1
|
Kiss T, Ungvari A, Gulej R, Nyúl-Tóth Á, Tarantini S, Benyo Z, Csik B, Yabluchanskiy A, Mukli P, Csiszar A, Ungvari Z. Whole brain irradiation-induced endothelial dysfunction in the mouse brain. GeroScience 2024; 46:531-541. [PMID: 37953375 PMCID: PMC10828224 DOI: 10.1007/s11357-023-00990-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 10/05/2023] [Indexed: 11/14/2023] Open
Abstract
Whole brain irradiation (WBI), also known as whole brain radiation therapy (WBRT), is a well-established treatment for multiple brain metastases and as a preventive measure to reduce the risk of recurrence after surgical removal of a cerebral metastasis. However, WBI has been found to lead to a gradual decline in neurocognitive function in approximately 50% of patients who survive the treatment, significantly impacting their overall quality of life. Recent preclinical investigations have shed light on the underlying mechanisms of this adverse effect, revealing a complex cerebrovascular injury that involves the induction of cellular senescence in various components of the neurovascular unit, including endothelial cells. The emergence of cellular senescence following WBI has been implicated in the disruption of the blood-brain barrier and impairment of neurovascular coupling responses following irradiation. Building upon these findings, the present study aims to test the hypothesis that WBI-induced endothelial injury promotes endothelial dysfunction, which mimics the aging phenotype. To investigate this hypothesis, we employed a clinically relevant fractionated WBI protocol (5 Gy twice weekly for 4 weeks) on young mice. Both the WBI-treated and control mice were fitted with a cranial window, enabling the assessment of microvascular endothelial function. In order to evaluate the endothelium-dependent, NO-mediated cerebral blood flow (CBF) responses, we topically administered acetylcholine and ATP, and measured the resulting changes using laser Doppler flowmetry. We found that the increases in regional CBF induced by acetylcholine and ATP were significantly diminished in mice subjected to WBI. These findings provide additional preclinical evidence supporting the notion that WBI induces dysfunction in cerebrovascular endothelial cells, which in turn likely contributes to the detrimental long-term effects of the treatment. This endothelial dysfunction resembles an accelerated aging phenotype in the cerebrovascular system and is likely causally linked to the development of cognitive impairment. By integrating these findings with our previous results, we have deepened our understanding of the lasting consequences of WBI. Moreover, our study underscores the critical role of cerebromicrovascular health in safeguarding cognitive function over the long term. This enhanced understanding highlights the importance of prioritizing cerebromicrovascular health in the context of preserving cognitive abilities.
Collapse
Affiliation(s)
- Tamas Kiss
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Translational Medicine, Semmelweis University, Budapest, Hungary
- Eötvös Loránd Research Network and Semmelweis University (ELKH-SE) Cerebrovascular and Neurocognitive Disorders Research Group, Budapest, Hungary
| | - Anna Ungvari
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary.
- Department of Public Health, Semmelweis University, Semmelweis University, Budapest, Hungary.
| | - Rafal Gulej
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ádám Nyúl-Tóth
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- Department of Public Health, Semmelweis University, Semmelweis University, Budapest, Hungary
| | - Stefano Tarantini
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Zoltan Benyo
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Translational Medicine, Semmelweis University, Budapest, Hungary
- Eötvös Loránd Research Network and Semmelweis University (ELKH-SE) Cerebrovascular and Neurocognitive Disorders Research Group, Budapest, Hungary
| | - Boglarka Csik
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Andriy Yabluchanskiy
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Peter Mukli
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Anna Csiszar
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Translational Medicine, Semmelweis University, Budapest, Hungary
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
| | - Zoltan Ungvari
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| |
Collapse
|
2
|
Sun Y, Liu P, Wang Z, Zhang H, Xu Y, Hu S, Yan Y. Efficacy and indications of gamma knife radiosurgery for recurrent low-and high-grade glioma. BMC Cancer 2024; 24:37. [PMID: 38183008 PMCID: PMC10768340 DOI: 10.1186/s12885-023-11772-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/17/2023] [Indexed: 01/07/2024] Open
Abstract
PURPOSE To investigate the indications and efficacy of gamma knife radiosurgery (GKRS) as a salvage treatment for recurrent low-and high-grade glioma. METHODS This retrospective study of 107 patients with recurrent glioma treated with GKRS between 2009 and 2022, including 68 high-grade glioma (HGG) and 39 low-grade glioma (LGG) cases. The Kaplan-Meier method was used to calculate the overall survival (OS) and progression-free survival (PFS). The log-rank test was used to analyze the multivariate prognosis of the Cox proportional hazards model. Adverse reactions were evaluated according to the Common Terminology Criteria for Adverse Events version 4.03. The prognostic value of main clinical features was estimated, including histopathology, Karnofsky performance status (KPS), recurrence time interval, target location, two or more GKRS, surgery for recurrence, site of recurrence, left or right side of the brain and so on. RESULTS The median follow-up time was 74.5 months. The median OS and PFS were 17.0 months and 5.5 months for all patients. The median OS and PFS were 11.0 months and 5.0 months for HGG, respectively. The median OS and PFS were 49.0 months and 12.0 months for LGG, respectively. Multivariate analysis showed that two or more GKRS, left or right side of the brain and brainstem significantly affected PFS. Meanwhile, the KPS index, two or more GKRS, pathological grade, and brainstem significantly affected OS. Stratified analysis showed that surgery for recurrence significantly affected OS and PFS for LGG. KPS significantly affected OS and PFS for HGG. No serious adverse events were noted post-GKRS. CONCLUSION GKRS is a safe and effective salvage treatment for recurrent glioma. Moreover, it can be applied after multiple recurrences with tolerable adverse effects.
