Eberle
- Radiation Oncology Center KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - S Gomez Ordoñez
- Radiation Oncology Center KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - T Lazeroms
- Radiation Oncology Center KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - E Kessler
- Radiation Oncology Center KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - M Brendel
- Department of Neuroradiology, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - L Schwyzer
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - O Riesterer
- Radiation Oncology Center KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland.,Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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18
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Risk Factors for Radiation Necrosis in Patients Undergoing Cranial Stereotactic Radiosurgery. Cancers (Basel) 2021; 13:cancers13194736. [PMID: 34638223 PMCID: PMC8507553 DOI: 10.3390/cancers13194736] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 11/26/2022] Open
Abstract
Simple Summary Radiation necrosis is a known complication after stereotactic radiosurgery of intracranial tumors. We evaluated 388 patients who underwent stereotactic radiosurgery at our institution. The most common tumors were metastases (47.2%), followed by vestibular schwannomas (32.2%) and meningiomas (13.4%). 15.7% developed radiation necrosis after a median of 8 months. According to our data, larger tumor diameter (HR 1.065) and higher radiation dose (HR 1.302) were associated with an increased risk of radiation necrosis independently of tumor type. Advanced age was shown to be a risk factor for radiation necrosis only in cases with metastasis (HR 1.066). The data from this study suggest that the development of radiation necrosis is dependent on size and dose, not on the type of the neoplasm. Abstract Purpose: single-staged stereotactic radiosurgery (SRS) is an established part of the multimodal treatment in neuro-oncology. Radiation necrosis after high-dose irradiation is a known complication, but there is a lack of evidence about the risk factors. The aim of this study was to evaluate possible risk factors for radiation necrosis in patients undergoing radiosurgery. Methods: patients treated with radiosurgery between January 2004 and November 2020 were retrospectively analyzed. The clinical data, imaging and medication were gathered from electronic patient records. The largest diameter of the tumors was measured using MRI scans in T1 weighted imaging with gadolinium and the edema in T2 weighted sequences. The diagnosis of a radiation necrosis was established analyzing imaging criteria combined with clinical course or pathologically confirmed by subsequent surgical intervention. Patients developing radiation necrosis detected after SRS were compared to patients without evidence of an overshooting irradiation reaction. Results: 388 patients were included retrospectively, 61 (15.7%) of whom developed a radiation necrosis. Median follow-up was 24 (6–62) months with a radiation necrosis after 8 (6–12) months. The most frequent tumors were metastases in 47.2% of the cases, followed by acoustic neuromas in 32.2% and meningiomas in 13.4%. Seventy-three (18.9%) patients already underwent one or more previous radiosurgical procedures for different lesions. The mean largest diameter of the tumors amounted to 16.3 mm (±6.1 mm). The median—80%—isodose administered was 16 (14–25) Gy. Of the radiation necroses, 25 (43.1%) required treatment, in 23 (39.7%) thereof, medical treatment was applied and in 2 (3.4%) cases, debulking surgery was performed. In this study, significantly more radiation necroses arose in patients with higher doses (HR 1.3 [CI 1.2; 1.5], p < 0.001) leading to a risk increment of over 180% between a radiation isodose of 14 and 20 Gy. The maximum diameter was a second significant risk factor (p = 0.028) with an HR of 1065 for every 1 mm increase in multivariate analysis. Conclusion: large diameter and high doses were reliable independent risk factors leading to more frequent radiation necroses, regardless of tumor type in patients undergoing radiosurgery. Alternative therapeutic procedures may be considered in lesions with large volume and an expected high radiation doses due to the increased risk of developing radiation necrosis.
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19
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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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20
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Kondoh T, Sonoda T. Treatment Options for Leptomeningeal Metastases of Solid Cancers: Literature Review and Personal Experience. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 128:71-84. [PMID: 34191063 DOI: 10.1007/978-3-030-69217-9_8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Leptomeningeal metastases (LM) may complicate the clinical course of any solid cancer or hematological malignancy. Diagnosis of such cases requires a multifaceted approach, including careful evaluation of the clinical history, detailed neurological examination, advanced imaging studies, and related laboratory data analysis. Therapeutic options for management of LM have not been standardized yet. Conventional intrathecal chemotherapy with or without involved-field fractionated radiotherapy has only modest efficacy, and the prognosis of most patients remains grim. Therefore, development of new, more aggressive multimodal treatment strategies is definitely needed. Immune checkpoint inhibitors-in particular, molecular targeted therapy-have demonstrated promising results in selected groups of patients. There may be an important role for stereotactic radiosurgery as well. Because organization of prospective randomized multi-institutional trials on treatment of LM of solid cancers may be problematic, practical guidelines for optimal therapeutic strategies in such cases should be established on the basis of integrated results of small-scale prospective and retrospective studies.
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Affiliation(s)
- Takeshi Kondoh
- Department of Neurosurgery, Shinsuma General Hospital, Kobe, Japan.
| | - Takashi Sonoda
- Department of Oncology, Meiwa Hospital, Nishinomiya, Japan
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21
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McCutcheon IE. Stereotactic Radiosurgery to Prevent Local Recurrence of Brain Metastasis After Surgery: Neoadjuvant Versus Adjuvant. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 128:85-100. [PMID: 34191064 DOI: 10.1007/978-3-030-69217-9_9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Over the past 15-20 years, stereotactic radiosurgery (SRS) has become the dominant method for treating patients with brain metastases (BM). The role of surgery for management of large tumors also remains important. Combining these two treatment modalities may well achieve the best local control, safety, and symptomatic relief in cases of neoplasms for which resection is desirable. After 10 years of retrospective studies that suggested patients might do better if surgery were followed by early adjuvant SRS, a prospective, randomized, controlled trial was conducted to compare such treatment with postoperative observation after tumor removal, and it showed significantly better local control in the former cohort, especially in smaller lesions, but no difference in overall survival. On the other hand, in the past 5 years, some groups have argued that neoadjuvant SRS before resection of BM might be superior to adjuvant SRS, while no clinical trial has yet been concluded that compares these two treatment strategies. For now, adjuvant and neoadjuvant SRS show evidence of utility in achieving better local control after surgical removal of BM in comparison with surgery alone, but no specific guidelines exist favoring one method over the other, and both should be considered beneficial in clinical care.
