1
|
Metastatic Neoplasm Volume Kinetics Following Two-Staged Stereotactic Radiosurgery. World Neurosurg 2022; 161:e210-e219. [PMID: 35123024 DOI: 10.1016/j.wneu.2022.01.109] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Multisession staged stereotactic radiosurgery (2-SSRS) represents an alternative approach for management of large brain metastases (LBMs), with potential advantages over fractionated SRS. We investigated the clinical efficacy and safety of 2-SSRS in patients with LBMs. METHODS LBMs patients treated with 2-SSRS between 2014-2020 were evaluated. Demographic, clinical, and radiologic information was obtained. Volumetric measurements at first SSRS, second SSRS, and follow-up imaging studies were obtained. Characteristics that might predict response to 2-SSRS were evaluated through Fischer-exact or Mann-Whitney U test. RESULTS Twenty-four patients with 26 LBMs were included in the study. Median marginal doses for first and second SSRS were 15 Gy (14-18 Gy) and 15 Gy (12-16 Gy), respectively. Median tumor volumes at first SSRS, second SSRS, and 3-month follow-up were 8.1 cm3 (1.5-28.5 cm3), 3.3 cm3 (0.8-26.1 cm3), and 2.2 cm3 (0.2-10.1 cm3), respectively. Overall, 24/26 lesions (92%) demonstrated early local control following the first SSRS with 17 lesions (71%) demonstrating a decrease of >30% in the T1 post-contrast MRI volume before the second SSRS and 3 lesions (12%) remaining stable. Eventually, four lesions showed disease progression after 2-SSRS. The median time to local progression was not reached and the median time to intracranial progression was 9.1 months. CONCLUSIONS Our study supports the effectiveness and safety of 2-SSRS as a treatment modality for patients with large, symptomatic brain metastases, especially in poor surgical candidates. The local failure rate and low occurrence of adverse effects are comparable to other staged radiosurgery studies.
Collapse
|
2
|
Mitchell D, Kwon HJ, Kubica PA, Huff WX, O’Regan R, Dey M. Brain metastases: An update on the multi-disciplinary approach of clinical management. Neurochirurgie 2022; 68:69-85. [PMID: 33864773 PMCID: PMC8514593 DOI: 10.1016/j.neuchi.2021.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/16/2021] [Accepted: 04/03/2021] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Brain metastasis (BM) is the most common malignant intracranial neoplasm in adults with over 100,000 new cases annually in the United States and outnumbering primary brain tumors 10:1. OBSERVATIONS The incidence of BM in adult cancer patients ranges from 10-40%, and is increasing with improved surveillance, effective systemic therapy, and an aging population. The overall prognosis of cancer patients is largely dependent on the presence or absence of brain metastasis, and therefore, a timely and accurate diagnosis is crucial for improving long-term outcomes, especially in the current era of significantly improved systemic therapy for many common cancers. BM should be suspected in any cancer patient who develops new neurological deficits or behavioral abnormalities. Gadolinium enhanced MRI is the preferred imaging technique and BM must be distinguished from other pathologies. Large, symptomatic lesion(s) in patients with good functional status are best treated with surgery and stereotactic radiosurgery (SRS). Due to neurocognitive side effects and improved overall survival of cancer patients, whole brain radiotherapy (WBRT) is reserved as salvage therapy for patients with multiple lesions or as palliation. Newer approaches including multi-lesion stereotactic surgery, targeted therapy, and immunotherapy are also being investigated to improve outcomes while preserving quality of life. CONCLUSION With the significant advancements in the systemic treatment for cancer patients, addressing BM effectively is critical for overall survival. In addition to patient's performance status, therapeutic approach should be based on the type of primary tumor and associated molecular profile as well as the size, number, and location of metastatic lesion(s).
Collapse
Affiliation(s)
- D Mitchell
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - HJ Kwon
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - PA Kubica
- Department of Neurosurgery, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA
| | - WX Huff
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - R O’Regan
- Department of Medicine/Hematology Oncology, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA
| | - M Dey
- Department of Neurosurgery, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA,Correspondence Should Be Addressed To: Mahua Dey, MD, University of Wisconsin School of Medicine & Public Health, 600 Highland Ave, Madison, WI 53792; Tel: 317-274-2601;
| |
Collapse
|
3
|
Vellayappan BA, McGranahan T, Graber J, Taylor L, Venur V, Ellenbogen R, Sloan AE, Redmond KJ, Foote M, Chao ST, Suh JH, Chang EL, Sahgal A, Lo SS. Radiation Necrosis from Stereotactic Radiosurgery-How Do We Mitigate? Curr Treat Options Oncol 2021; 22:57. [PMID: 34097171 DOI: 10.1007/s11864-021-00854-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2021] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT Intracranial stereotactic radiosurgery (SRS) is an effective and convenient treatment for many brain conditions. Data regarding safety come mostly from retrospective single institutional studies and a small number of prospective studies. Variations in target delineation, treatment delivery, imaging follow-up protocols and dose prescription limit the interpretation of this data. There has been much clinical focus on radiation necrosis (RN) in particular, as it is being increasingly recognized on follow-up imaging. Symptomatic RN may be treated with medical therapy (such as corticosteroids and bevacizumab) with surgical resection being reserved for refractory patients. Nevertheless, RN remains a challenging condition to manage, and therefore upfront patient selection for SRS remains critical to provide complication-free control. Mitigation strategies need to be considered in situations where the baseline risk of RN is expected to be high-such as large target volume or re-irradiation. These may involve reduction in the prescribed dose or hypofractionated stereotactic radiation therapy (HSRT). Recently published guidelines and international meta-analysis report the benefit of HSRT in larger lesions, without compromising control rates. However, careful attention to planning parameters and SRS techniques still need to be adhered, even with HSRT. In cases where the risk is deemed to be high despite mitigation, a combination approach of surgery with or without post-operative radiation should be considered.
Collapse
Affiliation(s)
- Balamurugan A Vellayappan
- Department of Radiation oncology, National University Cancer Institute, 1E Kent Ridge Road, Level 7 Tower block, Singapore, 119228, Singapore.
| | - Tresa McGranahan
- Department of Neurology, Alvord Brain Tumor Center, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Jerome Graber
- Department of Neurology, Alvord Brain Tumor Center, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Lynne Taylor
- Department of Neurology, Alvord Brain Tumor Center, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Vyshak Venur
- Department of Neurology, Alvord Brain Tumor Center, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Richard Ellenbogen
- Department of Neurology, Alvord Brain Tumor Center, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Andrew E Sloan
- Department of Neurological Surgery, Seidman Cancer Center and University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH, USA
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, MD, USA
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Samuel T Chao
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John H Suh
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eric L Chang
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| |
Collapse
|
4
|
Efficacy and safety of hypofractionated stereotactic radiotherapy for brain metastases using three fractions: A single-centre retrospective study. Cancer Radiother 2021; 25:763-770. [PMID: 34083125 DOI: 10.1016/j.canrad.2021.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/30/2021] [Accepted: 05/08/2021] [Indexed: 12/27/2022]
Abstract
PURPOSE Hypofractionated stereotactic radiotherapy (HFSRT) has become a standard of care for patients with a limited number of brain metastases (BM). An increasing number of linear accelerators (LA) are able to accurately perform HFSRT including VersaHD® (Elekta®) LA. The main aim of this study was to report clinical outcomes of BM treated by HFSRT using 3×7.7Gy on 70% isodose line in terms of local control (LC). PATIENTS AND METHODS Between November 2016 and October 2018, all patients suffering from histologically-proven primary with one or several newly diagnosed BM treated by HFSRT were retrospectively included and evaluated. Patients who had received prior treatment by neurosurgery or cerebral radiotherapy were excluded. RESULTS Among 44 patients, 61 BM were treated. With a median follow-up of 31.9 months, LC rates at 6 and 12 months were 93.2% and 90.9, respectively. Single-BM was independently predictive of LC (P=0.025) and overall survival (P=0.013). Acute toxicity rates were acceptable: 65.9% of patients had grade 1 and 2 and no acute grade 3 toxicity according to the NCI-CTCAE (version 5.0). Regarding delayed toxicity, one case (2.3%) of radionecrosis was confirmed by magnetic resonance spectroscopy. CONCLUSION In our single-centre retrospective analysis, BM treatment by HFSRT delivered in three fractions showed a 12-month LC rate of 90.9% without major toxicities, which suggests safety and efficiency of this technique. However, longer-term follow-up and prospective studies are still needed to confirm these results.