Collapse
Affiliation(s)
- Ying Sun
- Department of Radiation Oncology, General Hospital of Northern Theater Command, 110016, Shenyang, China
| | - Peiru Liu
- Beifang Hospital of China Medical University, 110016, Shenyang, China
| | - Zixi Wang
- Graduate School of Dalian Medical University, 116000, Dalian, China
| | - Haibo Zhang
- Department of Radiation Oncology, General Hospital of Northern Theater Command, 110016, Shenyang, China
| | - Ying Xu
- Department of Radiation Oncology, General Hospital of Northern Theater Command, 110016, Shenyang, China
| | - Shenghui Hu
- Department of Radiation Oncology, General Hospital of Northern Theater Command, 110016, Shenyang, China
| | - Ying Yan
- Department of Radiation Oncology, General Hospital of Northern Theater Command, 110016, Shenyang, China.
| |
Collapse
|
3
|
Gulej R, Nyúl-Tóth Á, Ahire C, DelFavero J, Balasubramanian P, Kiss T, Tarantini S, Benyo Z, Pacher P, Csik B, Yabluchanskiy A, Mukli P, Kuan-Celarier A, Krizbai IA, Campisi J, Sonntag WE, Csiszar A, Ungvari Z. Elimination of senescent cells by treatment with Navitoclax/ABT263 reverses whole brain irradiation-induced blood-brain barrier disruption in the mouse brain. GeroScience 2023; 45:2983-3002. [PMID: 37642933 PMCID: PMC10643778 DOI: 10.1007/s11357-023-00870-x] [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: 02/12/2023] [Accepted: 07/06/2023] [Indexed: 08/31/2023] Open
Abstract
Whole brain irradiation (WBI), a commonly employed therapy for multiple brain metastases and as a prophylactic measure after cerebral metastasis resection, is associated with a progressive decline in neurocognitive function, significantly impacting the quality of life for approximately half of the surviving patients. Recent preclinical investigations have shed light on the multifaceted cerebrovascular injury mechanisms underlying this side effect of WBI. In this study, we aimed to test the hypothesis that WBI induces endothelial senescence, contributing to chronic disruption of the blood-brain barrier (BBB) and microvascular rarefaction. To accomplish this, we utilized transgenic p16-3MR mice, which enable the identification and selective elimination of senescent cells. These mice were subjected to a clinically relevant fractionated WBI protocol (5 Gy twice weekly for 4 weeks), and cranial windows were applied to both WBI-treated and control mice. Quantitative assessment of BBB permeability and capillary density was performed using two-photon microscopy at the 6-month post-irradiation time point. The presence of senescent microvascular endothelial cells was assessed by imaging flow cytometry, immunolabeling, and single-cell RNA-sequencing (scRNA-seq). WBI induced endothelial senescence, which associated with chronic BBB disruption and a trend for decreased microvascular density in the mouse cortex. In order to investigate the cause-and-effect relationship between WBI-induced senescence and microvascular injury, senescent cells were selectively removed from animals subjected to WBI treatment using Navitoclax/ABT263, a well-known senolytic drug. This intervention was carried out at the 3-month post-WBI time point. In WBI-treated mice, Navitoclax/ABT263 effectively eliminated senescent endothelial cells, which was associated with decreased BBB permeability and a trend for increased cortical capillarization. Our findings provide additional preclinical evidence that senolytic treatment approaches may be developed for prevention of the side effects of WBI.
Collapse
Affiliation(s)
- Rafal Gulej
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Ádám Nyúl-Tóth
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- International Training Program in Geroscience, Institute of Biophysics, Biological Research Centre, Eötvös Loránd Research Network, Szeged, Hungary
| | - Chetan Ahire
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Jordan DelFavero
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Priya Balasubramanian
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
| | - Tamas Kiss
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, First Department of Pediatrics, Semmelweis University, Budapest, Hungary
- Eötvös Loránd Research Network and Semmelweis University (ELKH-SE) Cerebrovascular and Neurocognitive Disorders Research Group, Budapest, Hungary
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Translational Medicine, Semmelweis University, Budapest, Hungary
- Graduate School, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Stefano Tarantini
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
| | - Zoltan Benyo
- Eötvös Loránd Research Network and Semmelweis University (ELKH-SE) Cerebrovascular and Neurocognitive Disorders Research Group, Budapest, Hungary
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Translational Medicine, Semmelweis University, Budapest, Hungary
- Graduate School, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Pal Pacher
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institute On Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA
| | - Boglarka Csik
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Andriy Yabluchanskiy
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Peter Mukli
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Anna Kuan-Celarier
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - István A Krizbai
- International Training Program in Geroscience, Institute of Biophysics, Biological Research Centre, Eötvös Loránd Research Network, Szeged, Hungary
- Institute of Life Sciences, Vasile Goldiş Western University of Arad, Arad, Romania
| | | | - William E Sonntag
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Anna Csiszar
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Zoltan Ungvari
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary.
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA.
| |
Collapse
|
4
|
Begley SL, Goenka A, Schulder M. Brainstem Metastases Treated with Stereotactic Radiosurgery: Masked versus Framed Immobilization. World Neurosurg 2023; 175:e1158-e1165. [PMID: 37116783 DOI: 10.1016/j.wneu.2023.04.085] [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: 01/25/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Patients with brainstem metastases (BSMs) have minimal surgical options due to high-risk anatomy. To review our efficacy treating BSM using Gamma Knife stereotactic radiosurgery (SRS), we compared results on the basis of the utilization of mask-fixation (MF) or frame-fixation (FF). METHODS Data were retrospectively collected for 32 patients. Follow-up data for 49 lesions were analyzed for local control rate (LCR) and objective response rate (ORR). RESULTS Primary cancers included lung, breast, and melanoma; most lesions were pontine. MF was used in 18 patients. Average tumor volume was 0.99 cm3 (0.005-13.3 cm3). Thirty-nine lesions were treated with single-fraction 16 Gy. Ten lesions were treated in 3-5 fractions with mean dose of 22.5 Gy. Mean follow-up was 14.2 months (1.2-48.2 months). One-year LCR was 94.7%. ORR at last follow-up did not differ between MF and FF (P = 0.81). Average reduction of lesion volume at 6 and 12 months did not differ between MF and FF (64% vs. 45%, P = 0.77; 70% vs. 77%, P = 0.78). Failure occurred in a pontine colorectal cancer metastasis mask-immobilized for treatment with 14 Gy. CONCLUSIONS SRS for BSM achieved high LCR despite variability in tumor size and histology with no significant difference between MF and FF. Although trials have historically excluded patients with BSM, our data support SRS as a safe and efficacious treatment. This is the first study showing that MF provides equivalent, successful outcomes when compared with FF for patients with BSM.