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Affiliation(s)
- Ian E McCutcheon
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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22
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Guénolé M, Lucia F, Bourbonne V, Dissaux G, Reygagne E, Goasduff G, Pradier O, Schick U. Impact of concomitant systemic treatments on toxicity and intracerebral response after stereotactic radiotherapy for brain metastases. BMC Cancer 2020; 20:991. [PMID: 33050910 PMCID: PMC7557085 DOI: 10.1186/s12885-020-07491-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/04/2020] [Indexed: 12/31/2022] Open
Abstract
Background The aim of this study was to determine the safety and efficacy of fractionated stereotactic radiotherapy (SRT) in combination with systemic therapies (ST) for brain metastases (BM). Methods Ninety-nine patients (171 BM) received SRT and concurrent ST (group 1) and 95 patients (131 BM) received SRT alone without concurrent ST (group 2). SRT was planned on a linear accelerator, using volumetric modulated arc therapy. All ST were allowed including chemotherapy (CT), immunotherapy (IT), targeted therapy (TT) and hormonotherapy (HT). Treatment was considered to be concurrent if the timing between the drug administration and SRT did not exceed 1 month. Local control (LC), freedom for distant brain metastases (FFDBM), overall survival (OS) and radionecrosis (RN) were evaluated. Results After a median follow-up of 11.9 months (range 0.7–29.7), there was no significant difference between the two groups. However, patients who received concurrent IT (n = 30) had better 1-year LC, OS, FFDBM but a higher RN rate compared to patients who did not: 96% versus 78% (p = 0.02), 89% versus 77% (p = 0.02), 76% versus 53% (p = 0.004) and 80% versus 90% (p = 0.03), respectively. In multivariate analysis, concurrent IT (p = 0.022) and tumor volume < 2.07 cc (p = 0.039) were significantly correlated with improvement of LC. The addition of IT to SRT compared to SRT alone was associated with an increased risk of RN (p = 0.03). Conclusion SRT delivered concurrently with IT seems to be associated with improved LC, FFDBM and OS as well as with a higher rate of RN.
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Affiliation(s)
- Morgan Guénolé
- Radiation Oncology Department, University Hospital Morvan, 2 Avenue Foch, F-29200, Brest, France
| | - François Lucia
- Radiation Oncology Department, University Hospital Morvan, 2 Avenue Foch, F-29200, Brest, France. .,Latim INSERM UMR 1101, UBO, Brest, France.
| | - Vincent Bourbonne
- Radiation Oncology Department, University Hospital Morvan, 2 Avenue Foch, F-29200, Brest, France.,Latim INSERM UMR 1101, UBO, Brest, France
| | - Gurvan Dissaux
- Radiation Oncology Department, University Hospital Morvan, 2 Avenue Foch, F-29200, Brest, France.,Latim INSERM UMR 1101, UBO, Brest, France
| | - Emmanuelle Reygagne
- Radiation Oncology Department, University Hospital Morvan, 2 Avenue Foch, F-29200, Brest, France
| | - Gaëlle Goasduff
- Radiation Oncology Department, University Hospital Morvan, 2 Avenue Foch, F-29200, Brest, France
| | - Olivier Pradier
- Radiation Oncology Department, University Hospital Morvan, 2 Avenue Foch, F-29200, Brest, France.,Latim INSERM UMR 1101, UBO, Brest, France
| | - Ulrike Schick
- Radiation Oncology Department, University Hospital Morvan, 2 Avenue Foch, F-29200, Brest, France.,Latim INSERM UMR 1101, UBO, Brest, France
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23
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Risk of radiation necrosis after hypofractionated stereotactic radiotherapy (HFSRT) for brain metastases: a single center retrospective study. J Neurooncol 2020; 149:447-453. [DOI: 10.1007/s11060-020-03628-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 09/18/2020] [Indexed: 01/11/2023]
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Perlow HK, Dibs K, Liu K, Jiang W, Rajappa P, Blakaj DM, Palmer J, Raval RR. Whole-Brain Radiation Therapy Versus Stereotactic Radiosurgery for Cerebral Metastases. Neurosurg Clin N Am 2020; 31:565-573. [PMID: 32921352 DOI: 10.1016/j.nec.2020.06.006] [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] [Indexed: 10/23/2022]
Abstract
Whole-brain radiation therapy (WBRT) was frequently used to treat brain metastases in the past. Stereotactic radiosurgery (SRS) is now generally preferred to WBRT for patients with limited brain metastases. SRS can also be used to treat extensive brain metastases (>10-15 metastases), and clinical trials are currently comparing WBRT with SRS for extensive disease. SRS may allow for an increased risk of radiation necrosis or leptomeningeal disease dissemination after treatment. Preoperative SRS and multifraction radiotherapy decrease the risk of these side effects and may soon become standard of care. Combining SRS with immune checkpoint inhibitors may improve patient outcomes.
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Affiliation(s)
- Haley K Perlow
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA
| | - Khaled Dibs
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA
| | - Kevin Liu
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA
| | - William Jiang
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA
| | - Prajwal Rajappa
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA; Department of Neurological Surgery, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Dukagjin M Blakaj
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA
| | - Joshua Palmer
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA
| | - Raju R Raval
- Department of Radiation Oncology, The James Cancer Hospital & Solove Research Institute Ohio State University Wexner Medical Center, 460 West 10th Avenue, Suite D252, Columbus, OH 43210, USA.
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25
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Milano MT, Grimm J, Niemierko A, Soltys SG, Moiseenko V, Redmond KJ, Yorke E, Sahgal A, Xue J, Mahadevan A, Muacevic A, Marks LB, Kleinberg LR. Single- and Multifraction Stereotactic Radiosurgery Dose/Volume Tolerances of the Brain. Int J Radiat Oncol Biol Phys 2020; 110:68-86. [PMID: 32921513 DOI: 10.1016/j.ijrobp.2020.08.013] [Citation(s) in RCA: 158] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/03/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE As part of the American Association of Physicists in Medicine Working Group on Stereotactic Body Radiotherapy investigating normal tissue complication probability (NTCP) after hypofractionated radiation therapy, data from published reports (PubMed indexed 1995-2018) were pooled to identify dosimetric and clinical predictors of radiation-induced brain toxicity after single-fraction stereotactic radiosurgery (SRS) or fractionated stereotactic radiosurgery (fSRS). METHODS AND MATERIALS Eligible studies provided NTCPs for the endpoints of radionecrosis, edema, or symptoms after cranial SRS/fSRS and quantitative dose-volume metrics. Studies of patients with only glioma, meningioma, vestibular schwannoma, or brainstem targets were excluded. The data summary and analyses focused on arteriovenous malformations (AVM) and brain metastases. RESULTS Data from 51 reports are summarized. There was wide variability in reported rates of radionecrosis. Available data for SRS/fSRS for brain metastases were more amenable to NTCP modeling than AVM data. In the setting of brain metastases, SRS/fSRS-associated radionecrosis can be difficult to differentiate from tumor progression. For single-fraction SRS to brain metastases, tissue volumes (including target volumes) receiving 12 Gy (V12) of 5 cm3, 10 cm3, or >15 cm3 were associated with risks of symptomatic radionecrosis of approximately 10%, 15%, and 20%, respectively. SRS for AVM was associated with modestly lower rates of symptomatic radionecrosis for equivalent V12. For brain metastases, brain plus target volume V20 (3-fractions) or V24 (5-fractions) <20 cm3 was associated with <10% risk of any necrosis or edema, and <4% risk of radionecrosis requiring resection. CONCLUSIONS The risk of radionecrosis after SRS and fSRS can be modeled as a function of dose and volume treated. The use of fSRS appears to reduce risks of radionecrosis for larger treatment volumes relative to SRS. More standardized dosimetric and toxicity reporting is needed to facilitate future pooled analyses that can refine predictive models of brain toxicity risks.