Collapse
|
5
|
Fractionated Stereotactic Radiation Therapy Using Volumetric Modulated Arc Therapy in Patients with Solitary Brain Metastases. BIOMED RESEARCH INTERNATIONAL 2021; 2020:6342057. [PMID: 32964040 PMCID: PMC7501556 DOI: 10.1155/2020/6342057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 06/21/2020] [Accepted: 07/20/2020] [Indexed: 11/18/2022]
Abstract
Purpose To analyze retrospectively the clinical efficacy and safety for patients treated with fractionated stereotactic radiation therapy (FSRT) using volumetric modulated arc therapy. Methods Between 2016 and 2017, 46 patients with solitary brain metastasis who underwent FSRT consisting of 25-40 Gy/5 fractions were recruited in this study. All targets within the same course received different prescriptions according to size. Toxicities were graded according to the Common Terminology Criteria for Adverse Events version 4.0. Results The median follow-up was 11 months (3-53 months). The 6-month and 12-month local control rate calculated by Kaplan-Meier estimate was, respectively, 95% and 86%. Tumor diameter < 2.5 cm obtained 100% improved 12-month local control rate compared with 66% in those with ≥2.5 cm (P < 0.001). The 12-month local control calculated by Kaplan-Meier estimate was 95% in tumors with >30 Gy treatment and only 60% in tumors with ≤30 Gy treatment (P = 0.001). Multivariate analysis revealed that the prescription dose ≤ 30 Gy resulted in increased local failure (hazard ratio (HR), 0.14 (range, 0.019-0.95; P = .046)). Grade 3 or worse toxic effects were found in 5 (11%) patients, and no patient experienced surgical resection for symptomatic radioactive necrosis. Conclusions FSRT for solid brain metastasis appears to have the advantages of a high rate of local control with a minimal risk of severe toxicity and deserves application in the clinical practice.
Collapse
|
6
|
Samanci Y, Karakose F, Senyurek S, Peker S. Single-fraction versus hypofractionated gamma knife radiosurgery for small metastatic brain tumors. Clin Exp Metastasis 2021; 38:305-320. [PMID: 33733707 DOI: 10.1007/s10585-021-10086-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/08/2021] [Indexed: 12/31/2022]
Abstract
Stereotactic radiosurgery (SRS) has become a standard of care for the treatment of metastatic brain tumors (METs). Although a better balance of tumor control and toxicity of hypofractionated SRS (hfSRS) compared with single-fraction SRS (sfSRS) was demonstrated in large METs, there is no data comparing two approaches for small METs (< 4 cm3). It was aimed to compare clinical outcomes between sfSRS versus hfSRS Gamma Knife radiosurgery (GKRS) in a series of patients with unresected, small METs. Patients (n = 208) treated with sfGKRS or hfGKRS between June 2017 and May 2020 were retrospectively examined in a single center. The co-primary endpoints of local control (LC) and toxicity were estimated by applying the Kaplan-Meier method. Multivariate analysis using Cox proportional hazards (HR) modeling was used to assess the effect of independent variables on the outcomes. The actuarial LC rate was 99.7% at six months and 98.8% at 18 months in the sfGKRS group, and 99.4% and 94.3% in the hfGKRS group (p = 0.089), respectively. In multivariate analysis, MET volume (p = 0.023, HR 2.064) and biologically effective dose (BED10) (p < 0.0001, HR 0.753) was associated with LC. In total, treatment-related toxicity was observed in 13 (8.7%) patients during a median period of 10 weeks (range 1-31). Radiation necrosis was observed in four patients (1.9%), and all patients were in the sfGKRS group (p = 0.042). Only the maximum dose was associated with toxicity (p = 0.032, HR 1.047). Our current results suggest that hfGKRS is advantageous and beneficial also in patients with unresected, small METs.
Collapse
Affiliation(s)
- Yavuz Samanci
- Department of Neurosurgery, Koç University Hospital, Istanbul, Turkey
| | - Fatih Karakose
- Department of Radiation Oncology, Koç University Hospital, Istanbul, Turkey
| | - Sukran Senyurek
- Department of Radiation Oncology, Koç University Hospital, Istanbul, Turkey
| | - Selcuk Peker
- Department of Neurosurgery, School of Medicine, Koç University, Istanbul, Turkey.
| |
Collapse
|
7
|
Redmond KJ, Gui C, Benedict S, Milano MT, Grimm J, Vargo JA, Soltys SG, Yorke E, Jackson A, El Naqa I, Marks LB, Xue J, Heron DE, Kleinberg LR. Tumor Control Probability of Radiosurgery and Fractionated Stereotactic Radiosurgery for Brain Metastases. Int J Radiat Oncol Biol Phys 2020; 110:53-67. [PMID: 33390244 DOI: 10.1016/j.ijrobp.2020.10.034] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/25/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE As part of the American Association of Physicists in Medicine Working Group on Stereotactic Body Radiotherapy, tumor control probability (TCP) after stereotactic radiosurgery (SRS) and fractionated stereotactic radiosurgery (fSRS) for brain metastases was modeled based on pooled dosimetric and clinical data from published English-language literature. METHODS AND MATERIALS PubMed-indexed studies published between January 1995 and September 2017 were used to evaluate dosimetric and clinical predictors of TCP after SRS or fSRS for brain metastases. Eligible studies had ≥10 patients and included detailed dose-fractionation data with corresponding ≥1-year local control (LC) data, typically evaluated as a >20% increase in diameter of the targeted lesion using the pre-SRS diameter as a reference. RESULTS Of 2951 potentially eligible manuscripts, 56 included sufficient dose-volume data for analyses. Accepting that necrosis and pseudoprogression can complicate the assessment of LC, for tumors ≤20 mm, single-fraction doses of 18 and 24 Gy corresponded with >85% and 95% 1-year LC rates, respectively. For tumors 21 to 30 mm, an 18 Gy single-fraction dose was associated with 75% LC. For tumors 31 to 40 mm, a 15 Gy single-fraction dose yielded ∼69% LC. For 3- to 5-fraction fSRS using doses in the range of 27 to 35 Gy, 80% 1-year LC has been achieved for tumors of 21 to 40 mm in diameter. CONCLUSIONS TCP for SRS and fSRS are presented. For small lesions ≤20 mm, single doses of ≈18 Gy appear generally associated with excellent rates of LC; for melanoma, higher doses seem warranted. For larger lesions >20 mm, local control rates appear to be ≈ 70% to 75% with usual doses of 15 to 18 Gy, and in this setting, fSRS regimens should be considered. Greater consistency in reporting of dosimetric and LC data is needed to facilitate future pooled analyses. As systemic and biologic therapies evolve, updated analyses will be needed to further assess the necessity, efficacy, and toxicity of SRS and fSRS.
Collapse
Affiliation(s)
- Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Chengcheng Gui
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stanley Benedict
- Department of Radiation Oncology, University of California at Davis Comprehensive Cancer Center, Sacramento, California
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Jimm Grimm
- Department of Radiation Oncology, Geisinger Medical Center, Danville, Pennsylvania
| | - J Austin Vargo
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Ellen Yorke
- Medical Physics Department, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Jackson
- Medical Physics Department, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Issam El Naqa
- Department of Machine Learning and Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Lawrence B Marks
- Department of Radiation Oncology and the Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Jinyu Xue
- Department of Radiation Oncology, New York University, New York, New York
| | - Dwight E Heron
- Department of Radiation Oncology, Bon Secours Mercy Health System, Youngstown, Ohio
| | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
8
|
Milano MT, Grimm J, Niemierko A, Soltys SG, Moiseenko V, Redmond KJ, Yorke E, Sahgal A, Xue J, Mahadevan A, Muacevic A, Marks LB, Kleinberg LR. Single- and Multifraction Stereotactic Radiosurgery Dose/Volume Tolerances of the Brain. Int J Radiat Oncol Biol Phys 2020; 110:68-86. [PMID: 32921513 DOI: 10.1016/j.ijrobp.2020.08.013] [Citation(s) in RCA: 158] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/03/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE As part of the American Association of Physicists in Medicine Working Group on Stereotactic Body Radiotherapy investigating normal tissue complication probability (NTCP) after hypofractionated radiation therapy, data from published reports (PubMed indexed 1995-2018) were pooled to identify dosimetric and clinical predictors of radiation-induced brain toxicity after single-fraction stereotactic radiosurgery (SRS) or fractionated stereotactic radiosurgery (fSRS). METHODS AND MATERIALS Eligible studies provided NTCPs for the endpoints of radionecrosis, edema, or symptoms after cranial SRS/fSRS and quantitative dose-volume metrics. Studies of patients with only glioma, meningioma, vestibular schwannoma, or brainstem targets were excluded. The data summary and analyses focused on arteriovenous malformations (AVM) and brain metastases. RESULTS Data from 51 reports are summarized. There was wide variability in reported rates of radionecrosis. Available data for SRS/fSRS for brain metastases were more amenable to NTCP modeling than AVM data. In the setting of brain metastases, SRS/fSRS-associated radionecrosis can be difficult to differentiate from tumor progression. For single-fraction SRS to brain metastases, tissue volumes (including target volumes) receiving 12 Gy (V12) of 5 cm3, 10 cm3, or >15 cm3 were associated with risks of symptomatic radionecrosis of approximately 10%, 15%, and 20%, respectively. SRS for AVM was associated with modestly lower rates of symptomatic radionecrosis for equivalent V12. For brain metastases, brain plus target volume V20 (3-fractions) or V24 (5-fractions) <20 cm3 was associated with <10% risk of any necrosis or edema, and <4% risk of radionecrosis requiring resection. CONCLUSIONS The risk of radionecrosis after SRS and fSRS can be modeled as a function of dose and volume treated. The use of fSRS appears to reduce risks of radionecrosis for larger treatment volumes relative to SRS. More standardized dosimetric and toxicity reporting is needed to facilitate future pooled analyses that can refine predictive models of brain toxicity risks.