Collapse
Affiliation(s)
- Sabrina L Begley
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, USA.
| | - Anuj Goenka
- Department of Radiation Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York, USA
| | - Michael Schulder
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, USA
| |
Collapse
|
5
|
Chen WC, Baal UH, Baal JD, Pai JS, Boreta L, Braunstein SE, Raleigh DR. Efficacy and Safety of Stereotactic Radiosurgery for Brainstem Metastases: A Systematic Review and Meta-analysis. JAMA Oncol 2021; 7:1033-1040. [PMID: 33983393 DOI: 10.1001/jamaoncol.2021.1262] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Owing to the proximity to critical neurologic structures, treatment options for brainstem metastases (BSM) are limited, and BSM growth can cause acute morbidity or death. Stereotactic radiosurgery (SRS) is the only local therapy for BSM, but efficacy and safety of this approach are incompletely understood because patients with BSM are excluded from most clinical trials. Objective To perform a systematic review and comparative meta-analysis of SRS studies for BSM in the context of prospective trials of SRS or molecular therapy for nonbrainstem brain metastases (BM). Data Sources A comprehensive search of Pubmed/MEDLINE and Embase was performed on December 6, 2019. Study Selection English-language studies of SRS for BSM with at least 10 patients and reporting 1 or more outcomes of interest were included. Duplicate studies or studies with overlapping data sets were excluded. Studies were independently evaluated by 2 reviewers, and discrepancies were resolved by consensus. A total of 32 retrospective studies published between 1999 and 2019 were included in the analysis. Data Extraction and Synthesis Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify studies. Study quality was assessed using Methodological Index for Non-Randomized Studies criteria. Fixed and random-effects meta-analyses and meta-regressions were performed for the outcomes of interest. Main Outcomes and Measures Primary study outcomes included 1-year and 2-year local control and overall survival, objective response rate, symptom response rate, neurological death rate, and rate of grade 3 to 5 toxic effects as described in Common Terminology Criteria for Adverse Events, version 4.0. Results The 32 retrospective studies included in the analysis comprised 1446 patients with 1590 BSM that were treated with SRS (median [range] dose, 16 [11-39] Gy; median [range] fractions, 1 [1-13]). Local control at 1 year was 86% (95% CI, 83%-88%; I2 = 38%) in 1410 patients across 31 studies, objective response rate was 59% (95% CI, 47%-71%; I2 = 88%) in 642 patients across 17 studies, and symptom improvement was 55% (95% CI, 47%-63%; I2 = 41%) in 323 patients across 13 studies. Deaths from BSM progression after SRS were rare (19 of 703 [2.7%] deaths across 19 studies), and the neurologic death rate in patients with BSM (24%; 95% CI, 19%-31%; I2 = 62%) was equivalent to the neurologic death rate in patients with BM who were treated on prospective trials. The rate of treatment-related grade 3 to 5 toxic effects was 2.4% (95% CI, 1.5%-3.7%; I2 = 33%) in 1421 patients across 31 studies. These results compared favorably to trials of targeted or immunotherapy for BM, which had a wide objective response rate range from 17% to 56%. Conclusions and Relevance Results of this systematic review and meta-analysis show that SRS for BSM was associated with effectiveness and safety and was comparable to SRS for nonbrainstem BM, suggesting that patients with BSM should be eligible for clinical trials of SRS. In this analysis, patients treated with SRS for BSM rarely died from BSM progression and often experienced symptomatic improvement. Given the apparent safety and efficacy of SRS for BSM in the context of acute morbidity or death from BSM growth, consideration of SRS at the time of enrollment on emerging trials of targeted therapy for BM should be considered.
Collapse
Affiliation(s)
- William C Chen
- Department of Radiation Oncology, University of California, San Francisco
| | - Ulysis H Baal
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Joe D Baal
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Jon S Pai
- Department of Internal Medicine, University of Southern California, Los Angeles
| | - Lauren Boreta
- Department of Radiation Oncology, University of California, San Francisco
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California, San Francisco
| | - David R Raleigh
- Department of Radiation Oncology, University of California, San Francisco.,Department of Neurological Surgery, University of California, San Francisco
| |
Collapse
|
6
|
Lehrer EJ, Snyder MH, Desai BD, Li CE, Narayan A, Trifiletti DM, Schlesinger D, Sheehan JP. Clinical and radiographic adverse events after Gamma Knife radiosurgery for brainstem lesions: A dosimetric analysis. Radiother Oncol 2020; 147:200-209. [PMID: 32413528 DOI: 10.1016/j.radonc.2020.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/30/2020] [Accepted: 05/08/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To analyze the association between dosvolume relationships and adverse events in brainstem lesions treated with Gamma Knife radiosurgery (GKRS). METHODS Treatment plans were generated on BrainLab Elements and GammaPlan software. Dosimetric data were analyzed as continuous variables for patients who received GKRS to brain metastases or arteriovenous malformations (AVM) within or abutting the brainstem. Adverse events were classified as clinical and/or radiographic. Logistic and cox regression were used to assess the relationship between dosimetric variables and adverse events. RESULTS Sixty-one patients who underwent single fraction GKRS for brain metastases or AVM were retrospectively analyzed. Median age was 62 years (range: 12-92 years) and the median prescription dose was 18 Gy (range: 13-25 Gy). Median follow-up was 6months. Clinical and radiographic complications were seen in ten (16.4%) and 17 (27.9%) patients, respectively. On logistic regression, increasing D05% was found to be associated with an increased probability of developing a clinical complication post-GKRS (OR: 1.18; 95% CI: 1.01-1.39; p = 0.04). Furthermore, mean brainstem dose (HR: 1.43; 95% CI: 1.05-1.94; p < 0.02), D05% (HR: 1.09; 95% CI: 1.01-1.18; p = 0.03), and D95% (HR: 2.37; 95% CI: 0.99-5.67; p = 0.05) were associated with an increased hazard of experiencing post-GKRS complications over time. CONCLUSIONS Increasing D05% to the brainstem is associated with an increased risk of developing clinical complications. Clinicians may consider this parameter in addition to fractionated stereotactic radiation therapy when well-established dose constraints are not met in this patient population. Additional data are needed to further validate these findings.