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Affiliation(s)
- Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York.
| | - Jimm Grimm
- Department of Radiation Oncology, Geisinger Cancer Institute, Danville, Pennsylvania
| | - Andrzej Niemierko
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, California
| | - Vitali Moiseenko
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York City, New York
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Jinyu Xue
- Department of Radiation Oncology, NYU Langone Medical Center, New York City, NY
| | - Anand Mahadevan
- Department of Radiation Oncology, Geisinger Cancer Institute, Danville, Pennsylvania
| | | | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Pasquier D, Mouttet Audouard R, Martinage G, Lacornerie T, Mirabel X, Lartigau E. [Place and modalities of postoperative radiotherapy in the management of cerebral metastases]. Cancer Radiother 2020; 24:477-481. [PMID: 32828667 DOI: 10.1016/j.canrad.2020.06.019] [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: 05/15/2020] [Revised: 06/18/2020] [Accepted: 06/20/2020] [Indexed: 11/17/2022]
Abstract
Metastases are the most common brain tumors. After surgery, stereotactic radiotherapy (SRT) of the resection cavity is the standard of care. Data from two randomized trials indicate that SRT to the surgical bed is an effective treatment in reducing local failure as compared with observation, while reducing the risk of cognitive deterioration and maintaining quality of life as compared with whole brain radiation therapy. Local control appears higher after hypofractionated SRT compared to single-fraction SRT. Several questions such as target volumes, the optimal regimen in particular for large tumor bed, strategies to reduce the risk of lepto-meningeal recurrence, and the treatment sequence still need to be answered.
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Affiliation(s)
- D Pasquier
- Département universitaire de radiothérapie, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France; Centre de recherche en informatique, signal et automatique de Lille, CRIStAL UMR 9189, université de Lille, bâtiment Esprit, avenue Henri-Poincaré, 59655 Villeneuve-d'Ascq, France.
| | - R Mouttet Audouard
- Département universitaire de radiothérapie, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France
| | - G Martinage
- Département universitaire de radiothérapie, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France
| | - T Lacornerie
- Service de physique médicale, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France
| | - X Mirabel
- Département universitaire de radiothérapie, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France
| | - E Lartigau
- Département universitaire de radiothérapie, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France; Centre de recherche en informatique, signal et automatique de Lille, CRIStAL UMR 9189, université de Lille, bâtiment Esprit, avenue Henri-Poincaré, 59655 Villeneuve-d'Ascq, France
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Stereotactic Radiotherapy for Brain Metastases: Imaging Tools and Dosimetric Predictive Factors for Radionecrosis. J Pers Med 2020; 10:jpm10030059. [PMID: 32635476 PMCID: PMC7565332 DOI: 10.3390/jpm10030059] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/21/2020] [Accepted: 07/02/2020] [Indexed: 12/29/2022] Open
Abstract
Radionecrosis (RN) is the most important side effect after stereotactic radiotherapy (SRT) for brain metastases, with a reported incidence ranging from 3% to 24%. To date, there are no unanimously accepted criteria for iconographic diagnosis of RN, as well as no definitive dose-constraints correlated with the onset of this late effect. We reviewed the current literature and gave an overview report on imaging options for the diagnosis of RN and on dosimetric parameters correlated with the onset of RN. We performed a PubMed literature search according to the preferred reporting items and meta-analysis (PRISMA) guidelines, and identified articles published within the last ten years, up to 31 December 2019. When analyzing data on diagnostic tools, perfusion magnetic resonance imaging (MRI) seems to be very useful allowing evaluation of the blood flow in the lesion using the relative cerebral blood volume (rCBV) and blood vessel integrity using relative peak weight (rPH). It is necessary to combine morphological with functional imaging in order to match information about lesion morphology, metabolism and blood-flow. Eventually, serial imaging follow-up is needed. Regarding dosimetric parameters, in radiosurgery (SRS) V12 < 8 cm3 and V10 < 10.5 cm3 of normal brain are the most reliable prognostic factors, whereas in hypo-fractionated stereotactic radiotherapy (HSRT) V18 and V21 are considered the main predictive independent risk factors of RN.
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Gui C, Grimm J, Kleinberg LR, Zaki P, Spoleti N, Mukherjee D, Bettegowda C, Lim M, Redmond KJ. A Dose-Response Model of Local Tumor Control Probability After Stereotactic Radiosurgery for Brain Metastases Resection Cavities. Adv Radiat Oncol 2020; 5:840-849. [PMID: 33083646 PMCID: PMC7557194 DOI: 10.1016/j.adro.2020.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 05/09/2020] [Accepted: 06/15/2020] [Indexed: 11/09/2022] Open
Abstract
Purpose Recent randomized controlled trials evaluating stereotactic surgery (SRS) for resected brain metastases question the high rates of local control previously reported in retrospective studies. Tumor control probability (TCP) models were developed to quantify the relationship between radiation dose and local control after SRS for resected brain metastases. Methods and Materials Patients with resected brain metastases treated with SRS were evaluated retrospectively. Melanoma, sarcoma, and renal cell carcinoma were considered radio-resistant histologies. The planning target volume (PTV) was the region of enhancement on T1 post-gadolinium magnetic resonance imaging plus a 2-mm uniform margin. The primary outcome was local recurrence, defined as tumor progression within the resection cavity. Cox regression evaluated predictors of local recurrence. Dose-volume histograms for the PTV were obtained from treatment plans and converted to 3-fraction equivalent doses (α/β = 12 Gy). TCP models evaluated local control at 1-year follow-up as a logistic function of dose-volume histogram data. Results Among 150 cavities, 41 (27.3%) were radio-resistant. The median PTV volume was 14.6 mL (range, 1.3-65.3). The median prescription was 21 Gy (range, 15-25) in 3 fractions (range, 1-5). Local control rates at 12 and 24 months were 86% and 82%. On Cox regression, larger cavities (PTV > 12 cm3) predicted increased risk of local recurrence (P = .03). TCP modeling demonstrated relationships between improved 1-year local control and higher radiation doses delivered to radio-resistant cavities. Maximum PTV doses of 30, 35, and 40 Gy predicted 78%, 89%, and 94% local control among all radio-resistant cavities, versus 69%, 79%, and 86% among larger radio-resistant cavities. Conclusions After SRS for resected brain metastases, larger cavities are at greater risk of local recurrence. TCP models suggests that higher radiation doses may improve local control among cavities of radio-resistant histology. Given maximum tolerated doses established for single-fraction SRS, fractionated regimens may be required to optimize local control in large radio-resistant cavities.