Collapse
Affiliation(s)
- Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York.
| | - Jimm Grimm
- Department of Radiation Oncology, Geisinger Cancer Institute, Danville, Pennsylvania
| | - Andrzej Niemierko
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, California
| | - Vitali Moiseenko
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York City, New York
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Jinyu Xue
- Department of Radiation Oncology, NYU Langone Medical Center, New York City, NY
| | - Anand Mahadevan
- Department of Radiation Oncology, Geisinger Cancer Institute, Danville, Pennsylvania
| | | | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
9
|
Napolitano M, Ranieri A, Maniscalco GT, Riccardi F, De Dominicis G, Caiazzo P. Brain Radionecrosis After Adjuvant Radiation Therapy for a Primary Intracerebral Undifferentiated Sarcoma. World Neurosurg 2020; 143:285-288. [PMID: 32763370 DOI: 10.1016/j.wneu.2020.07.174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/25/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Primary intracranial sarcomas of the central nervous system are rare tumors. They mainly arise from intracranial mesenchymal tissue present in the meninges and can occur at any age. Sometimes osteosarcoma can involve the skull rather than long body bones. In this latter case it is the more common subtype. Surgery, when possible, is a mandatory option often associated with radiation therapy (RT) and chemotherapy. Brain radionecrosis (BRN) is commonly observed due to the growing use of radiosurgery and higher cumulative doses of radiation therapy. The combination of perfusion magnetic resonance imaging and 18fluoro-deoxy-glucose positron emission tomography can help to differentiate tumor progression from radiation injury. Steroids, anticoagulants, and bevacizumab usually control BRN. However, BRN can also have an unfavorable course. CASE DESCRIPTION Here, we present a case of a 60-year-old male who underwent surgery for a brain tumor. The examination showed a primary undifferentiated high-grade sarcoma. Adjuvant RT was given with a total dose of 60 Gy. Six months later, the patient underwent a second surgery that revealed a BRN progressing despite different pharmacologic attempts. CONCLUSIONS Primary intracranial sarcomas of the central nervous system are less prevalent among older adults with respect to the younger population. The use of RT alone or combined with chemotherapy is aimed at prolonging survival. However, it is not clearly defined if adjuvant treatments affect this parameter in older patients. RT should be carefully discussed owing to its potential severe neurologic toxicity. Indeed, a BRN can have a significant impact on quality of life and lead to death in certain cases.
Collapse
Affiliation(s)
- Massimo Napolitano
- Neurology Division, Neuro-Oncology Service, Cardarelli Hospital, Naples, Italy.
| | - Angelo Ranieri
- Neurology Division, Neuro-Oncology Service, Cardarelli Hospital, Naples, Italy
| | | | | | | | | |
Collapse
|
10
|
McClelland S, Lautenschlaeger T, Zang Y, Hanna NH, Shiue K, Kamer AP, Agrawal N, Ellsworth SG, Rhome RM, Watson GA. Radiosurgery dose reduction for brain metastases on immunotherapy (RADREMI): A prospective phase I study protocol. Rep Pract Oncol Radiother 2020; 25:500-506. [PMID: 32477016 DOI: 10.1016/j.rpor.2020.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/10/2020] [Accepted: 04/10/2020] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Up to 20% of patients with brain metastases treated with immune checkpoint inhibitor (ICI) therapy and concomitant stereotactic radiosurgery (SRS) suffer from symptomatic radiation necrosis. The goal of this study is to evaluate Radiosurgery Dose Reduction for Brain Metastases on Immunotherapy (RADREMI) on six-month symptomatic radiation necrosis rates. METHODS This study is a prospective single arm Phase I pilot study which will recruit patients with brain metastases receiving ICI delivered within 30 days before SRS. All patients will be treated with RADREMI dosing, which involves SRS doses of 18 Gy for 0-2 cm lesions, 14 Gy for 2.1-3 cm lesions, and 12 Gy for 3.1-4 cm lesions. All patients will be monitored for six-month symptomatic radiation necrosis (defined as a six-month rate of clinical symptomatology requiring steroid administration and/or operative intervention concomitant with imaging findings consistent with radiation necrosis) and six-month local control. We expect that RADREMI dosing will significantly reduce the symptomatic radiation necrosis rate of concomitant SRS + ICI without significantly sacrificing the local control obtained by the present RTOG 90-05 SRS dosing schema. Local control will be defined according to the Response Assessment in Neuro-Oncology (RANO) criteria. DISCUSSION This study is the first prospective trial to investigate the safety of dose-reduced SRS in treatment of brain metastases with concomitant ICI. The findings should provide fertile soil for future multi-institutional collaborative efficacy trials of RADREMI dosing for this patient population. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT04047602 (registration date: July 25, 2019).
Collapse
Affiliation(s)
- Shearwood McClelland
- Department of Radiation Oncology, Indiana University School of Medicine, 535 Barnhill Drive, RT 041, Indianapolis, IN 46202, US
| | - Tim Lautenschlaeger
- Department of Radiation Oncology, Indiana University School of Medicine, 535 Barnhill Drive, RT 041, Indianapolis, IN 46202, US
| | - Yong Zang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, US
| | - Nasser H Hanna
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, US
| | - Kevin Shiue
- Department of Radiation Oncology, Indiana University School of Medicine, 535 Barnhill Drive, RT 041, Indianapolis, IN 46202, US
| | - Aaron P Kamer
- Department of Radiology, Indiana University School of Medicine, Indianapolis, IN, US
| | - Namita Agrawal
- Department of Radiation Oncology, Indiana University School of Medicine, 535 Barnhill Drive, RT 041, Indianapolis, IN 46202, US
| | - Susannah G Ellsworth
- Department of Radiation Oncology, Indiana University School of Medicine, 535 Barnhill Drive, RT 041, Indianapolis, IN 46202, US
| | - Ryan M Rhome
- Department of Radiation Oncology, Indiana University School of Medicine, 535 Barnhill Drive, RT 041, Indianapolis, IN 46202, US
| | - Gordon A Watson
- Department of Radiation Oncology, Indiana University School of Medicine, 535 Barnhill Drive, RT 041, Indianapolis, IN 46202, US
| |
Collapse
|
11
|
Remick JS, Kowalski E, Khairnar R, Sun K, Morse E, Cherng HRR, Poirier Y, Lamichhane N, Becker SJ, Chen S, Patel AN, Kwok Y, Nichols E, Mohindra P, Woodworth GF, Regine WF, Mishra MV. A multi-center analysis of single-fraction versus hypofractionated stereotactic radiosurgery for the treatment of brain metastasis. Radiat Oncol 2020; 15:128. [PMID: 32466775 PMCID: PMC7257186 DOI: 10.1186/s13014-020-01522-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/24/2020] [Indexed: 12/22/2022] Open
Abstract
Background Hypofractionated-SRS (HF-SRS) may allow for improved local control and a reduced risk of radiation necrosis compared to single-fraction-SRS (SF-SRS). However, data comparing these two treatment approaches are limited. The purpose of this study was to compare clinical outcomes between SF-SRS versus HF-SRS across our multi-center academic network. Methods Patients treated with SF-SRS or HF-SRS for brain metastasis from 2013 to 2018 across 5 radiation oncology centers were retrospectively reviewed. SF-SRS dosing was standardized, whereas HF-SRS dosing regimens were variable. The co-primary endpoints of local control and radiation necrosis were estimated using the Kaplan Meier method. Multivariate analysis using Cox proportional hazards modeling was performed to evaluate the impact of select independent variables on the outcomes of interest. Propensity score adjustments were used to reduce the effects confounding variables. To assess dose response for HF-SRS, Biologic Effective Dose (BED) assuming an α/β of 10 (BED10) was used as a surrogate for total dose. Results One-hundred and fifty six patients with 335 brain metastasis treated with SF-SRS (n = 222 lesions) or HF-SRS (n = 113 lesions) were included. Prior whole brain radiation was given in 33% (n = 74) and 34% (n = 38) of lesions treated with SF-SRS and HF-SRS, respectively (p = 0.30). After a median follow up time of 12 months in each cohort, the adjusted 1-year rate of local control and incidence of radiation necrosis was 91% (95% CI 86–96%) and 85% (95% CI 75–95%) (p = 0.26) and 10% (95% CI 5–15%) and 7% (95% CI 0.1–14%) (p = 0.73) for SF-SRS and HF-SRS, respectively. For lesions > 2 cm, the adjusted 1 year local control was 97% (95% CI 84–100%) for SF-SRS and 64% (95% CI 43–85%) for HF-SRS (p = 0.06). On multivariate analysis, SRS fractionation was not associated with local control and only size ≤2 cm was associated with a decreased risk of developing radiation necrosis (HR 0.21; 95% CI 0.07–0.58, p < 0.01). For HF-SRS, 1 year local control was 100% for lesions treated with a BED10 ≥ 50 compared to 77% (95% CI 65–88%) for lesions that received a BED10 < 50 (p = 0.09). Conclusions In this comparison study of dose fractionation for the treatment of brain metastases, there was no difference in local control or radiation necrosis between HF-SRS and SF-SRS. For HF-SRS, a BED10 ≥ 50 may improve local control.