Collapse
Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - M Harrison Snyder
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Bhargav D Desai
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Chelsea E Li
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Aditya Narayan
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | | | - David Schlesinger
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| |
Collapse
|
7
|
Linac-Based Fractionated Stereotactic Radiotherapy with a Micro-Multileaf Collimator for Brainstem Metastasis. World Neurosurg 2019; 132:e680-e686. [DOI: 10.1016/j.wneu.2019.08.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/08/2019] [Accepted: 08/09/2019] [Indexed: 11/18/2022]
|
8
|
Winograd E, Rivers CI, Fenstermaker R, Fabiano A, Plunkett R, Prasad D. The case for radiosurgery for brainstem metastases. J Neurooncol 2019; 143:585-595. [DOI: 10.1007/s11060-019-03195-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/11/2019] [Accepted: 05/16/2019] [Indexed: 11/30/2022]
|
9
|
Zhang J, Liu Q, Yuan Z, Zhao L, Wang X, Wang P. Clinical Efficacy of CyberKnife Radiosurgery for Adult Brainstem Glioma: 10 Years Experience at Tianjin CyberKnife Center and Review of the Literature. Front Oncol 2019; 9:257. [PMID: 31032223 PMCID: PMC6473059 DOI: 10.3389/fonc.2019.00257] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/21/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Brainstem glioma is a rare brain tumor with poor prognosis and difficulty for surgical resection. We sought to retrospectively analyze and evaluate the clinical efficacy of CyberKnife for brainstem gliomas. Methods: From 2006 to 2015, a total of 21 brainstem gliomas patients who received CyberKnife radiosurgery treatment enrolled in this study and 18 patients with follow up. CyberKnife image-guided radiosurgical system were applied consecutively with the median prescribed total dose of 26 Gy (14–33 Gy) at two to six fractions on days utilizing CyberKnife system, and the median biological equivalent doses of 59.8 Gy (33.6–76.56 Gy). The clinic pathlogical features, survival were analyzed to explore the efficacy of CyberKnife radiosurgery in treatment of brainstem glioma. Results: With median follow-up of 54.5 months, patients with brainstem gliomas had median overall survival of 19 months, five patients still alive. The primary endpoints of the 1- and 2-year overall survival rates were 87.5 and 52.4%, respectively. During the treatment course, six patients were observed to have pseudoprogression with mass effect on MRI. Four patients developed radiation complications. Grade 2 radiation-related toxicity were observed in three patients and one patient with grade 3. Conclusion: The efficacy of brainstem gliomas—treated with CyberKnife is efficacious with mild toxicity.
Collapse
Affiliation(s)
- Jiaqi Zhang
- Department of Radiotherapy, National Clinical Research Center of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Qun Liu
- Department of Radiotherapy, National Clinical Research Center of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Zhiyong Yuan
- Department of Radiotherapy, National Clinical Research Center of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Lujun Zhao
- Department of Radiotherapy, National Clinical Research Center of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Xiaoguang Wang
- Department of Radiotherapy, National Clinical Research Center of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Ping Wang
- Department of Radiotherapy, National Clinical Research Center of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| |
Collapse
|
10
|
Pease M, Withrow J, Ozpinar A, Lunsford LD. Gamma Knife Radiosurgery for Trigeminal Neuralgia Caused by a Cavernous Malformation: Case Report and Literature Review. Stereotact Funct Neurosurg 2019; 96:412-415. [PMID: 30650431 DOI: 10.1159/000495476] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 11/14/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Trigeminal neuralgia (TN) related to a brainstem cavernous malformation (CM) is a rare entity. We present the first radiosurgical management of a patient with TN secondary to a CM. CLINICAL PRESENTATION An 80-year-old female presented with a 33-year history of progressively severe TN refractory to medications. Imaging confirmed a solitary CM located at the pontine dorsal root entry zone of cranial nerve 5. TREATMENT Stereotactic radiosurgery of the trigeminal nerve was performed using the Leksell gamma knife. A single 4-mm isocenter of radiation was focused on the trigeminal nerve and a maximum dose of 80 Gy (40 Gy at the 50% isodose line) was delivered to the nerve. RESULTS At 1 year, the patient noted that the severe pain attacks had been reduced by 75%, although a background lingering discomfort persisted. Pain suppression medications had been significantly reduced to lamotrigine 100 mg twice daily. Her preoperative distribution of sensory dysfunction mildly increased. CONCLUSION For medically refractory TN related to a CM, radiosurgery of the afferent nerve may ameliorate pain without a major decrease in sensation. The more than 30-year history of pain in our patient may have reduced the chance of more significant pain relief.
Collapse
Affiliation(s)
- Matthew Pease
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA,
| | - Joseph Withrow
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alp Ozpinar
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
11
|
Patel A, Dong T, Ansari S, Cohen-Gadol A, Watson GA, Moraes FYD, Nakamura M, Murovic J, Chang SD, Hatiboglu MA, Chung C, Miller JC, Lautenschlaeger T. Toxicity of Radiosurgery for Brainstem Metastases. World Neurosurg 2018; 119:e757-e764. [PMID: 30096494 DOI: 10.1016/j.wneu.2018.07.263] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 07/28/2018] [Accepted: 07/30/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although stereotactic radiosurgery (SRS) is an effective modality in the treatment of brainstem metastases (BSM), radiation-induced toxicity remains a critical concern. To better understand how severe or life-threatening toxicity is affected by the location of lesions treated in the brainstem, a review of all available studies reporting SRS treatment for BSM was performed. METHODS Twenty-nine retrospective studies investigating SRS for BSM were reviewed. RESULTS The rates of grade 3 or greater toxicity, based on the Common Terminology Criteria for Adverse Events, varied from 0 to 9.5% (mean 3.4 ± 2.9%). Overall, the median time to toxicity after SRS was 3 months, with 90% of toxicities occurring before 9 months. A total of 1243 cases had toxicity and location data available. Toxicity rates for lesions located in the medulla were 0.8% (1/131), compared with midbrain and pons, respectively, 2.8% (8/288) and 3.0% (24/811). CONCLUSIONS Current data suggest that brainstem substructure location does not predict for toxicity and lesion volume within this cohort with median tumor volumes 0.04-2.8 cc does not predict for toxicity.