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Affiliation(s)
- Chengcheng Gui
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Jimm Grimm
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Lawrence Richard Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Peter Zaki
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Nicholas Spoleti
- Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
| | - Michael Lim
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
| | - Kristin Janson Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
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Soliman H, Myrehaug S, Tseng CL, Ruschin M, Hashmi A, Mainprize T, Spears J, Das S, Yang V, da Costa L, Maralani P, Heyn C, Atenafu EG, Sahgal A. Image-Guided, Linac-Based, Surgical Cavity-Hypofractionated Stereotactic Radiotherapy in 5 Daily Fractions for Brain Metastases. Neurosurgery 2020; 85:E860-E869. [PMID: 31173150 DOI: 10.1093/neuros/nyz162] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 01/18/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Cavity stereotactic radiotherapy has emerged as a standard option following resection of brain metastases. However, the optimal approach with either single-fraction or hypofractionated stereotactic radiotherapy (HSRT) remains a significant question. OBJECTIVE To report outcomes for 5-fraction HSRT to the surgical cavity, based on contouring according to a recently reported international consensus guideline. METHODS Patients treated with cavity HSRT were identified from a prospective institutional database. Local brain control (LC), distant brain failure (DBF), leptomeningeal disease (LMD), and overall survival rates were determined. Univariate and multivariable analyses were performed on potential predictive factors. RESULTS One hundred thirty-seven cavities in 122 patients were treated at a median total dose of 30 Gy (range, 25-35 Gy). The median follow-up was 16 mo (range, 1-60 mo). Nonsmall cell lung cancer was the most common histology (44%), followed by breast cancer (21%). In 57% of surgical cavities, the preoperative tumor diameter was >3 cm. One-year LC, DBF, LMD, and overall survival rates were 84%, 45%, 22%, and 62%, respectively. Multivariable analyses identified colorectal (hazard ratio [HR] 4.1, P = .0066) and melanoma (HR 2.4, P = .012) metastases as predictors of local recurrence; preoperative tumor diameter >2 cm (HR 8.9, P = .012) and absence of targeted therapy (HR 4.4, P = .03) as predictors of DBF; and breast cancer histology (HR 2.1, P = .05) and subtotal resection (HR 2.6, P = .009) as predictors of LMD. Symptomatic radiation necrosis was observed in 7 patients (6%). CONCLUSION High rates of LC were observed following this 5-fraction HSRT regimen. Superiority as compared to single-fraction SRS requires a randomized trial.
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Affiliation(s)
- Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Ahmed Hashmi
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Todd Mainprize
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Julian Spears
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Sunit Das
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Victor Yang
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Leodante da Costa
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Pejman Maralani
- Neuroradiology Division, Department of Medical Imaging, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Chris Heyn
- Neuroradiology Division, Department of Medical Imaging, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
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Faruqi S, Ruschin M, Soliman H, Myrehaug S, Zeng KL, Husain Z, Atenafu E, Tseng CL, Das S, Perry J, Maralani P, Heyn C, Mainprize T, Sahgal A. Adverse Radiation Effect After Hypofractionated Stereotactic Radiosurgery in 5 Daily Fractions for Surgical Cavities and Intact Brain Metastases. Int J Radiat Oncol Biol Phys 2020; 106:772-779. [DOI: 10.1016/j.ijrobp.2019.12.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 11/05/2019] [Accepted: 12/02/2019] [Indexed: 11/25/2022]
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Post-operative stereotactic radiosurgery following excision of brain metastases: A systematic review and meta-analysis. Radiother Oncol 2020; 142:27-35. [DOI: 10.1016/j.radonc.2019.08.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 07/21/2019] [Accepted: 08/27/2019] [Indexed: 11/23/2022]
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Traylor JI, Habib A, Patel R, Muir M, Gadot R, Briere T, Yeboa DN, Li J, Rao G. Fractionated stereotactic radiotherapy for local control of resected brain metastases. J Neurooncol 2019; 144:343-350. [PMID: 31313060 DOI: 10.1007/s11060-019-03233-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 06/26/2019] [Indexed: 01/03/2023]
Abstract
PURPOSE Postoperative stereotactic radiosurgery (SRS) has been shown to establish local control in patients with resected brain metastases, yet its efficacy may be limited, particularly for resected lesions with large post-operative resection cavities. We describe the efficacy of postoperative fractionated stereotactic radiotherapy (FSRT) for local control in patients who have undergone resection for brain metastases. METHODS In this retrospective cohort study, we analyzed patients who received FSRT for resected brain metastases in 3 or 5 fractions. Time to local recurrence was the primary endpoint in this study. RESULTS Sixty-seven patients (n = 29 female, n = 38 male) met study criteria for review. The median age of the cohort was 62 years (range 18-79 years). Median preoperative tumor volume was 11.1 cm3 (range 0.4-77.0 cm3). The rate of local control was 91.0% at 6 months, 85.1% at 12 months, and 85.1% at 18 months. Estimates of freedom from local recurrence at 6 and 12 months were 90.9% and 84.3%, respectively. Higher biologically equivalent doses (BED10) were found to be predictive of longer freedom from local recurrence on univariate and multivariable analysis. Larger cavity volumes were found to correspond to longer time to local recurrence on univariate and multivariable analysis. CONCLUSION Our results suggest that postoperative FSRT may be an effective method for providing local control to the surgical bed in patients with resected brain metastases, particularly for larger tumors not amenable to conventional, single-fraction SRS. Additional prospective studies are needed to confirm these findings.
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Affiliation(s)
- Jeffrey I Traylor
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ahmed Habib
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rajan Patel
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew Muir
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ron Gadot
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tina Briere
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Debra N Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ganesh Rao
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. .,Department of of Neurosurgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Room FC7.2000, Unit 853, Houston, TX, 77030-4009, USA.