Collapse
Affiliation(s)
- Jill S Remick
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Emily Kowalski
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Rahul Khairnar
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Kai Sun
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emily Morse
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hua-Ren R Cherng
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Yannick Poirier
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Narottam Lamichhane
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Stewart J Becker
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shifeng Chen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Akshar N Patel
- Chesapeake Oncology Hematology Associates, Glen Bernie, MD, USA
| | - Young Kwok
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Elizabeth Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Graeme F Woodworth
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
12
|
Cummings M, Youn P, Bergsma DP, Usuki KY, Walter K, Sharma M, Okunieff P, Schell MC, Milano MT. Single-Fraction Radiosurgery Using Conservative Doses for Brain Metastases: Durable Responses in Select Primaries With Limited Toxicity. Neurosurgery 2019; 83:437-444. [PMID: 28945885 DOI: 10.1093/neuros/nyx427] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 07/11/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Optimal doses for single-fraction stereotactic radiosurgery (SRS) in the treatment of brain metastases are not well established. Our institution utilized conservative dosing compared to maximum-tolerated doses from the Radiation Therapy Oncology Group 90-05 Phase I study. OBJECTIVE To report individual lesion control (LC) from conservative single-fraction doses and determine factors affecting LC. METHODS From 2003 to 2015, patients who underwent linear accelerator-based single-fraction SRS for cerebral/cerebellar metastases and receiving at least 1 follow-up magnetic resonance imaging (MRI) were identified. Lesion response was assessed by a size-based rating system and modified "Response Assessment in Neuro-Oncology Brain Metastases" (RANO-BM) criteria. RESULTS Among 188 patients with 519 lesions, median survival was 13.1 mo; median follow-up time with MRI was 9.6 mo per course. Median tumor-periphery dose was 15 Gy (range: 7.5-20.7). Median lesion volume was 0.5 cc and diameter was 9 mm (range: 2-45). Concordance between RANO-BM and size-based system was 93%. Crude 1-yr LC was 80%, 73%, 56%, and 38% for lesions 1 to 10, 11 to 20, 21 to 30, >31 mm, respectively. On multivariate analysis, increased size, melanoma and colorectal histology, and progression after whole brain radiation therapy predicted worse LC. When excluding lesions treated as a boost, dose was a significant predictor of LC in multivariate models (hazard ratio 0.89, P = .01). Symptomatic radiation necrosis occurred in 10 lesions in 10 patients. CONCLUSION Histology predicts LC after conservative SRS doses with evidence of a dose-response relationship. Conservative single-fraction SRS doses confer minimal toxicity and acceptable control in certain subgroups (breast cancer, <5 mm), with suboptimal control in larger lesions and in combination with whole brain radiation therapy.
Collapse
Affiliation(s)
- Michael Cummings
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Paul Youn
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Derek P Bergsma
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Kenneth Y Usuki
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Kevin Walter
- Department of Neurosurgery, University of Rochester, Rochester, New York
| | - Manju Sharma
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Paul Okunieff
- Department of Radiation Oncology, University of Florida, Gainesville, Florida
| | - Michael C Schell
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| |
Collapse
|
13
|
Donovan EK, Parpia S, Greenspoon JN. Incidence of radionecrosis in single-fraction radiosurgery compared with fractionated radiotherapy in the treatment of brain metastasis. ACTA ACUST UNITED AC 2019; 26:e328-e333. [PMID: 31285676 DOI: 10.3747/co.26.4749] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Radiation-induced brain necrosis ["radionecrosis" (rn)] is a relatively uncommon but potentially severe adverse effect of stereotactic radiosurgery (srs) for brain metastasis. Although dose, volume, and hypofractionation have been suggested to affect rn rates, patient and treatment variability in this population make it difficult to clearly delineate the risk. We set out to establish the effect of fractionation on rn rates by reviewing patients receiving simultaneous multi-fraction and single-fraction treatment at our centre. Methods Patients receiving simultaneous (within 1 month) 1-fraction (ssrs) and 3-fraction (fsrs) radiosurgery treatments during 2012-2015 were identified in our institution's database. Serial post-srs magnetic resonance imaging (mri) was reviewed to determine rn and local recurrence. The effect of maximum dose, volume, whole-brain radiotherapy (wbrt), and fractionation on rn development was assessed using logistic regression for paired data. Results are reported using odds ratios (ors) and corresponding 95% confidence intervals (cis). Results Of 90 patients identified, 22 had at least a 6-month mri follow-up. Median follow-up was 320 days. The most common primary tumour type was non-small-cell lung cancer, followed by breast and rectal cancer. Radionecrosis developed in 16 patients [21 of 62 lesions (34%), with 4 being symptomatic (20%)]. Of the 21 lesions in which rn developed, 11 received 3 fractions, and 10 received 1 fraction. The or for the association between the incidence of rn and maximum dose was 1.0 (95% ci: 0.9 to 1.1); for fractionation it was 1.0 (95% ci: 0.3 to 3.6); for previous wbrt, it was 0.4 (95% ci: 0.2 to 1.2); and for a 10-unit increase in volume, it was 3.1 (95% ci: 1.0 to 9.6). Local recurrence developed in 8 patients (12%), 6 of whom belonged to the ssrs group. Conclusions Our results indicate that patients receiving srs for multiple brain metastases experience a higher rate of rn than is reported in the literature and poorer survival despite having equivalent local control. Maximum dose did not appear to be associated with rn risk in our cohort, but volume was significantly associated with rn risk. Although fractionated treatment did not directly lower the rate of rn in this population, it might have played a role in reducing the magnitude of the rn risk in large-volume lesions. Further investigation will help to delineate optimal dose and fractionation so as to minimize rn while maintaining local control in this group.
Collapse
Affiliation(s)
- E K Donovan
- Department of Oncology, McMaster University, Juravinski Hospital and Cancer Centre, Hamilton, ON
| | - S Parpia
- Department of Statistics and Epidemiology, Juravinski Hospital, McMaster University, Hamilton, ON
| | - J N Greenspoon
- Department of Oncology, McMaster University, Juravinski Hospital and Cancer Centre, Hamilton, ON
| |
Collapse
|
14
|
Izard MA, Moutrie V, Rogers JM, Beath K, Grace M, Karle B, Ho A, Fuller JW. Volume not number of metastases: Gamma Knife radiosurgery management of intracranial lesions from an Australian perspective. Radiother Oncol 2019; 133:43-49. [DOI: 10.1016/j.radonc.2018.12.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/31/2018] [Accepted: 12/17/2018] [Indexed: 10/27/2022]
|
15
|
Brown PD, Ahluwalia MS, Khan OH, Asher AL, Wefel JS, Gondi V. Whole-Brain Radiotherapy for Brain Metastases: Evolution or Revolution? J Clin Oncol 2018; 36:483-491. [PMID: 29272161 PMCID: PMC6075843 DOI: 10.1200/jco.2017.75.9589] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
An estimated 20% of patients with cancer will develop brain metastases. Approximately 200,000 individuals in the United States alone receive whole-brain radiotherapy (WBRT) each year to treat brain metastases. Historically, the prognosis of patients with brain metastases has been poor; however, with new therapies, this is changing. Because patients are living longer following the diagnosis and treatment of brain metastases, there has been rising concern about treatment-related toxicities associated with WBRT, including neurocognitive toxicity. In addition, recent clinical trials have raised questions about the use of WBRT. To better understand this rapidly changing landscape, this review outlines the treatment roles and toxicities of WBRT and alternative therapies for the management of brain metastases.