Collapse
Affiliation(s)
- Ajay Patel
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Tuo Dong
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA; Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shaheryar Ansari
- Goodman Campbell Brain and Spine and Department of Neurological Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Aaron Cohen-Gadol
- Goodman Campbell Brain and Spine and Department of Neurological Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Gordon A Watson
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA; Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Fabio Ynoe de Moraes
- Department of Radiation Oncology, University of Toronto - Princess Margaret Cancer Centre, Toronto, Canada
| | - Masaki Nakamura
- Department of Radiation Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Judith Murovic
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Steven D Chang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Mustafa Aziz Hatiboglu
- Department of Neurosurgery, Bezmialem Vakif University Vatan Caddesi, Fatih, Istanbul, Turkey
| | - Caroline Chung
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - James C Miller
- Goodman Campbell Brain and Spine and Department of Neurological Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Tim Lautenschlaeger
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA; Indiana University School of Medicine, Indianapolis, Indiana, USA.
| |
Collapse
|
12
|
Patel A, Mohammadi H, Dong T, Shiue KRY, Frye D, Le Y, Ansari S, Watson GA, Miller JC, Lautenschlaeger T. Brainstem metastases treated with Gamma Knife stereotactic radiosurgery: the Indiana University Health experience. CNS Oncol 2017; 7:15-23. [PMID: 29239214 PMCID: PMC6001560 DOI: 10.2217/cns-2017-0029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Brainstem metastases offer a unique challenge in cancer treatment, yet stereotactic radiosurgery (SRS) has proven to be an effective modality in treating these tumors. This report discusses the clinical outcomes of patients with brainstem metastases treated at Indiana University with Gamma Knife (GK) radiosurgery from 2008 to 2016. 19 brainstem metastases from 14 patients who had follow-up brain imaging were identified. Median tumor volume was 0.04 cc (range: 0.01–2.0 cc). Median prescribed dose was 17.5 Gy to the 50% isodose line (range: 14–22 Gy). Median survival after GK SRS treatment to brainstem lesion was 17.2 months (range: 2.8–45.6 months). The experience at Indiana University confirms the safety and efficacy of range of GK SRS prescription doses (14–22 Gy) to brainstem metastases.
Collapse
Affiliation(s)
- Ajay Patel
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Homan Mohammadi
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Tuo Dong
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | | | - Douglas Frye
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Yi Le
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Shaheryar Ansari
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Gordon A Watson
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - James C Miller
- Goodman Campbell Brain & Spine & Department of Neurological Surgery, Indiana University, Indianapolis, IN 46202, USA
| | - Tim Lautenschlaeger
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| |
Collapse
|
13
|
Murray L, Menard C, Zadeh G, Au K, Bernstein M, Millar BA, Laperriere N, Chung C. Radiosurgery for brainstem metastases with and without whole brain radiotherapy: clinical series and literature review. ACTA ACUST UNITED AC 2016; 6:21-30. [PMID: 28367275 PMCID: PMC5357261 DOI: 10.1007/s13566-016-0281-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/09/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The objective of this study was to investigate outcomes for patients with brainstem metastases treated with stereotactic radiosurgery (SRS). METHODS Patients with brainstem metastases treated with SRS between April 2006 and June 2012 were identified from a prospective database. Patient and treatment-related factors were recorded. Kaplan-Meier analysis was used to calculate survival and freedom from local and distant brain progression. Univariate and multivariate Cox regression was used to identify factors important for overall survival. RESULTS In total, 44 patients received SRS for 48 brainstem metastases of whom 33 (75 %) also received whole brain radiotherapy (WBRT): 23 patients (52 %) WBRT prior to SRS, 6 (13.6 %) WBRT concurrently with SRS and 4 (9.0 %) WBRT after SRS. Eight patients received a second course of WBRT at further progression. Median target volume was 1.33 cc (range 0.04-12.17) and median prescribed marginal dose was 15 Gy (range 10-22). There were four cases of local failure, and 6-month and 1-year freedom from local failure was 84.6 and 76.9 %, respectively. Median overall survival (OS) was 5.4 months. There were four cases of radionecrosis, 2 (4.8 %) of which were symptomatic. The absence of external beam brain radiotherapy (predominantly WBRT) showed a trend towards improved OS on univariate analysis. Neither local nor distant brain failure significantly impacted OS. CONCLUSION This retrospective series of patients treated with SRS for brainstem metastases, largely in combination with at least one course of WBRT, demonstrates that this approach is safe and results in good local control. In this cohort, no variables significantly impacted OS, including intracranial control.