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Donovan EK, Parpia S, Greenspoon JN. Incidence of radionecrosis in single-fraction radiosurgery compared with fractionated radiotherapy in the treatment of brain metastasis. Curr Oncol 2019; 26:e328-e333. [PMID: 31285676 PMCID: PMC6588068 DOI: 10.3747/co.26.4749] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction Radiation-induced brain necrosis ["radionecrosis" (rn)] is a relatively uncommon but potentially severe adverse effect of stereotactic radiosurgery (srs) for brain metastasis. Although dose, volume, and hypofractionation have been suggested to affect rn rates, patient and treatment variability in this population make it difficult to clearly delineate the risk. We set out to establish the effect of fractionation on rn rates by reviewing patients receiving simultaneous multi-fraction and single-fraction treatment at our centre. Methods Patients receiving simultaneous (within 1 month) 1-fraction (ssrs) and 3-fraction (fsrs) radiosurgery treatments during 2012-2015 were identified in our institution's database. Serial post-srs magnetic resonance imaging (mri) was reviewed to determine rn and local recurrence. The effect of maximum dose, volume, whole-brain radiotherapy (wbrt), and fractionation on rn development was assessed using logistic regression for paired data. Results are reported using odds ratios (ors) and corresponding 95% confidence intervals (cis). Results Of 90 patients identified, 22 had at least a 6-month mri follow-up. Median follow-up was 320 days. The most common primary tumour type was non-small-cell lung cancer, followed by breast and rectal cancer. Radionecrosis developed in 16 patients [21 of 62 lesions (34%), with 4 being symptomatic (20%)]. Of the 21 lesions in which rn developed, 11 received 3 fractions, and 10 received 1 fraction. The or for the association between the incidence of rn and maximum dose was 1.0 (95% ci: 0.9 to 1.1); for fractionation it was 1.0 (95% ci: 0.3 to 3.6); for previous wbrt, it was 0.4 (95% ci: 0.2 to 1.2); and for a 10-unit increase in volume, it was 3.1 (95% ci: 1.0 to 9.6). Local recurrence developed in 8 patients (12%), 6 of whom belonged to the ssrs group. Conclusions Our results indicate that patients receiving srs for multiple brain metastases experience a higher rate of rn than is reported in the literature and poorer survival despite having equivalent local control. Maximum dose did not appear to be associated with rn risk in our cohort, but volume was significantly associated with rn risk. Although fractionated treatment did not directly lower the rate of rn in this population, it might have played a role in reducing the magnitude of the rn risk in large-volume lesions. Further investigation will help to delineate optimal dose and fractionation so as to minimize rn while maintaining local control in this group.
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Affiliation(s)
- E K Donovan
- Department of Oncology, McMaster University, Juravinski Hospital and Cancer Centre, Hamilton, ON
| | - S Parpia
- Department of Statistics and Epidemiology, Juravinski Hospital, McMaster University, Hamilton, ON
| | - J N Greenspoon
- Department of Oncology, McMaster University, Juravinski Hospital and Cancer Centre, Hamilton, ON
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Munshi A, Sarkar B, Roy S, Ganesh T, Mohanti B. Dose fall-off patterns with volumetric modulated arc therapy and three-dimensional conformal radiotherapy including the “organ at risk” effect. Experience of linear accelerator-based frameless radiosurgery from a single institution. Cancer Radiother 2019; 23:138-146. [DOI: 10.1016/j.canrad.2018.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 09/22/2018] [Accepted: 10/02/2018] [Indexed: 12/31/2022]
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Cavity volume changes after surgery of a brain metastasis-consequences for stereotactic radiation therapy. Strahlenther Onkol 2018; 195:207-217. [PMID: 30386864 DOI: 10.1007/s00066-018-1387-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 10/17/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE For a large or symptomatic brain metastasis, resection and adjuvant radiotherapy are recommended. Hypofractionated stereotactic radiotherapy (HFSRT) is increasingly applied in patients with a limited number of lesions. Exact target volume definition is critical given the small safety margins. Whilst technical advances have minimized inaccuracy due to patient positioning and radiation targeting, little is known about changes in target volume. This study sought to evaluate potential changes in the resection cavity of a brain metastasis. METHODS In all, 57 patients treated with HFSRT after surgical resection of one brain metastasis between 2008 and 2015 in our institution were included in this study. Gross tumor volume (GTV) of the initial metastasis and the volume of the resection cavity in the post-operative, planning, and follow-up MRIs were measured and compared. RESULTS The mean cavity size decreased after surgery with the greatest change of -23.4% (±41.5%) occurring between post-operative MRI and planning MRI (p < 0.01). During this time period, the cavity volume decreased, remained stable, and increased in 79.1, 3.5, and 17.4%, respectively. A further decrease of -20.7% (±58.1%) was perceived between planning MRI and first follow-up (p < 0.01). No significant difference in pattern of change could be observed depending on the volume of initial GTV, size of the post-operative resection cavity, initial or post-resection FLAIR (fluid-attenuated inversion recovery) hyper-intensity, postsurgical ischemia, or primary tumor. The resection cavities of patients with post-operative ischemia were significantly larger than resection cavities of patients without ischemia. CONCLUSION The resection cavity seems to be very dynamic after surgery. Hence, it remains necessary to use very recent scans for treatment planning.
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Short-term outcomes and clinical efficacy of stereotactic body radiation therapy (SBRT) in treatment of adrenal gland metastases from lung cancer. Radiat Oncol 2018; 13:205. [PMID: 30348187 PMCID: PMC6196411 DOI: 10.1186/s13014-018-1152-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 10/08/2018] [Indexed: 12/25/2022] Open
Abstract
Background To assess the efficacy and safety of stereotactic body radiation therapy (SBRT) in the management of adrenal gland metastases (AGMs) from lung cancer. Moreover, it is the first two-institutional experience and the largest-to-date study to report the safety and efficacy of SBRT for inoperable AGM from lung cancer. Methods In this retrospective study, 30 patients (27 males, 3 females) with 32 AGMs were treated by SBRT from October 2006 to June 2016. Of these, 11 patients were treated with the intent of controlling all known metastatic sites and 19 for palliation of bulky AGMs. Follow-up was performed every 3 months for evaluations of efficacy and safety. Factors predictive of overall survival (OS) and local control (LC) were identified with univariate and then multivariate analysis. Results Median follow-up time was 10.7 months (2.9–96.4 months). The complete response (CR), partial response (PR), stable disease (SD) and progressive disease (PD) rates were 23.3%, 33.3%, 33.3% and 16.7% respectively. The 6-month, 1, and 2-year LC rates were 96.9%, 96.9%, and 72.7% respectively. Additionally, the 6-month, 1, and 2-year OS rates were 85.6%, 58.1%, and 54.0% respectively while 6-month, 1, and 2-year progression free survival (PFS) rates were 39.5%, 24.6%, and 8.2%, respectively. All the patients with cancer-induced pain (8 with abdominal pain and 6 with lumbar back pain) had significant alleviations after SBRT. The treatment was well tolerated with only 1 patient reporting grade-3 diarrhoea. No predictors of OS and LC were found after multivariate analysis, while it was demonstrated that biologic equivalent dose (BED10, α/β = 10) ≥85.5Gy (P = 0.007) and gross tumor volume < 30 ml (P = 0.003) correlated with LC only after univariate analysis. Conclusion SBRT is a safe and effective treatment modality in the management of AGMs from lung cancer with high LC rates and acceptable toxicity.