Collapse
Affiliation(s)
- Paul D. Brown
- Paul D. Brown, Mayo Clinic, Rochester, MN; Manmeet S. Ahluwalia, Cleveland Clinic, Cleveland, OH; Osaama H. Khan and Vinai Gondi, Northwestern University Feinberg School of Medicine, Chicago; Vinai Gondi, Northwestern Medicine Cancer Center, Warrenville, IL; Anthony L. Asher, Carolina Neurosurgery and Spine Associates and Neurosciences Institute, Carolinas HealthCare System, Charlotte, NC; and Jeffrey S. Wefel, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Manmeet S. Ahluwalia
- Paul D. Brown, Mayo Clinic, Rochester, MN; Manmeet S. Ahluwalia, Cleveland Clinic, Cleveland, OH; Osaama H. Khan and Vinai Gondi, Northwestern University Feinberg School of Medicine, Chicago; Vinai Gondi, Northwestern Medicine Cancer Center, Warrenville, IL; Anthony L. Asher, Carolina Neurosurgery and Spine Associates and Neurosciences Institute, Carolinas HealthCare System, Charlotte, NC; and Jeffrey S. Wefel, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Osaama H. Khan
- Paul D. Brown, Mayo Clinic, Rochester, MN; Manmeet S. Ahluwalia, Cleveland Clinic, Cleveland, OH; Osaama H. Khan and Vinai Gondi, Northwestern University Feinberg School of Medicine, Chicago; Vinai Gondi, Northwestern Medicine Cancer Center, Warrenville, IL; Anthony L. Asher, Carolina Neurosurgery and Spine Associates and Neurosciences Institute, Carolinas HealthCare System, Charlotte, NC; and Jeffrey S. Wefel, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anthony L. Asher
- Paul D. Brown, Mayo Clinic, Rochester, MN; Manmeet S. Ahluwalia, Cleveland Clinic, Cleveland, OH; Osaama H. Khan and Vinai Gondi, Northwestern University Feinberg School of Medicine, Chicago; Vinai Gondi, Northwestern Medicine Cancer Center, Warrenville, IL; Anthony L. Asher, Carolina Neurosurgery and Spine Associates and Neurosciences Institute, Carolinas HealthCare System, Charlotte, NC; and Jeffrey S. Wefel, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey S. Wefel
- Paul D. Brown, Mayo Clinic, Rochester, MN; Manmeet S. Ahluwalia, Cleveland Clinic, Cleveland, OH; Osaama H. Khan and Vinai Gondi, Northwestern University Feinberg School of Medicine, Chicago; Vinai Gondi, Northwestern Medicine Cancer Center, Warrenville, IL; Anthony L. Asher, Carolina Neurosurgery and Spine Associates and Neurosciences Institute, Carolinas HealthCare System, Charlotte, NC; and Jeffrey S. Wefel, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Vinai Gondi
- Paul D. Brown, Mayo Clinic, Rochester, MN; Manmeet S. Ahluwalia, Cleveland Clinic, Cleveland, OH; Osaama H. Khan and Vinai Gondi, Northwestern University Feinberg School of Medicine, Chicago; Vinai Gondi, Northwestern Medicine Cancer Center, Warrenville, IL; Anthony L. Asher, Carolina Neurosurgery and Spine Associates and Neurosciences Institute, Carolinas HealthCare System, Charlotte, NC; and Jeffrey S. Wefel, University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
16
|
Vetlova ER, Golanov AV, Banov SM. [A modern strategy of combined surgical and radiation treatment in patients with brain metastases]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2018; 81:108-115. [PMID: 29393294 DOI: 10.17116/neiro2017816108-115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The treatment standards for patients with brain metastases have been developed for several decades. An important element in the evolution of approaches to the treatment of these patients is the development of microsurgery, stereotactic radiotherapy, and targeted therapy and introduction of these techniques into clinical practice. Surgery is an effective treatment option in patients having single brain metastases and/or occuring in life-threatening clinical situations. Irradiation of the whole brain after surgical treatment is a necessary step in achieving satisfactory local control of intracranial metastatic foci, but the development of neurocognitive disorders and deterioration of life quality after this irradiation necessitate the search for alternative radiotherapy techniques in this clinical situation. Currently, an alternative to postoperative irradiation of the whole brain is stereotactic radiotherapy, which is used before or after surgical treatment. Stereotactic radiotherapy improves local control of intracranial metastatic foci and reduces the risk of neurotoxicity. In this review, we analyze the literature data on outcomes of stereotactic irradiation as a component of combined treatment of patients with metastatic brain lesions.
Collapse
Affiliation(s)
- E R Vetlova
- Burdenko Neurosurgical Institute, Moscow, Russia, 125047
| | - A V Golanov
- Burdenko Neurosurgical Institute, Moscow, Russia, 125047
| | - S M Banov
- Gamma Knife Center, Moscow, Russia, 125047
| |
Collapse
|
17
|
Marcrom SR, McDonald AM, Thompson JW, Popple RA, Riley KO, Markert JM, Willey CD, Bredel M, Fiveash JB. Fractionated stereotactic radiation therapy for intact brain metastases. Adv Radiat Oncol 2017; 2:564-571. [PMID: 29204523 PMCID: PMC5707424 DOI: 10.1016/j.adro.2017.07.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 06/12/2017] [Accepted: 07/14/2017] [Indexed: 11/06/2022] Open
Abstract
Purpose Limited data exist on fractionated stereotactic radiation therapy (FSRT) for brain metastases. We sought to evaluate the safety and efficacy of FSRT and further define its role in brain metastasis management. Methods and materials A total of 72 patients were treated with linear accelerator–based FSRT to 182 previously untreated, intact brain metastases. Targets received 25 or 30 Gy in 5 fractions. All targets within the same course received the same prescription regardless of size. Toxicity was recorded per Radiation Therapy Oncology Group central nervous system toxicity criteria. Results The median follow-up was 5 months (range, 1-71 months). The Kaplan-Meier estimate of 12-month local control was 86%. Tumors <3 cm in diameter demonstrated improved 12-month local control of 95% compared with 61% in tumors ≥3 cm (P < .001). The Kaplan-Meier estimate of 12-month local control was 91% in tumors treated with 30 Gy and only 75% in tumors treated with 25 Gy (P = .015). Tumor diameter ≥3 cm resulted in increased local failure, and a 30 Gy prescription resulted in decreased local failure on multivariate analysis (hazard ratio [HR], 8.11 [range, 2.09-31.50; P = .003] and HR, 0.26 [range, 0.07-0.93; P = .038]). Grade 4 central nervous system toxicity occurred in 4 patients (6%) requiring surgery, and no patient experienced irreversible grade 3 or 5 toxicity. Increasing tumor diameter was associated with increased toxicity risk (HR, 2.45 [range, 1.04-5.742; P = .04]). Conclusions FSRT for brain metastases appears to demonstrate a high rate of local control with minimal risk of severe toxicity. Local control appears to be associated with smaller tumor sizeand a higher prescription dose. FSRT is a viable option for those who are poor single-fraction candidates.
Collapse
Affiliation(s)
- Samuel R Marcrom
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Andrew M McDonald
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jonathan W Thompson
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Richard A Popple
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kristen O Riley
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - James M Markert
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Christopher D Willey
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Markus Bredel
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - John B Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| |
Collapse
|
18
|
Trifiletti DM, Hill C, Cohen-Inbar O, Xu Z, Sheehan JP. Stereotactic radiosurgery for small brain metastases and implications regarding management with systemic therapy alone. J Neurooncol 2017; 134:289-296. [DOI: 10.1007/s11060-017-2519-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/29/2017] [Indexed: 12/26/2022]
|
19
|
Abstract
BACKGROUND Cerebral radiation necrosis (RN) is a severe complication of radiotherapy for cerebral pathologies. This study discusses the radiographic and pathological features of 12 patients with RN and investigates the management strategy. METHODS Eleven patients with brain tumors, and one with cerebral cavernous angioma, treated by surgical resection or Gamma Knife alone before radiotherapy developed RN during follow-up. Surgical resection for the cerebral RN was performed in nine patients, and the other three patients received medical treatment. The clinical features, magnetic resonance imaging (MRI), surgical findings, and pathological sections are reviewed. RESULTS The diagnosis of RN was confirmed by histological study in all the patients; those with surgical and medical treatment recovered. CONCLUSION As a major complication of radiotherapy, from the clinical and neuroradiological points of view, RN may simulate tumor recurrence. Due to the increasing number of patients with RN who will need to be treated in future years, the definite diagnosis and appropriate treatment of RN remain critical.
