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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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Upadhyay R, Klamer BG, Perlow HK, White JR, Bazan JG, Jhawar SR, Blakaj DM, Grecula JC, Arnett A, Mestres-Villanueva MA, Healy EH, Thomas EM, Chakravarti A, Raval RR, Lustberg M, Williams NO, Palmer JD, Beyer SJ. Stereotactic Radiosurgery for Women Older than 65 with Breast Cancer Brain Metastases. Cancers (Basel) 2023; 16:137. [PMID: 38201564 PMCID: PMC10778270 DOI: 10.3390/cancers16010137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 12/20/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Breast cancer is the second most common cause of brain metastases (BM). Despite increasing incidence of BM in older women, there are limited data on the optimal management of BM in this age group. In this study, we assessed the survival outcomes and treatment patterns of older breast cancer patients ≥65 years old with BM compared to younger patients at our institution. METHODS An IRB-approved single-institutional retrospective review of biopsy-proven breast cancer patients with BM treated with 1- to 5-fraction stereotactic radiation therapy (SRS) from 2015 to 2020 was performed. Primary endpoint was intracranial progression-free survival (PFS) defined as the time interval between the end of SRS to the date of the first CNS progression. Secondary endpoints were overall survival (OS) from the end of SRS and radiation treatment patterns. Kaplan-Meier estimates and Cox proportional hazard regression method were used for survival analyses. RESULTS A total of 112 metastatic breast cancer patients with BMs were included of which 24 were ≥65 years old and 88 were <65 years old. Median age at RT was 72 years (range 65-84) compared to 52 years (31-64) in younger patients. There were significantly higher number of older women with ER/PR positive disease (75% vs. 49%, p = 0.036), while younger patients were more frequently triple negative (32% vs. 12%, p = 0.074) and HER2 positive (42% vs. 29%, p = 0.3). Treatment-related adverse events were similar in both groups. Overall, 14.3% patients had any grade radiation necrosis (RN) (older vs. young: 8.3% vs. 16%, p = 0.5) while 5.4% had grade 3 or higher RN (0% vs. 6.8%, p = 0.7). Median OS after RT was poorer in older patients compared to younger patients (9.5 months vs. 14.5 months, p = 0.037), while intracranial PFS from RT was similar between the two groups (9.7 months vs. 7.1 months, p = 0.580). On univariate analysis, significant predictors of OS were age ≥65 years old (hazard risk, HR = 1.70, p = 0.048), KPS ≤ 80 (HR = 2.24, p < 0.001), HER2 positive disease (HR = 0.46, p < 0.001), isolated CNS metastatic disease (HR = 0.29, p < 0.001), number of brain metastases treated with RT (HR = 1.06, p = 0.028), and fractionated SRS (HR = 0.53, p = 0.013). On multivariable analysis, KPS ≤ 80, HER2 negativity and higher number of brain metastases predicted for poorer survival, while age was not a significant factor for OS after adjusting for other variables. Patients who received systemic therapy after SRS had a significantly improved OS on univariate and multivariable analysis (HR = 0.32, p < 0.001). Number of brain metastases treated was the only factor predictive of worse PFS (HR = 1.06, p = 0.041), which implies a 6% additive risk of progression for every additional metastasis treated. CONCLUSIONS Although older women had poorer OS than younger women, OS was similar after adjusting for KPS, extracranial progression, and systemic therapy; and there was no difference in rates of intracranial PFS, neurological deaths, and LMD in the different age groups. This study suggests that age alone may not play an independent role in treatment-selection and that outcomes for breast cancer patients with BMs and personalized decision-making including other clinical factors should be considered. Future studies are warranted to assess neurocognitive outcomes and other radiation treatment toxicities in older patients.
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Affiliation(s)
- Rituraj Upadhyay
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA; (R.U.); (H.K.P.); (S.R.J.); (D.M.B.); (J.C.G.); (A.A.); (M.A.M.-V.); (E.M.T.); (A.C.); (R.R.R.); (J.D.P.)
| | - Brett G. Klamer
- Department of Biostatistics, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA;
| | - Haley K. Perlow
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA; (R.U.); (H.K.P.); (S.R.J.); (D.M.B.); (J.C.G.); (A.A.); (M.A.M.-V.); (E.M.T.); (A.C.); (R.R.R.); (J.D.P.)
| | - Julia R. White
- Department of Radiation Oncology, The University of Kansas Medical Center, Kansas City, KS 66103, USA;
| | - Jose G. Bazan
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, Duarte, CA 91010, USA;
| | - Sachin R. Jhawar
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA; (R.U.); (H.K.P.); (S.R.J.); (D.M.B.); (J.C.G.); (A.A.); (M.A.M.-V.); (E.M.T.); (A.C.); (R.R.R.); (J.D.P.)
| | - Dukagjin M. Blakaj
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA; (R.U.); (H.K.P.); (S.R.J.); (D.M.B.); (J.C.G.); (A.A.); (M.A.M.-V.); (E.M.T.); (A.C.); (R.R.R.); (J.D.P.)