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Ayas AW, Grau S, Jablonska K, Ruess D, Ruge M, Marnitz S, Goldbrunner R, Kocher M. Postoperative local fractionated radiotherapy for resected single brain metastases. Strahlenther Onkol 2018; 194:1163-1170. [PMID: 30218137 DOI: 10.1007/s00066-018-1368-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 08/28/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Evaluation of postoperative fractionated local 3D-conformal radiotherapy (3DRT) of the resection cavity in brain metastases. PATIENTS AND METHODS Between 2011 and 2016, 57 patients underwent resection of a single, previously untreated (37/57, 65%) or recurrent (20/57, 35%) brain metastasis (median maximal diameter 3.5 cm [1.1-6.5 cm]) followed by 3DRT. For definition of the gross tumor volume (GTV), the resection cavity was used and for the clinical target volume (CTV), margins of 1.0-1.5 cm were added. Median dose was 48.0 Gy (30.0-50.4 Gy) in 25 (10-28) fractions; most patients had 36.0-42.0 Gy in 3.0 Gy fractions (n = 16, EQD210Gy 39.0-45.5 Gy) or 40.0-50.4 Gy in 1.8-2.0 Gy fractions (n = 37, EQD210Gy 39.3-50.0 Gy). RESULTS Median follow-up was 18 months. Local control rates were 83% at 1 year and 78% at 2 years and were significantly influenced by histology (breast cancer 100%, non-small lung cancer 87%, melanoma 80%, colorectal cancer 26% at 2 years, p = 0.006) and resection status (p < 0.0001), but not by EQD210Gy or size of the planning target volume (median 96.7 ml [16.7-282.8 ml]). At 1 and 2 years, 74% and 52% of the patients were free from distant brain metastases. Salvage procedures were applied in 25/27 (93%) of recurrent patients. Survival was 68% at 1 year and 41% at 2 years and was significantly improved in younger patients (p = 0.006) with higher Karnofsky performance score (p < 0.0001) and without prior radiotherapy (54% vs. 9% at 2 years, p = 0.006). No cases of radiographic or symptomatic radionecrosis were observed. CONCLUSION Adjuvant fractionated local 3DRT is highly effective in radiosensitive, completely resected metastases and should be considered for treating large resection cavities as an alternative to postoperative stereotactic single dose or hypofractionated radiosurgery.
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Affiliation(s)
- Ahmad Walid Ayas
- Department of Radiation Oncology, Center for Integrated Oncology, University Hospital Cologne, Cologne, Germany
| | - Stefan Grau
- Department of Neurosurgery, Center for Integrated Oncology, University Hospital Cologne, Cologne, Germany
| | - Karolina Jablonska
- Department of Radiation Oncology, Center for Integrated Oncology, University Hospital Cologne, Cologne, Germany
| | - Daniel Ruess
- Department of Stereotactic and Functional Neurosurgery, Center for Integrated Oncology, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Maximilian Ruge
- Department of Stereotactic and Functional Neurosurgery, Center for Integrated Oncology, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Simone Marnitz
- Department of Radiation Oncology, Center for Integrated Oncology, University Hospital Cologne, Cologne, Germany
| | - Roland Goldbrunner
- Department of Neurosurgery, Center for Integrated Oncology, University Hospital Cologne, Cologne, Germany
| | - Martin Kocher
- Department of Radiation Oncology, Center for Integrated Oncology, University Hospital Cologne, Cologne, Germany.
- Department of Stereotactic and Functional Neurosurgery, Center for Integrated Oncology, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
- Institute of Neuroscience and Medicine (INM-4), Forschungszentrum Juelich, Juelich, Germany.
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Marchan EM, Peterson J, Sio TT, Chaichana KL, Harrell AC, Ruiz-Garcia H, Mahajan A, Brown PD, Trifiletti DM. Postoperative Cavity Stereotactic Radiosurgery for Brain Metastases. Front Oncol 2018; 8:342. [PMID: 30234013 PMCID: PMC6127288 DOI: 10.3389/fonc.2018.00342] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 08/06/2018] [Indexed: 11/26/2022] Open
Abstract
During the past decade, tumor bed stereotactic radiosurgery (SRS) after surgical resection has been increasingly utilized in the management of brain metastases. SRS has risen as an alternative to adjuvant whole brain radiation therapy (WBRT), which has been shown in several studies to be associated with increased neurotoxicity. Multiple recent articles have shown favorable local control rates compared to those of WBRT. Specifically, improvements in local control can be achieved by adding a 2 mm margin around the resection cavity. Risk factors that have been established as increasing the risk of local recurrence after resection include: subtotal resection, larger treatment volume, lower margin dose, and a long delay between surgery and SRS (>3 weeks). Moreover, consensus among experts in the field have established the importance of (a) fusion of the pre-operative magnetic resonance imaging scan to aid in volume delineation (b) contouring the entire surgical tract and (c) expanding the target to include possible microscopic disease that may extend to meningeal or venous sinus territory. These strategies can minimize the risks of symptomatic radiation-induced injury and leptomeningeal dissemination after postoperative SRS. Emerging data has arisen suggesting that multifraction postoperative SRS, or alternatively, preoperative SRS could provide decreased rates of radiation necrosis and leptomeningeal disease. Future prospective randomized clinical trials comparing outcomes between these techniques are necessary in order to improve outcomes in these patients.
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Affiliation(s)
- Eduardo M Marchan
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Jennifer Peterson
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Kaisorn L Chaichana
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, United States
| | - Anna C Harrell
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States.,Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, United States
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Lesueur P, Lequesne J, Barraux V, Kao W, Geffrelot J, Grellard JM, Habrand JL, Emery E, Marie B, Thariat J, Stefan D. Radiosurgery or hypofractionated stereotactic radiotherapy for brain metastases from radioresistant primaries (melanoma and renal cancer). Radiat Oncol 2018; 13:138. [PMID: 30055640 PMCID: PMC6064124 DOI: 10.1186/s13014-018-1083-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 07/20/2018] [Indexed: 01/08/2023] Open
Abstract
Background Until 50% of patients with renal cancer or melanoma, develop brain metastases during the course of their disease. Stereotactic radiotherapy has become a standard of care for patients with a limited number of brain metastases. Given the radioresistant nature of melanoma and renal cancer, optimization of the fractionation of stereotactic radiotherapy is needed. The purpose of this retrospective study was to elucidate if hypofractionated stereotactic radiotherapy (HFSRT) impacts local control of brain metastases from radioresistant tumors such as melanoma and renal cancer, in comparison with radiosurgery (SRS). Methods Between 2012 and 2016, 193 metastases, smaller than 3 cm, from patients suffering from radioresistant primaries (melanoma and renal cancer) were treated with HFSRT or SRS. The primary outcome was local progression free survival (LPFS) at 6, 12 and 18 months. Overall survival (OS) and cerebral progression free survival (CPFS) were secondary outcomes, and were evaluated per patient. Objective response rate and radionecrosis incidence were also reported. The statistical analysis included a supplementary propensity score analysis to deal with bias induced by non-randomized data. Results After a median follow-up of 7.4 months, LPFS rates at 6, 12 and 18 months for the whole population were 83, 74 and 70%, respectively. With respect to fractionation, LPFS rates at 6, 12 and 18 months were 89, 79 and 73% for the SRS group and 80, 72 and 68% for the HFSRT group. The fractionation schedule was not statistically associated with LPFS (HR = 1.39, CI95% [0.65–2.96], p = 0.38). Time from planning MRI to first irradiation session longer than 14 days was associated with a poorer local control rate. Over this time, LPFS at 12 months was reduced from 86 to 70% (p = 0.009). Radionecrosis occurred in 7.1% for HFSRT treated metastases to 9.6% to SRS treated metastases, without any difference according to fractionation (p = 0.55). The median OS was 9.6 months. Six, 12 and 18 months CPFS rates were 54, 24 and 17%, respectively. Conclusion Fractionation does not decrease LPFS. Even for small radioresistant brain metastases (< 3 cm), HFSRT, with 3 or 6 fractions, leads to an excellent local control rate of 72% at 1 year with a rate of 7.1% of radionecrosis. HFSRT is a safe and efficient alternative treatment to SRS. Electronic supplementary material The online version of this article (10.1186/s13014-018-1083-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Paul Lesueur
- Radiotherapy department, Centre François Baclesse, Caen, France. .,Laboratoire d'accueil et de recherche avec les ions accélérés, CEA-CIMAP, Caen, France. .,Medical university of Caen, Caen, France.