Collapse
|
20
|
Olson AC, Thomas S, Qin R, Singh B, Salama JK, Kirkpatrick J, Salama AK. Outcomes and toxicity of stereotactic radiosurgery for melanoma brain metastases in patients receiving ipilimumab. Melanoma Manag 2016; 3:177-186. [PMID: 30190887 DOI: 10.2217/mmt-2016-0004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/17/2016] [Indexed: 02/07/2023] Open
Abstract
Purpose Patients with melanoma treated with ipilimumab and radiosurgery (stereotactic radiosurgery [SRS]) were reviewed for efficacy/safety. Methods Patients who received ipilimumab and SRS for brain metastases were analyzed for control of SRS-treated metastasis and overall survival. Results We identified 27 patients, 26 were assessable for outcomes. Median time-to-treated metastasis progression was 6.3 months (95% CI: 3.1-12.2). Overall survival was 23.4 months (95% CI: 5.7-not estimable) for SRS prior to/during ipilimumab (n = 14), and 10.4 months (95% CI: 1.9-not estimable) for SRS after ipilimumab (n = 12). Overall, no unexpected toxicities were seen: 11% of patients experienced grade 3 CNS toxicity and 7% developed radionecrosis. Conclusion SRS for melanoma brain metastases with ipilimumab was well-tolerated. There may be improved survival for patients receiving SRS prior to/during ipilimumab.
Collapse
Affiliation(s)
- Adam C Olson
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA.,Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Samantha Thomas
- Department of Biostatistics, Duke Cancer Institute, Durham, NC, USA.,Department of Biostatistics, Duke Cancer Institute, Durham, NC, USA
| | - Rosie Qin
- Duke University School of Medicine, Durham, NC, USA.,Duke University School of Medicine, Durham, NC, USA
| | - Bhavana Singh
- Department of Medicine, Duke University Medical Center, Durham, NC, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Joseph K Salama
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA.,Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - John Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA.,Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - April Ks Salama
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, NC, USA.,Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
21
|
Wang SJ, Choi M, Fuller CD, Salter BJ, Fuss M. Intensity-Modulated Radiosurgery for Patients with Brain Metastases: A Mature Outcomes Analysis. Technol Cancer Res Treat 2016; 6:161-8. [PMID: 17535023 DOI: 10.1177/153303460700600302] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The purpose of this study was to evaluate the outcomes of patients with brain metastases treated by tomotherapeutic Intensity-modulated Radiosurgery (IMRS). Using retrospective chart review, we analyzed the outcomes of 78 patients (age 33–83 years, median 57 years) who underwent 111 sessions of IMRS (1 to 7 sessions per patient, median 1) for brain metastases (1 to 4 targets per IMRS session, median 1) treated between 2000 and 2005 using a serial tomotherapeutic intensity-modulated radiotherapy treatment (IMRT) planning and delivery system (Peacock, Nomos Corp., Cranberry Township, PA). Treatment planning was performed using an inverse treatment planning optimization algorithm that was optimized for IMRS. A median prescription dose of 15 Gy in combination with WBI, and median 20 Gy for IMRS alone was delivered using 2–4 couch angles over 4–24 rotational arcs. Overall survival was calculated using Kaplan-Meier analysis. To determine the effects of prognostic variables on survival, univariate and multivariate analyses using proportional hazards were performed to assess the effects of age, tumor size, the combination with whole brain irradiation, presence of multiple brain metastases, and presence of extracranial disease. The median overall survival was 6.5 months (95% CI, 5.5–7.9). One- and two-year survival rates were 24% and 10%. In multivariate analyses, age greater than 60 years was the only statistically significant variable that affected survival (hazard rate 1.29, p=0.049). We conclude that tomotherapeutic IMRS is safe and effective to treat patients with brain metastases.
Collapse
Affiliation(s)
- Samuel J Wang
- Department of Radiation Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, MC L337, Portland, Oregon 97239, USA.
| | | | | | | | | |
Collapse
|
22
|
Mohammadi AM, Schroeder JL, Angelov L, Chao ST, Murphy ES, Yu JS, Neyman G, Jia X, Suh JH, Barnett GH, Vogelbaum MA. Impact of the radiosurgery prescription dose on the local control of small (2 cm or smaller) brain metastases. J Neurosurg 2016; 126:735-743. [PMID: 27231978 DOI: 10.3171/2016.3.jns153014] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The impact of the stereotactic radiosurgery (SRS) prescription dose (PD) on local progression and radiation necrosis for small (≤ 2 cm) brain metastases was evaluated. METHODS An institutional review board-approved retrospective review was performed on 896 patients with brain metastases ≤ 2 cm (3034 tumors) who were treated with 1229 SRS procedures between 2000 and 2012. Local progression and/or radiation necrosis were the primary end points. Each tumor was followed from the date of radiosurgery until one of the end points was reached or the last MRI follow-up. Various criteria were used to differentiate tumor progression and radiation necrosis, including the evaluation of serial MRIs, cerebral blood volume on perfusion MR, FDG-PET scans, and, in some cases, surgical pathology. The median radiographic follow-up per lesion was 6.2 months. RESULTS The median patient age was 56 years, and 56% of the patients were female. The most common primary pathology was non-small cell lung cancer (44%), followed by breast cancer (19%), renal cell carcinoma (14%), melanoma (11%), and small cell lung cancer (5%). The median tumor volume and median largest diameter were 0.16 cm3 and 0.8 cm, respectively. In total, 1018 lesions (34%) were larger than 1 cm in maximum diameter. The PD for 2410 tumors (80%) was 24 Gy, for 408 tumors (13%) it was 19 to 23 Gy, and for 216 tumors (7%) it was 15 to 18 Gy. In total, 87 patients (10%) had local progression of 104 tumors (3%), and 148 patients (17%) had at least radiographic evidence of radiation necrosis involving 199 tumors (7%; 4% were symptomatic). Univariate and multivariate analyses were performed for local progression and radiation necrosis. For local progression, tumors less than 1 cm (subhazard ratio [SHR] 2.32; p < 0.001), PD of 24 Gy (SHR 1.84; p = 0.01), and additional whole-brain radiation therapy (SHR 2.53; p = 0.001) were independently associated with better outcome. For the development of radiographic radiation necrosis, independent prognostic factors included size greater than 1 cm (SHR 2.13; p < 0.001), location in the corpus callosum (SHR 5.72; p < 0.001), and uncommon pathologies (SHR 1.65; p = 0.05). Size (SHR 4.78; p < 0.001) and location (SHR 7.62; p < 0.001)-but not uncommon pathologies-were independent prognostic factors for the subgroup with symptomatic radiation necrosis. CONCLUSIONS A PD of 24 Gy results in significantly better local control of metastases measuring < 2 cm than lower doses. In addition, tumor size is an independent prognostic factor for both local progression and radiation necrosis. Some tumor pathologies and locations may also contribute to an increased risk of radiation necrosis.
Collapse
Affiliation(s)
- Alireza M Mohammadi
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center,.,Departments of 2 Neurosurgery and
| | - Jason L Schroeder
- Department of Neurosurgery, University of Toledo Medical Center, Toledo, Ohio
| | - Lilyana Angelov
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center,.,Departments of 2 Neurosurgery and
| | | | | | | | | | - Xuefei Jia
- Quantitative Health Science, Neurological Institute and Taussig Cancer Institute, Cleveland Clinic, Cleveland; and
| | | | - Gene H Barnett
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center,.,Departments of 2 Neurosurgery and
| | - Michael A Vogelbaum
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center,.,Departments of 2 Neurosurgery and
| |
Collapse
|
23
|
Amsbaugh M, Pan J, Yusuf MB, Dragun A, Dunlap N, Guan T, Boling W, Rai S, Woo S. Dose-Volume Response Relationship for Brain Metastases Treated with Frameless Single-Fraction Linear Accelerator-Based Stereotactic Radiosurgery. Cureus 2016; 8:e587. [PMID: 27284495 PMCID: PMC4889452 DOI: 10.7759/cureus.587] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Our aim was to identify a dose-volume response relationship for brain metastases treated with frameless stereotactic radiosurgery (SRS). METHODS We reviewed patients who underwent frameless single-fraction linear accelerator SRS for brain metastases between 2007 and 2013 from an institutional database. Proportional hazards modeling was used to identify predictors of outcome. A ratio of maximum lesion dose per mm-diameter (Gy/mm) was constructed to establish a dose-volume relationship. RESULTS There were 316 metastases evaluated in 121 patients (2 - 33 mm in the largest diameter). The median peripheral dose was 18.0 Gy (range: 10.0 - 24.0 Gy). Local control was 84.8% for all lesions and was affected by location, peripheral dose, maximum dose, and lesion size (p values < 0.050). A dose-volume response relationship was constructed using the maximum dose and lesion size. A unit increase in Gy/mm was associated with decreased local failure (p = 0.005). Local control of 80%, 85%, and 90% corresponded to maximum doses per millimeter of 1.67 Gy/mm, 2.86 Gy/mm, and 4.4 Gy/mm, respectively. Toxicity was uncommon and only 1.0% of lesions developed radionecrosis requiring surgery. CONCLUSIONS For brain metastases less than 3 cm, a dose-volume response relationship exists between maximum radiosurgical dose and lesion size, which is predictive of local control.