Collapse
Affiliation(s)
- Louise Murray
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Cynthia Menard
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, ON Canada
| | - Karolyn Au
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, ON Canada
| | - Mark Bernstein
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, ON Canada
| | - Barbara-Ann Millar
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Normand Laperriere
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Caroline Chung
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| |
Collapse
|
14
|
Joshi R, Johnson MD, Maitz A, Marvin KS, Olson RE, Grills IS. Utility of graded prognostic assessment in evaluation of patients with brainstem metastases treated with radiosurgery. Clin Neurol Neurosurg 2016; 147:30-3. [DOI: 10.1016/j.clineuro.2016.05.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 05/03/2016] [Indexed: 11/15/2022]
|
15
|
Trifiletti DM, Lee CC, Kano H, Cohen J, Janopaul-Naylor J, Alonso-Basanta M, Lee JYK, Simonova G, Liscak R, Wolf A, Kvint S, Grills IS, Johnson M, Liu KD, Lin CJ, Mathieu D, Héroux F, Silva D, Sharma M, Cifarelli CP, Watson CN, Hack JD, Golfinos JG, Kondziolka D, Barnett G, Lunsford LD, Sheehan JP. Stereotactic Radiosurgery for Brainstem Metastases: An International Cooperative Study to Define Response and Toxicity. Int J Radiat Oncol Biol Phys 2016; 96:280-288. [PMID: 27478166 DOI: 10.1016/j.ijrobp.2016.06.009] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 05/22/2016] [Accepted: 06/07/2016] [Indexed: 11/17/2022]
Abstract
PURPOSE To pool data across multiple institutions internationally and report on the cumulative experience of brainstem stereotactic radiosurgery (SRS). METHODS AND MATERIALS Data on patients with brainstem metastases treated with SRS were collected through the International Gamma Knife Research Foundation. Clinical, radiographic, and dosimetric characteristics were compared for factors prognostic for local control (LC) and overall survival (OS) using univariate and multivariate analyses. RESULTS Of 547 patients with 596 brainstem metastases treated with SRS, treatment of 7.4% of tumors resulted in severe SRS-induced toxicity (grade ≥3, increased odds with increasing tumor volume, margin dose, and whole-brain irradiation). Local control at 12 months after SRS was 81.8% and was improved with increasing margin dose and maximum dose. Overall survival at 12 months after SRS was 32.7% and impacted by age, gender, number of metastases, tumor histology, and performance score. CONCLUSIONS Our study provides additional evidence that SRS has become an option for patients with brainstem metastases, with an excellent benefit-to-risk ratio in the hands of experienced clinicians. Prior whole-brain irradiation increases the risk of severe toxicity in brainstem metastasis patients undergoing SRS.
Collapse
Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia.
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, People's Republic of China
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jonathan Cohen
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James Janopaul-Naylor
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - John Y K Lee
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gabriela Simonova
- Department of Radiation and Stereotactic Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Roman Liscak
- Department of Radiation and Stereotactic Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Amparo Wolf
- Department of Neurosurgery, New York University Lagone Medical Center, New York, New York
| | - Svetlana Kvint
- Department of Neurosurgery, New York University Lagone Medical Center, New York, New York
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Matthew Johnson
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Kang-Du Liu
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, People's Republic of China
| | - Chung-Jung Lin
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, People's Republic of China
| | - David Mathieu
- Division of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Québec, Canada
| | - France Héroux
- Division of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Québec, Canada
| | - Danilo Silva
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Mayur Sharma
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Christopher P Cifarelli
- Departments of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown, West Virginia
| | - Christopher N Watson
- Departments of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown, West Virginia
| | - Joshua D Hack
- Departments of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown, West Virginia
| | - John G Golfinos
- Department of Neurosurgery, New York University Lagone Medical Center, New York, New York
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Lagone Medical Center, New York, New York
| | - Gene Barnett
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia; Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| |
Collapse
|
16
|
Liu SH, Murovic J, Wallach J, Cui G, Soltys SG, Gibbs IC, Chang SD. CyberKnife radiosurgery for brainstem metastases: Management and outcomes and a review of the literature. J Clin Neurosci 2016; 25:105-10. [PMID: 26778047 DOI: 10.1016/j.jocn.2015.10.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 10/10/2015] [Indexed: 11/20/2022]
Abstract
To our knowledge this paper is the first to use recursive partitioning analysis (RPA) for brainstem metastasis (BSM) patient outcomes, after CyberKnife radiosurgery (CKRS; Accuray, Sunnyvale, CA, USA); nine similar previous publications used mainly Gamma Knife radiosurgery (Elekta AB, Stockholm, Sweden). Retrospective chart reviews from 2006-2013 of 949 CKRS-treated brain metastasis patients showed 54 BSM patients (5.7%): 35 RPA Class II (65%) and 19 Class III (35%). There were 30 women (56%) and 24 men (44%). The median age was 59 years (range 36-80) and median follow-up was 5 months (range 1-52). Twenty-three patients (43%) had lung carcinoma BSM and 12 (22%) had breast cancer BSM. Fifty-four RPA Class II and III BSM patients had a median overall survival (OS) of 5 months, and for each Class 8 and 2 months, respectively. Of 36 RPA Class II and III patients with available symptoms (n=31) and findings (n=33), improvement/stability occurred in the majority for symptoms (86%) and findings (92%). Of 35 cases, 28 (80%) achieved BSM local control (LC); 13/14 with breast histology (93%) and 10/13 with lung histology (77%). All six RPA Class II and III patients with controlled extracranial systemic disease (ESD) experienced LC. Median tumor volume was 0.14 cm(3); of 34 RPA Class II and III cases, 26 LC patients had a 0,13 cm(3) median tumor volume while it was 0.27 cm(3) in the eight local failures. Of 35 cases, single session equivalent dosages less than the median (n=13), at the 17.9 Gy median (n=5) and greater than the median (n=17) had BSM LC in 10 (77%), four (80%) and 14 cases (82%), respectively. Univariate analysis showed Karnofsky Performance Score, RPA Class and ESD-control predicted OS. CKRS is useful for RPA Class II and III BSM patients with effective clinical and local BSM control.