| | - John C. Grecula
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA; (R.U.); (H.K.P.); (S.R.J.); (D.M.B.); (J.C.G.); (A.A.); (M.A.M.-V.); (E.M.T.); (A.C.); (R.R.R.); (J.D.P.)
| | - Andrea Arnett
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA; (R.U.); (H.K.P.); (S.R.J.); (D.M.B.); (J.C.G.); (A.A.); (M.A.M.-V.); (E.M.T.); (A.C.); (R.R.R.); (J.D.P.)
| | - Mariella A. Mestres-Villanueva
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA; (R.U.); (H.K.P.); (S.R.J.); (D.M.B.); (J.C.G.); (A.A.); (M.A.M.-V.); (E.M.T.); (A.C.); (R.R.R.); (J.D.P.)
| | - Erin H. Healy
- Department of Radiation Oncology, University of California, Irvine, CA 92697, USA;
| | - Evan M. Thomas
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA; (R.U.); (H.K.P.); (S.R.J.); (D.M.B.); (J.C.G.); (A.A.); (M.A.M.-V.); (E.M.T.); (A.C.); (R.R.R.); (J.D.P.)
| | - Arnab Chakravarti
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA; (R.U.); (H.K.P.); (S.R.J.); (D.M.B.); (J.C.G.); (A.A.); (M.A.M.-V.); (E.M.T.); (A.C.); (R.R.R.); (J.D.P.)
| | - Raju R. Raval
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA; (R.U.); (H.K.P.); (S.R.J.); (D.M.B.); (J.C.G.); (A.A.); (M.A.M.-V.); (E.M.T.); (A.C.); (R.R.R.); (J.D.P.)
| | - Maryam Lustberg
- Department of Medical Oncology, Yale Cancer Center, New Haven, CT 06511, USA;
| | - Nicole O. Williams
- Department of Medical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA;
| | - Joshua D. Palmer
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA; (R.U.); (H.K.P.); (S.R.J.); (D.M.B.); (J.C.G.); (A.A.); (M.A.M.-V.); (E.M.T.); (A.C.); (R.R.R.); (J.D.P.)
| | - Sasha J. Beyer
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA; (R.U.); (H.K.P.); (S.R.J.); (D.M.B.); (J.C.G.); (A.A.); (M.A.M.-V.); (E.M.T.); (A.C.); (R.R.R.); (J.D.P.)
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Harikar MM, Venkataram T, Palmisciano P, Scalia G, Baldoncini M, Cardali SM, Umana GE, Ferini G. Comparison of Staged Stereotactic Radiosurgery and Fractionated Stereotactic Radiotherapy in Patients with Brain Metastases > 2 cm without Prior Whole Brain Radiotherapy: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 178:213-232.e6. [PMID: 37543203 DOI: 10.1016/j.wneu.2023.07.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/30/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE To compare fractionated stereotactic radiotherapy (FSRT) with staged stereotactic radiosurgery (SSRS) in patients with brain metastases >2 cm without prior whole brain radiotherapy. METHODS In this systematic review and meta-analysis, PubMed, Scopus, Web of Science, Embase, and Cochrane were searched to include studies that evaluated FSRT and/or SSRS for brain metastases >2 cm or 4 cm3 in adult patients with a known primary malignancy and no prior history of whole brain radiotherapy. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed and an indirect random-effect meta-analyses was conducted to compare treatment outcomes between the two modalities. RESULTS A total of 10 studies were included, comprising 612 (778 metastases) and 250 patients (265 metastases) in the SSRS and FSRT groups, respectively. The SSRS group had significantly older patients (66.6 ± 17.51 years vs. 62.37 ± 37.89 years; P = 0.029) with lower rate of control of primary disease (11.59% vs. 78.7%, P < 0.00001), and more patients with Karnofsky performance status ≥70 at baseline (92.81% vs. 88.56%; P = 0.045). FSRT was associated with a statistically nonsignificant but clinically important lower 12-month overall survival (44.75% [95% confidence interval [CI]: 30.48%-59.95%] vs. 53.25% [95%CI: 45.15%-61.19%], P = 0.1615) and higher rate of salvage radiotherapy (18.18% [95%CI: 8.75%-34%] vs. 12.27% [95%CI: 5.98%-23.53%], P = 0.0841). Both groups had comparable rates of local tumor control, mortality, tumor progression, recurrence, neurological death, and 6-month overall survival. CONCLUSIONS SSRS and FSRT were found to be comparable for treating brain metastases >2 cm not previously irradiated. Given the paucity of such studies, trials directly comparing the two treatment strategies are warranted to support these findings.