Collapse
Affiliation(s)
| | - Jianmin Pan
- JG Brown Cancer Center, University of Louisville
| | | | | | - Neal Dunlap
- Radiation Oncology, University of Louisville
| | | | | | - Shesh Rai
- Bioinformatics and Biostatistics, University of Louisville
| | - Shiao Woo
- Radiation Oncology, University of Louisville
| |
Collapse
|
24
|
Won YK, Lee JY, Kang YN, Jang JS, Kang JH, Jung SL, Sung SY, Jo IY, Park HH, Lee DS, Chang JH, Lee YH, Kim YS. Stereotactic radiosurgery for brain metastasis in non-small cell lung cancer. Radiat Oncol J 2015; 33:207-16. [PMID: 26484304 PMCID: PMC4607574 DOI: 10.3857/roj.2015.33.3.207] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 08/13/2015] [Accepted: 09/02/2015] [Indexed: 11/15/2022] Open
Abstract
Purpose Stereotactic radiosurgery (SRS) has been introduced for small-sized single and oligo-metastases in the brain. The aim of this study is to assess treatment outcome, efficacy, and prognostic variables associated with survival and intracranial recurrence. Materials and Methods This study retrospectively reviewed 123 targets in 64 patients with non-small cell lung cancer (NSCLC) treated with SRS between January 2006 and December 2012. Treatment responses were evaluated using magnetic resonance imaging. Overall survival (OS) and intracranial progression-free survival (IPFS) were determined. Results The median follow-up was 13.9 months. The median OS and IPFS were 14.1 and 8.9 months, respectively. Fifty-seven patients died during the follow-up period. The 5-year local control rate was achieved in 85% of 108 evaluated targets. The 1- and 2-year OS rates were 55% and 28%, respectively. On univariate analysis, primary disease control (p < 0.001), the Eastern Cooperative Oncology Group (ECOG) performance status (0-1 vs. 2; p = 0.002), recursive partitioning analysis class (1 vs. 2; p = 0.001), and age (<65 vs. ≥65 years; p = 0.036) were significant predictive factors for OS. Primary disease control (p = 0.041) and ECOG status (p = 0.017) were the significant prognostic factors for IPFS. Four patients experienced radiation necrosis. Conclusion SRS is a safe and effective local treatment for brain metastases in patients with NSCLC. Uncontrolled primary lung disease and ECOG status were significant predictors of OS and intracranial failure. SRS might be a tailored treatment option along with careful follow-up of the intracranial and primary lung disease status.
Collapse
Affiliation(s)
- Yong Kyun Won
- Department of Radiation Oncology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Ja Young Lee
- Department of Radiation Oncology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Young Nam Kang
- Department of Radiation Oncology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Ji Sun Jang
- Department of Radiation Oncology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jin-Hyoung Kang
- Department of Medical Oncology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - So-Lyoung Jung
- Department of Radiology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Soo Yoon Sung
- Department of Radiation Oncology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - In Young Jo
- Department of Radiation Oncology, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea
| | - Hee Hyun Park
- Department of Radiation Oncology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Dong-Soo Lee
- Department of Radiation Oncology, Uijeongbu St. Mary's Hospital, The Catholic University of Korea College of Medicine, Uijeongbu, Korea
| | - Ji Hyun Chang
- Department of Radiation Oncology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yun Hee Lee
- Department of Radiation Oncology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yeon-Sil Kim
- Department of Radiation Oncology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| |
Collapse
|
25
|
Jeong WJ, Park JH, Lee EJ, Kim JH, Kim CJ, Cho YH. Efficacy and Safety of Fractionated Stereotactic Radiosurgery for Large Brain Metastases. J Korean Neurosurg Soc 2015; 58:217-24. [PMID: 26539264 PMCID: PMC4630352 DOI: 10.3340/jkns.2015.58.3.217] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 06/01/2015] [Accepted: 08/20/2015] [Indexed: 01/19/2023] Open
Abstract
Objective To investigate the efficacy and safety of fractionated stereotactic radiosurgery for large brain metastases (BMs). Methods Between June 2011 and December 2013, a total of 38 large BMs >3.0 cm in 37 patients were treated with fractionated Cyberknife radiosurgery. These patients comprised 16 men (43.2%) and 21 women, with a median age of 60 years (range, 38-75 years). BMs originated from the lung (n=19, 51.4%), the gastrointestinal tract (n=10, 27.0%), the breast (n=5, 13.5%), and other tissues (n=3, 8.1%). The median tumor volume was 17.6 cc (range, 9.4-49.6 cc). For Cyberknife treatment, a median peripheral dose of 35 Gy (range, 30-41 Gy) was delivered in 3 to 5 fractions. Results With a median follow-up of 10 months (range, 1-37 months), the crude local tumor control (LTC) rate was 86.8% and the estimated LTC rates at 12 and 24 months were 87.0% and 65.2%, respectively. The median overall survival (OS) and progression-free survival (PFS) rates were 16 and 11 months, respectively. The estimated OS and PFS rates at 6, 12, and 18 months were 81.1% and 65.5%, 56.8% and 44.9%, and 40.7% and 25.7%, respectively. Patient performance status and preoperative focal neurologic deficits improved in 20 of 35 (57.1%) and 12 of 17 patients (70.6%), respectively. Radiation necrosis with a toxicity grade of 2 or 3 occurred in 6 lesions (15.8%). Conclusion These results suggest a promising role of fractionated stereotactic radiosurgery in treating large BMs in terms of both efficacy and safety.
Collapse
Affiliation(s)
- Won Joo Jeong
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Hong Park
- Radiosurgery Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Jung Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Jin Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Hyun Cho
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
26
|
Serna A, Escolar PP, Puchades V, Mata F, Ramos D, Gómez MA, Iglesias A, Salinas J, Alcaraz M. Single fraction volumetric modulated arc radiosurgery of brain metastases. Clin Transl Oncol 2015; 17:596-603. [PMID: 25775918 DOI: 10.1007/s12094-015-1282-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 02/28/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To show the clinical results of the treatment of brain metastases via radiosurgery using Volumetric Modulated Arc Therapy (VMAT). MATERIALS AND METHODS 52 patients having lung (62 %), breast (17 %), colorectal (8 %) and other cancers (13 %) with one to three brain metastases were treated with 5 non-coplanar VMAT arcs. The treatment dose varied from 12 to 20 Gy, administered in one single session. The volume of metastases ranged from 0.04 to 24.92 cc. Radiosurgery alone was used for 54 % of cases, while 19 % received whole brain radiotherapy due to relapse. Patients were classified according to the Disease-specific graded prognostic assessment (DS-GPA) index and survival was assessed via the Kaplan-Meier model. RESULTS The median survival time was 7.2 months from the date of radiosurgery. The Karnofsky and DS-GPA indices were the most significant with regard to survival. Patients with a Karnofsky performance status (KPS) over 70 had a longer survival time of 9.2 months, as opposed to those with a KPS below 70 of 3.5 months. No significant differences were found with regard to the type of cancer or the number of lesions. Local tumour control was achieved for 42 metastases (82 %), of which a complete response was achieved for 7 lesions, a partial response for 21; 15 lesions were stabilized. Local progression was observed in 8 lesions (15 %). The median treatment time per patient was 29 min. CONCLUSIONS The VMAT technique proves to be safe and effective for treating brain metastases via radiosurgery.