Collapse
Affiliation(s)
- Szu-Hao Liu
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, R225, Stanford, CA 94305-5327, USA
| | - Judith Murovic
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, R225, Stanford, CA 94305-5327, USA
| | - Jonathan Wallach
- Department of Radiation Oncology, Stanford University School of Medicine, 875 Blake Wilbur Drive, Stanford, CA 94305-5327, USA
| | - Guosheng Cui
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, R225, Stanford, CA 94305-5327, USA
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University School of Medicine, 875 Blake Wilbur Drive, Stanford, CA 94305-5327, USA
| | - Iris C Gibbs
- Department of Radiation Oncology, Stanford University School of Medicine, 875 Blake Wilbur Drive, Stanford, CA 94305-5327, USA
| | - Steven D Chang
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, R225, Stanford, CA 94305-5327, USA.
| |
Collapse
|
17
|
Trifiletti DM, Lee CC, Winardi W, Patel NV, Yen CP, Larner JM, Sheehan JP. Brainstem metastases treated with stereotactic radiosurgery: safety, efficacy, and dose response. J Neurooncol 2015; 125:385-92. [PMID: 26341374 DOI: 10.1007/s11060-015-1927-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 09/01/2015] [Indexed: 11/28/2022]
Abstract
The safety and efficacy of stereotactic radiosurgery (SRS) in the brainstem is questioned by some over concern of violating historical brainstem SRS dose tolerance. Our purpose was to report on the clinical outcomes of patients treated at our institution with radiosurgery for brainstem metastases. Patients with metastatic tumors within or directly abutting the brainstem from 1992 to 2014 were analyzed. Patient and tumor characteristics, SRS parameters, and toxicity were recorded and analyzed for associations with local control and survival. Multivariate statistical analysis was performed using Cox proportional hazards modeling. One-hundred and eighty-nine (189) brainstem metastases from 161 patients were included in our analysis. Whole brain irradiation was administered prior to SRS in 52 % of patients. The median margin dose was 18 Gy prescribed to the 50 % isodose line. Median imaging follow up was 5.4 months and median survival was 5.5 months after SRS. At last follow up, local control was achieved in 87.3 % of brainstem lesions treated. There were 3 recorded events of grade 3-5 toxicity (1.8 %). On multivariate analysis, a margin dose ≥16 Gy was associated with improved local control (p = 0.049) and greater KPS score was associated with improved overall survival following SRS (p = 0.024). Patients with brainstem metastases who have limited intracranial disease and/or who have received whole brain irradiation should be considered for SRS. Margin doses of at least 16 Gy are associated with superior local control, and serious radiation toxicity in SRS for brainstem metastasis appears rare.
Collapse
Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia, 1240 Lee Street, Box 800383, Charlottesville, VA, 22908, USA.
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, ROC
| | - William Winardi
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Nirav V Patel
- Department of Radiation Oncology, University of Virginia, 1240 Lee Street, Box 800383, Charlottesville, VA, 22908, USA
| | - Chun-Po Yen
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, ROC
| | - James M Larner
- Department of Radiation Oncology, University of Virginia, 1240 Lee Street, Box 800383, Charlottesville, VA, 22908, USA
| | - Jason P Sheehan
- Department of Radiation Oncology, University of Virginia, 1240 Lee Street, Box 800383, Charlottesville, VA, 22908, USA.,Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, ROC
| |
Collapse
|
18
|
Voong KR, Farnia B, Wang Q, Luo D, McAleer MF, Rao G, Guha-Thakurta N, Likhacheva A, Ghia AJ, Brown PD, Li J. Gamma knife stereotactic radiosurgery in the treatment of brainstem metastases: The MD Anderson experience. Neurooncol Pract 2015; 2:40-47. [PMID: 26034640 DOI: 10.1093/nop/npu032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Brainstem metastases (BSMs) represent a significant treatment challenge. Stereotactic radiosurgery (SRS) is often used to treat BSM. We report our experience in the treatment of BSM with Gamma Knife SRS (GK_SRS). METHODS The records of 1962 patients with brain metastases treated with GK_SRS between 2009 and 2013 were retrospectively reviewed. Seventy-four patients with 77 BSMs and follow-up brain imaging were identified. Local control (LC), overall survival (OS), progression-free survival (PFS), and toxicity were assessed. RESULTS Median follow-up was 5.5 months (range, 0.2-48.5 months). Median tumor volume was 0.13 cm3 (range, 0.003-5.58 cm3). Median treatment dose was 16 Gy (range, 10-20 Gy) prescribed to 50% isodose line (range, 40%-86%). Crude LC was 94% (72/77). Kaplan-Meier estimate of median OS was 8.5 months (95% CI, 5.6-9.4 months). Symptomatic lesions and larger lesions, especially size ≥2 cm3, were associated with worse LC (HR = 8.70, P = .05; HR = 14.55, P = .02; HR = 62.81, P < .001) and worse OS (HR = 2.00, P = .02; HR = 2.14, P = .03; HR = 2.81, P = .008). Thirty-six percent of BSMs were symptomatic, of which 36% (10/28) resolved after SRS and 50% (14/28) had stable or improved symptoms. Actuarial median PFS was 3.9 months (95% CI, 2.7-4.9 months). Midbrain location was significant for worse PFS (HR = 2.29, P = .03). Toxicity was low (8%, 6/74), with size and midbrain location associated with increased toxicity (HR 1.57, P = .05; HR = 5.25, P = .045). CONCLUSIONS GK_SRS is associated with high LC (94%) and low toxicity (8%) for BSMs. Presence of symptoms or lesion size ≥ 2 cm3 was predictive of worse LC and OS.
Collapse
Affiliation(s)
- Khinh Ranh Voong
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Benjamin Farnia
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Qianghu Wang
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Dershan Luo
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Mary F McAleer
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Ganesh Rao
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Nandita Guha-Thakurta
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Anna Likhacheva
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Amol J Ghia
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Paul D Brown
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| | - Jing Li
- Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas (K.R.V., B.F., Q.W., M.F.M., A.L., A.J.G., P.D.B., J.L.); Department of Radiation Physics , The University of Texas MD Anderson Cancer Center , Houston, Texas (D.L.); Department of Neurosurgery , The University of Texas MD Anderson Cancer Center , Houston, Texas (G.R.); Department of Radiology , The University of Texas MD Anderson Cancer Center , Houston, Texas (N.G.-T.)