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Affiliation(s)
- Mandara M Harikar
- Clinical Trials Programme, Usher Institute of Molecular, Genetic and Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Tejas Venkataram
- Department of Neurosurgery, St. John's Medical College Hospital, Bangalore, India
| | - Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Gianluca Scalia
- Department of Head and Neck Surgery, Neurosurgery Unit, Garibaldi Hospital, Catania, Italy
| | - Matias Baldoncini
- Department of Neurological Surgery, San Fernando Hospital, San Fernando, Argentina
| | - Salvatore Massimiliano Cardali
- Department of Neurosurgery, Azienda Ospedaliera Papardo, University of Messina, Messina, Italy; Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
| | - Giuseppe E Umana
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy.
| | - Gianluca Ferini
- Department of Radiation Oncology, REM Radioterapia srl, Viagrande, Italy
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Sağlam Y. A novel weight optimized dynamic conformal arcs with TrueBeam™ Linac for very small tumors (≤1 cc) with single isocenter of multiple brain metastases (2≤, ≥4) in stereotactic radiosurgery: A comparison with volumetric modulated arc therapy. J Cancer Res Ther 2023; 19:1297-1304. [PMID: 37787298 DOI: 10.4103/jcrt.jcrt_1829_21] [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] [Indexed: 11/04/2022]
Abstract
Introduction We evaluated whether improved increase delivery efficiency of weight optimized dynamic conformal arc (WO-DCA) therapy in comparison to volumetric modulated arc therapy (VMAT) with single isocenter for SRS treatment of very small volume and multiple brain metastases (BMs). Materials and Methods 20 patients having a less than 1 cc volume and 2≤, ≥4 of multiple BMs, redesigned for 20 Gy in 1 fraction using WO-DCA and VMAT techniques with double full coplanar and three partial noncoplanar arcs. Plan qualities were compared using tumor coverage, conformity index (CI), gradient index (GI), V4Gy, V10Gy, and V12Gy volumes of brain, monitor units (MUs), and percent of quality assurance pass rate (QA%). Results Both techniques satisfied clinical requirements in coverage and CI. VMAT had a significantly higher MU and mean GI than WO-DCA (for MUs; 2330 vs. 1991; P < 0.001, and for GI; 4.72 vs. 3.39; P < 0.001). WO-DCA was found significantly lower V4Gy (171.11 vs. 232.80 cm3, P < 0.001), V10Gy (25.82 vs. 29.71 cm3, P < 0.05), and V12Gy (14.35 vs. 17.28 cm3, P < 0.05) volumes than VMAT. WO-DCA was associated with markedly increase QA pass rates for all plans (97.65% vs. 92.64%, P < 0.001). Conclusions WO-DCA may be the first choice compared to the VMAT in reducing the dose in the brain and minimizing small-field dosimetric errors for very small SRS treatment of brain metastases in the range of ≤ 1 cc and 2≤, ≥4.
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Affiliation(s)
- Yücel Sağlam
- Department of Radiation Oncology, School of Medicine, Koc University, Topkapi, Istanbul, Turkey
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Shiue K, Sahgal A, Lo SS. Precision Radiation for Brain Metastases With a Focus on Hypofractionated Stereotactic Radiosurgery. Semin Radiat Oncol 2023; 33:114-128. [PMID: 36990629 DOI: 10.1016/j.semradonc.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
There are multiple published randomized controlled trials supporting single-fraction stereotactic radiosurgery (SF-SRS) for patients presenting with 1 to 4 brain metastases, with the benefit of minimizing radiation-induced neurocognitive sequelae as compared to whole brain radiotherapy . More recently, the dogma of SF-SRS as the only means of delivering an SRS treatment has been challenged by hypofractionated SRS (HF-SRS). The ability to deliver 25-35 Gy in 3-5 HF-SRS fractions is a direct consequence of the evolution of radiation technologies to allow image guidance, specialized treatment planning, robotic delivery and/or patient positioning corrections in all 6 degrees-of-freedom, and frameless head immobilization. The intent is to mitigate the potentially devastating complication of radiation necrosis and improve rates of local control for larger metastases. This narrative review provides an overview of outcomes specific to HF-SRS in addition to the more recent developments of staged SRS, preoperative SRS, and hippocampal avoidance-whole brain radiotherapy with simultaneous integrated boost.
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Willman M, Willman J, Lucke-Wold B. Endocrine resistant breast cancer: brain metastasis. EXPLORATION OF TARGETED ANTI-TUMOR THERAPY 2022; 3:240-251. [PMID: 35505937 PMCID: PMC9060566 DOI: 10.37349/etat.2022.00081] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 03/09/2022] [Indexed: 02/05/2023] Open
Abstract
Endocrine resistant breast cancer metastasis continues to serve as a significant clinical challenge with high morbidity and mortality for patients. As the number of breast cancer cases continues to rise, the rate of brain metastasis has also increased. For single lesions or a large symptomatic lesion with other smaller lesions, surgical resection is a viable option in non-eloquent regions. Stereotactic radiosurgery is a great option for post-operative therapy or for 10 or fewer small lesions (< 3 cm in size). Whole-brain radiation can be used sparingly for large tumor burdens but should encompass hippocampus sparing techniques. Chemotherapy options have remained relatively limited due to decreased permeability of the blood-brain barrier. Emerging monoclonal antibody treatments have offered initial promise, especially for endocrine resistant breast cancer metastasis.
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Affiliation(s)
- Matthew Willman
- Department of Neurosurgery, University of Florida, Gainesville, FL 32610-0265, USA
| | - Jonathan Willman
- Department of Neurosurgery, University of Florida, Gainesville, FL 32610-0265, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32610-0265, USA
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