| | - Justine Lequesne
- Clinical research department, Centre François Baclesse, Caen, France
| | - Victor Barraux
- Medical physics department, Centre François Baclesse, Caen, France
| | - William Kao
- Radiotherapy department, Centre François Baclesse, Caen, France
| | | | | | - Jean-Louis Habrand
- Radiotherapy department, Centre François Baclesse, Caen, France.,Medical university of Caen, Caen, France
| | - Evelyne Emery
- Neurosurgery department, CHU Côte de Nacre, Caen, France.,Medical university of Caen, Caen, France
| | - Brigitte Marie
- Imaging department, Centre François Baclesse, Caen, France
| | - Juliette Thariat
- Radiotherapy department, Centre François Baclesse, Caen, France.,Medical university of Caen, Caen, France
| | - Dinu Stefan
- Radiotherapy department, Centre François Baclesse, Caen, France
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Postoperative hypofractionated stereotactic brain radiation (HSRT) for resected brain metastases: improved local control with higher BED 10. J Neurooncol 2018; 139:449-454. [PMID: 29749569 DOI: 10.1007/s11060-018-2885-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/26/2018] [Indexed: 11/27/2022]
Abstract
INTRODUCTION HSRT directed to large surgical beds in patients with resected brain metastases improves local control while sparing patients the toxicity associated with whole brain radiation. We review our institutional series to determine factors predictive of local failure. METHODS In a total of 39 consecutive patients with brain metastases treated from August 2011 to August 2016, 43 surgical beds were treated with HSRT in three or five fractions. All treatments were completed on a robotic radiosurgery platform using the 6D Skull tracking system. Volumetric MRIs from before and after surgery were used for radiation planning. A 2-mm PTV margin was used around the contoured surgical bed and resection margins; these were reviewed by the radiation oncologist and neurosurgeon. Lower total doses were prescribed based on proximity to critical structures or if prior radiation treatments were given. Local control in this study is defined as no volumetric MRI evidence of recurrence of tumor within the high dose radiation volume. Statistics were calculated using JMP Pro v13. RESULTS Of the 43 surgical beds analyzed, 23 were from NSCLC, 5 were from breast, 4 from melanoma, 5 from esophagus, and 1 each from SCLC, sarcoma, colon, renal, rectal, and unknown primary. Ten were treated with three fractions with median dose 24 Gy and 33 were treated with five fractions with median dose 27.5 Gy using an every other day fractionation. There were no reported grade 3 or higher toxicities. Median follow up was 212 days after completion of radiation. 10 (23%) surgical beds developed local failure with a median time to failure of 148 days. All but three patients developed new brain metastases outside of the treated field and were treated with stereotactic radiosurgery, whole brain radiation and/or chemotherapy. Five patients (13%) developed leptomeningeal disease. With a median follow up of 226 days, 30 Gy/5 fx was associated with the best local control (93%) with only 1 local failure. A lower total dose in five fractions (ie 27.5 or 25 Gy) had a local control rate of 70%. For three fraction SBRT, local control was 100% using a dose of 27 Gy in three fractions (follow up was > 600 days) and 71% if 24 Gy in three fractions was used. A higher total biologically equivalent dose (BED10) was statistically significant for improved local control (p = 0.04) with a threshold BED10 ≥ 48 associated with better local control. CONCLUSIONS HSRT after surgical resection for brain metastasis is well tolerated and has improved local control with BED10 ≥ 48 (30 Gy/5 fx and 27 Gy/3 fx). Additional study is warranted.
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Franzese O, Battaini F, Graziani G, Tentori L, Barbaccia ML, Aquino A, Roselli M, Fuggetta MP, Bonmassar E, Torino F. Drug-induced xenogenization of tumors: A possible role in the immune control of malignant cell growth in the brain? Pharmacol Res 2018. [DOI: 10.1016/j.phrs.2018.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Gui C, Moore J, Grimm J, Kleinberg L, McNutt T, Shen C, Chen L, Bettegowda C, Lim M, Redmond KJ. Local recurrence patterns after postoperative stereotactic radiation surgery to resected brain metastases: A quantitative analysis to guide target delineation. Pract Radiat Oncol 2018; 8:388-396. [PMID: 30029965 DOI: 10.1016/j.prro.2018.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 04/13/2018] [Accepted: 04/21/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE In the treatment of resected metastatic brain disease, a recent phase 3 trial by the North Central Cancer Treatment Group (N107C/CEC.3) surprisingly found that the local control rate for whole-brain radiation therapy was better than that of stereotactic radiation surgery (SRS). To optimize target delineation, we performed a quantitative analysis of local failure patterns after postoperative SRS. METHODS AND MATERIALS Patients with brain metastases who were treated with surgery and SRS to the cavity were evaluated. Local failure was defined by pathologic confirmation or magnetic resonance imaging evidence of progression leading to further overlapping radiation therapy. T1 postgadolinium magnetic resonance imaging scans that were taken preoperatively and at recurrence were co-registered to the simulation computed tomography. Three volumes were compared: (1) Preoperative tumors, (2) resection cavities that were originally contoured as clinical target volumes for SRS, and (3) recurrent tumors. Overlap volume histograms quantified the proximity of the three volumes to the meninges. RESULTS In the cohort of 173 patients, 18 patients experienced local failure in 19 resection cavities. The original SRS target volume overlapped with a median of 69.6% of the recurrent tumor. When the entire preoperative tumor was included, the overlap with the recurrent tumor increased to a median of 76.8%. Recurrent tumors were closer to the meninges than corresponding preoperative tumors (P = .03) but a median 8.2 mm expansion of the target volume from the meninges was needed to increase overlap with the recurrent tumor to 90%. Increases in overlap with the recurrent tumor were achieved most efficiently by uniformly expanding the contoured cavity and a median 2.8 mm expansion covered 90% of the recurrent tumor. CONCLUSIONS Our quantitative analysis of recurrence patterns suggests that a larger 3 mm uniform expansion of the SRS target volume substantially increases coverage of the volume that is later occupied by the recurrent tumor and may provide improved local control. The extent of the preoperative tumor in the target volume or expanding the target volume from the meninges provides little benefit.