| |
Collapse
|
19
|
DU C, Li Z, Wang Z, Wang L, Tian YU. Stereotactic aspiration combined with gamma knife radiosurgery for the treatment of cystic brainstem metastasis originating from lung adenosquamous carcinoma: A case report. Oncol Lett 2015; 9:1607-1613. [PMID: 25789009 PMCID: PMC4356421 DOI: 10.3892/ol.2015.2968] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 01/22/2015] [Indexed: 11/23/2022] Open
Abstract
Brainstem metastases have a poor prognosis and are difficult to manage. The present study describes the first case of histopathologically-confirmed brainstem metastasis originating from lung adenosquamous carcinoma, and discusses the outcomes of treatment by stereotactic aspiration combined with gamma knife radiosurgery (GKRS). A 59-year-old female presented with a cystic mass (15×12×13 mm; volume, 1.3 cm3) located in the pons, two years following surgical treatment for adenosquamous carcinoma of the lung. The patient received initial GKRS for the lesion in the pons with a total dose of 54.0 Gy, however, the volume of the mass subsequently increased to 3.9 cm3 over a period of three months. Computed tomography-guided stereotactic biopsy and aspiration of the intratumoral cyst were performed, yielding 2.0 cm3 of yellow-white fluid. Histology confirmed the diagnosis of adenosquamous carcinoma. Aspiration provided immediate symptomatic relief, and was followed one week later by repeat GKRS with a dose of 12.0 Gy. The patient survived for 12 months following the repeat GKRS; however, later succumbed to the disease after lapsing into a two-week coma. The findings of this case suggest that stereotactic aspiration of cysts may improve the effects of GKRS for the treatment of cystic brainstem metastasis; the decrease in tumor volume allowed a higher radiation dose to be administered with a lower risk of radiation-induced side effects. Therefore, stereotactic aspiration combined with GKRS may be an effective treatment for brainstem metastasis originating from adenosquamous carcinoma.
Collapse
Affiliation(s)
- Chao DU
- Department of Neurosurgery, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Zhaohui Li
- Department of Neurosurgery, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Zhijia Wang
- Department of Radiology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Liping Wang
- Department of Pathology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Y U Tian
- Department of Neurosurgery, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| |
Collapse
|
20
|
Gamma knife treatment of brainstem metastases. Int J Mol Sci 2014; 15:9748-61. [PMID: 24886816 PMCID: PMC4100118 DOI: 10.3390/ijms15069748] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Revised: 05/01/2014] [Accepted: 05/05/2014] [Indexed: 11/16/2022] Open
Abstract
The management of brainstem metastases is challenging. Surgical treatment is usually not an option, and chemotherapy is of limited utility. Stereotactic radiosurgery has emerged as a promising palliative treatment modality in these cases. The goal of this study is to assess our single institution experience treating brainstem metastases with Gamma Knife radiosurgery (GKRS). This retrospective chart review studied 41 patients with brainstem metastases treated with GKRS. The most common primary tumors were lung, breast, renal cell carcinoma, and melanoma. Median age at initial treatment was 59 years. Nineteen (46%) of the patients received whole brain radiation therapy (WBRT) prior to or concurrent with GKRS treatment. Thirty (73%) of the patients had a single brainstem metastasis. The average GKRS dose was 17 Gy. Post-GKRS overall survival at six months was 42%, at 12 months was 22%, and at 24 months was 13%. Local tumor control was achieved in 91% of patients, and there was one patient who had a fatal brain hemorrhage after treatment. Karnofsky performance score (KPS) >80 and the absence of prior WBRT were predictors for improved survival on multivariate analysis (HR 0.60 (p = 0.02), and HR 0.28 (p = 0.02), respectively). GKRS was an effective treatment for brainstem metastases, with excellent local tumor control.
Collapse
|
21
|
Wang DD, Lau D, Rolston JD, Englot DJ, Sneed PK, McDermott MW. Pain experience using conventional versus angled anterior posts during stereotactic head frame placement for radiosurgery. J Clin Neurosci 2014; 21:1538-42. [PMID: 24814855 DOI: 10.1016/j.jocn.2014.02.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 02/05/2014] [Indexed: 10/25/2022]
Abstract
Stereotactic frame placement for radiosurgery is assumed to be an uncomfortable experience. We developed angled anterior posts for the Leksell frame to avoid pin penetration of the temporalis muscle. This study aimed to determine the frequency of angled post requirement and quantify the patient pain experience from frame placement. We prospectively enrolled 63 patients undergoing radiosurgery. Angled posts were used when conventional post trajectory was posterior or within 3mm of the superior temporal line to avoid temporalis muscle penetration. Pain scores (0 to 10) were collected prior to frame placement, immediately after frame placement, before radiosurgery, after radiosurgery, and a day after radiosurgery. A total of 63 patients were enrolled: 33 (48%) patients required angled posts. Women were significantly more likely to require angled posts than men (60.0% versus 33.3%, respectively; p=0.034). Mean pain scores were very low, ranging from 0.33 to 2.23. There were no significant differences in pain outcomes between both groups at all time points. Stereotactic frame placement is not perceived to be a painful procedure. This information may be useful when counseling patients about the pain experience with frame application and the option of using angled anterior posts.
Collapse
Affiliation(s)
- Doris D Wang
- Department of Neurosurgery, University of California San Francisco, 505 Parnassus Avenue, M 779, San Francisco, CA 94143-0112, USA
| | - Darryl Lau
- Department of Neurosurgery, University of California San Francisco, 505 Parnassus Avenue, M 779, San Francisco, CA 94143-0112, USA
| | - John D Rolston
- Department of Neurosurgery, University of California San Francisco, 505 Parnassus Avenue, M 779, San Francisco, CA 94143-0112, USA
| | - Dario J Englot
- Department of Neurosurgery, University of California San Francisco, 505 Parnassus Avenue, M 779, San Francisco, CA 94143-0112, USA
| | - Patricia K Sneed
- Department of Radiation Oncology, University of California San Francisco, CA, USA
| | - Michael W McDermott
- Department of Neurosurgery, University of California San Francisco, 505 Parnassus Avenue, M 779, San Francisco, CA 94143-0112, USA.
| |
Collapse
|
22
|
Anaesthetic techniques for unique cancer surgery procedures. Best Pract Res Clin Anaesthesiol 2013; 27:513-26. [DOI: 10.1016/j.bpa.2013.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 09/26/2013] [Accepted: 09/30/2013] [Indexed: 11/19/2022]
|