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Affiliation(s)
- Chengcheng Gui
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Joseph Moore
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Jimm Grimm
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Lawrence Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Todd McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Colette Shen
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Linda Chen
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
| | - Michael Lim
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland.
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Keller A, Doré M, Cebula H, Thillays F, Proust F, Darié I, Martin SA, Delpon G, Lefebvre F, Noël G, Antoni D. Hypofractionated Stereotactic Radiation Therapy to the Resection Bed for Intracranial Metastases. Int J Radiat Oncol Biol Phys 2017; 99:1179-1189. [DOI: 10.1016/j.ijrobp.2017.08.014] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 07/27/2017] [Accepted: 08/11/2017] [Indexed: 11/30/2022]
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[Delineation of the surgical bed of operated brain metastases treated with adjuvant stereotactic irradiation: A review]. Cancer Radiother 2017; 21:804-813. [PMID: 29170039 DOI: 10.1016/j.canrad.2017.04.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/30/2017] [Accepted: 04/19/2017] [Indexed: 11/22/2022]
Abstract
Stereotactic radiotherapy of the surgical bed of brain metastases is a technique that comes supplant indications of adjuvant whole brain radiotherapy after surgery. After a growing number of retrospective studies, a phase III trial has been presented and validated this indication. However, several criteria such as the dose, the fractionation, the use of a margin and definition of volumes remain to be defined. Our study consisted in making a literature review in order to provide a guideline of delineation of surgical beds of brain metastases, as well as the different modalities of their implementation process.
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Increasing time to postoperative stereotactic radiation therapy for patients with resected brain metastases: investigating clinical outcomes and identifying predictors associated with time to initiation. J Neurooncol 2017; 136:545-553. [PMID: 29143275 DOI: 10.1007/s11060-017-2679-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 11/11/2017] [Indexed: 10/18/2022]
Abstract
We sought to determine the impact of time to initiation (TTI) of post-operative radiosurgery on clinical outcomes for patients with resected brain metastases and to identify predictors associated with TTI. All patients with resected brain metastases treated with postoperative SRS or fractionated stereotactic radiation therapy (fSRT) from 2012 to 2016 at a single institution were reviewed. TTI was defined as the interval from resection to first day of radiosurgery. Receiver operating characteristic (ROC) curves were used to identify an optimal threshold for TTI with respect to local failure (LF). Survival outcomes were estimated using the Kaplan-Meier method and analyzed using the log-rank test and Cox proportional hazards models. Logistic regression models were used to identify factors associated with ROC-determined TTI covariates. A total of 79 resected lesions from 73 patients were evaluated. An ROC curve of LF and TTI identified an optimal threshold for TTI of 30.5 days, with an area under the curve of 0.637. TTI > 30 days was associated with an increased hazard of LF (HR 4.525, CI 1.239-16.527) but was not significantly associated with survival (HR 1.002, CI 0.547-1.823) or distant brain failure (DBF, HR 1.943, CI 0.989-3.816). Fifteen patients (20.5%) required post-operative inpatient rehabilitation. Post-operative rehabilitation was associated with TTI > 30 days (OR 1.48, CI 1.142-1.922). In our study of resected brain metastases, longer time to initiation of post-operative radiosurgery was associated with increased local failure. Ideally, post-op SRS should be initiated within 30 days of resection if feasible.
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46
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Keller A, Doré M, Antoni D, Menoux I, Thillays F, Clavier JB, Delpon G, Jarnet D, Bourrier C, Lefebvre F, Chibbaro S, Darié I, Proust F, Noël G. [Risk of radionecrosis after hypofractionated stereotactic radiotherapy targeting the postoperative resection cavity of brain metastases]. Cancer Radiother 2017; 21:377-388. [PMID: 28551018 DOI: 10.1016/j.canrad.2017.01.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 01/02/2017] [Accepted: 01/31/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To investigate the factors that potentially lead to brain radionecrosis after hypofractionated stereotactic radiotherapy targeting the postoperative resection cavity of brain metastases. METHODS AND MATERIALS A retrospective analysis conducted in two French centres, was performed in patients treated with trifractionated stereotactic radiotherapy (3×7.7Gy prescribed to the 70% isodose line) for resected brain metastases. Patients with previous whole-brain irradiation were excluded of the analysis. Radionecrosis was diagnosed according to a combination of criteria including clinical, serial imaging or, in some cases, histology. Univariate and multivariate analyses were performed to determine the predictive factors of radionecrosis including clinical and dosimetric variables such as volume of brain receiving a specific dose (V8Gy-V22Gy). RESULTS One hundred eighty-one patients, with a total of 189 cavities were treated between March 2008 and February 2015. Thirty-five patients (18.5%) developed radionecrosis after a median follow-up of 15 months (range: 3-38 months) after hypofractionated stereotactic radiotherapy. One third of patients with radionecrosis were symptomatic. Multivariate analysis showed that infra-tentorial location was predictive of radionecrosis (hazard ratio [HR]: 2.97; 95% confidence interval [95% CI]: 1.47-6.01; P=0.0025). None V8Gy-V22Gy was associated with appearance of radionecrosis, even if V14Gy trended toward significance (P=0.059). CONCLUSION Analysis of patients and treatment variables revealed that infratentorial location of brain metastases was predictive for radionecrosis after hypofractionated stereotactic radiotherapy for postoperative resection cavities.
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Affiliation(s)
- A Keller
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France
| | - M Doré
- Département de radiothérapie, institut de cancérologie de l'Ouest, boulevard Jacques-Monod, 44805 Saint-Herblain, France
| | - D Antoni
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France; Laboratoire EA 3430, fédération de médecine translationnelle de Strasbourg, université de Strasbourg, 67000 Strasbourg, France
| | - I Menoux
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France
| | - F Thillays
- Département de radiothérapie, institut de cancérologie de l'Ouest, boulevard Jacques-Monod, 44805 Saint-Herblain, France
| | - J B Clavier
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France
| | - G Delpon
- Département de radiothérapie, institut de cancérologie de l'Ouest, boulevard Jacques-Monod, 44805 Saint-Herblain, France
| | - D Jarnet
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France
| | - C Bourrier
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France
| | - F Lefebvre
- Laboratoire de biostatistiques, faculté de médecine, 4, rue Kirschleger, 67085 Strasbourg cedex, France
| | - S Chibbaro
- Département de neurochirurgie, hôpital de Hautepierre, avenue Molière, 67200 Strasbourg, France
| | - I Darié
- Service de neurochirurgie, centre hospitalier régional d'Orléans, 1, rue Porte-Madeleine, 45000 Orléans, France
| | - F Proust
- Département de neurochirurgie, hôpital de Hautepierre, avenue Molière, 67200 Strasbourg, France
| | - G Noël
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France; Laboratoire EA 3430, fédération de médecine translationnelle de Strasbourg, université de Strasbourg, 67000 Strasbourg, France.
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