Collapse
Affiliation(s)
- A Serna
- Department of Medical Physics and Radiation Protection, Santa Lucia University Hospital, 30202, Cartagena, Murcia, Spain,
| | | | | | | | | | | | | | | | | |
Collapse
|
27
|
de Azevedo Santos TR, Tundisi CF, Ramos H, Maia MAC, Pellizzon ACA, Silva MLG, Fogaroli RC, Chen MJ, Suzuki SH, Dias JES, Sanematsu PI, de Castro DG. Local control after radiosurgery for brain metastases: predictive factors and implications for clinical decision. Radiat Oncol 2015; 10:63. [PMID: 25884621 PMCID: PMC4353457 DOI: 10.1186/s13014-015-0367-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 02/23/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate the local control of brain metastases (BM) in patients treated with stereotactic radiosurgery (SRS), correlate the outcome with treatment parameters and lesion characteristics, and define its implications for clinical decisions. METHODS Between 2007 and 2012, 305 BM in 141 consecutive patients were treated with SRS. After exclusions, 216 BM in 100 patients were analyzed. Doses were grouped as follows: ≤15 Gy, 16-20 Gy, and ≥21 Gy. Sizes were classified as ≤10 mm and >10 mm. Local control (LC) and overall survival (OS) were estimated using the Kaplan-Meier method. Log-rank statistics were used to identify the prognostic factors affecting LC and OS. For multivariate analyses, a Cox proportional model was applied including all potentially significant variables reached on univariate analyses. RESULTS Median age was 54 years (18-80). Median radiological follow-up of the lesions was 7 months (1-66). Median LC and the LC at 1 year were 22.3 months and 69.7%, respectively. On univariate analysis, tumor size, SRS dose, and previous whole brain irradiation (WBRT) were significant factors for LC. Patients with lesions >10 and ≤10 mm had an LC at 1 year of 58.6% and 79.1%, respectively (p = 0.008). In lesions receiving ≤15 Gy, 16-20 Gy, and ≥21 Gy, the 1-year LC rates were 39.6%, 71.7%, and 92.3%, respectively (p < 0.001). When WBRT was done previously, LC at 1 year was 57.9% compared with 78.4% for those who did not undergo WBRT (p = 0.004). On multivariate analysis, dose remained the single most powerful prognostic factor for LC. Median OS for all patients was 17 months, with no difference among the groups. CONCLUSIONS Dose is the most important predictive factor for LC of BM. Doses below 16 Gy correlated with poor LC. The SRS dose as salvage treatment after previous WBRT should not be reduced unless there is a pressing reason to do so.
Collapse
Affiliation(s)
| | | | - Henderson Ramos
- Department of Radiation Oncology, AC Camargo Cancer Center, São Paulo, Brazil.
| | | | | | | | | | - Michael Jenwei Chen
- Department of Radiation Oncology, AC Camargo Cancer Center, São Paulo, Brazil.
| | | | | | | | | |
Collapse
|
28
|
Hall MD, McGee JL, McGee MC, Hall KA, Neils DM, Klopfenstein JD, Elwood PW. Cost-effectiveness of stereotactic radiosurgery with and without whole-brain radiotherapy for the treatment of newly diagnosed brain metastases. J Neurosurg 2014; 121 Suppl:84-90. [DOI: 10.3171/2014.7.gks14972] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ObjectStereotactic radiosurgery (SRS) alone is increasingly used in patients with newly diagnosed brain metastases. Stereotactic radiosurgery used together with whole-brain radiotherapy (WBRT) reduces intracranial failure rates, but this combination also causes greater neurocognitive toxicity and does not improve survival. Critics of SRS alone contend that deferring WBRT results in an increased need for salvage therapy and in higher costs. The authors compared the cost-effectiveness of treatment with SRS alone, SRS and WBRT (SRS+WBRT), and surgery followed by SRS (S+SRS) at the authors' institution.MethodsThe authors retrospectively reviewed the medical records of 289 patients in whom brain metastases were newly diagnosed and who were treated between May 2001 and December 2007. Overall survival curves were plotted using the Kaplan-Meier method. Multivariate proportional hazards analysis (MVA) was used to identify factors associated with overall survival. Survival data were complete for 96.2% of patients, and comprehensive data on the resource use for imaging, hospitalizations, and salvage therapies were available from the medical records. Treatment costs included the cost of initial and all salvage therapies for brain metastases, hospitalizations, management of complications, and imaging. They were computed on the basis of the 2007 Medicare fee schedule from a payer perspective. Average treatment cost and average cost per month of median survival were compared. Sensitivity analysis was performed to examine the impact of variations in key cost variables.ResultsNo significant differences in overall survival were observed among patients treated with SRS alone, SRS+WBRT, or S+SRS with respective median survival of 9.8, 7.4, and 10.6 months. The MVA detected a significant association of overall survival with female sex, Karnofsky Performance Scale (KPS) score, primary tumor control, absence of extracranial metastases, and number of brain metastases. Salvage therapy was required in 43% of SRS-alone and 26% of SRS+WBRT patients (p < 0.009). Despite an increased need for salvage therapy, the average cost per month of median survival was $2412 per month for SRS alone, $3220 per month for SRS+WBRT, and $4360 per month for S+SRS (p < 0.03). Compared with SRS+WBRT, SRS alone had an average incremental cost savings of $110 per patient. Sensitivity analysis confirmed that the average treatment cost of SRS alone remained less than or was comparable to SRS+WBRT over a wide range of costs and treatment efficacies.ConclusionsDespite an increased need for salvage therapy, patients with newly diagnosed brain metastases treated with SRS alone have similar overall survival and receive more cost-effective care than those treated with SRS+WBRT. Compared with SRS+WBRT, initial management with SRS alone does not result in a higher average cost.
Collapse
Affiliation(s)
- Matthew D. Hall
- Departments of 1Radiology and
- 4Department of Radiation Oncology, City of Hope National Medical Center, Duarte, California
| | - James L. McGee
- Departments of 1Radiology and
- 3Illinois Neurological Institute, Peoria, Illinois; and
| | - Mackenzie C. McGee
- Departments of 1Radiology and
- 3Illinois Neurological Institute, Peoria, Illinois; and
| | | | - David M. Neils
- 2Neurosurgery, University of Illinois College of Medicine at Peoria, Peoria, Illinois
| | - Jeffrey D. Klopfenstein
- 2Neurosurgery, University of Illinois College of Medicine at Peoria, Peoria, Illinois
- 3Illinois Neurological Institute, Peoria, Illinois; and
| | - Patrick W. Elwood
- 2Neurosurgery, University of Illinois College of Medicine at Peoria, Peoria, Illinois
- 3Illinois Neurological Institute, Peoria, Illinois; and
| |
Collapse
|
29
|
Ahluwalia MS, Vogelbaum MV, Chao ST, Mehta MM. Brain metastasis and treatment. F1000PRIME REPORTS 2014; 6:114. [PMID: 25580268 PMCID: PMC4251415 DOI: 10.12703/p6-114] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Despite major therapeutic advances in the management of patients with systemic malignancies, management of brain metastases remains a significant challenge. These patients often require multidisciplinary care that includes surgical resection, radiation therapy, chemotherapy, and targeted therapies. Complex decisions about the sequencing of therapies to control extracranial and intracranial disease require input from neurosurgeons, radiation oncologists, and medical/neuro-oncologists. With advances in understanding of the biology of brain metastases, molecularly defined disease subsets and the advent of targeted therapy as well as immunotherapeutic agents offer promise. Future care of these patients will entail tailoring treatment based on host (performance status and age) and tumor (molecular cytogenetic characteristics, number of metastases, and extracranial disease status) factors. Considerable work involving preclinical models and better clinical trial designs that focus not only on effective control of tumor but also on quality of life and neurocognition needs to be done to improve the outcome of these patients.
Collapse
Affiliation(s)
- Manmeet S. Ahluwalia
- Burkhardt Brain Tumor Neuro-Oncology Center, Neurological InstituteCleveland Clinic, 9500 Euclid Avenue, Cleveland, OHUSA
| | - Michael V. Vogelbaum
- Burkhardt Brain Tumor Neuro-Oncology Center, Neurological InstituteCleveland Clinic, 9500 Euclid Avenue, Cleveland, OHUSA
| | - Samuel T. Chao
- Burkhardt Brain Tumor Neuro-Oncology Center, Neurological InstituteCleveland Clinic, 9500 Euclid Avenue, Cleveland, OHUSA
| | - Minesh M. Mehta
- Department of Radiation Oncology, University of Maryland School of MedicineBaltimore, MD 21201USA
| |
Collapse
|
30
|
Sia J, Paul E, Dally M, Ruben J. Stereotactic radiosurgery for 318 brain metastases in a single Australian centre: the impact of histology and other factors. J Clin Neurosci 2014; 22:303-7. [PMID: 25304434 DOI: 10.1016/j.jocn.2014.07.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 07/10/2014] [Accepted: 07/15/2014] [Indexed: 10/24/2022]
Abstract
While melanoma brain metastases (BM) are consistently associated with worse survival compared to other histologies, whether they correlate with worse local control (LC) following stereotactic radiosurgery (SRS) is not yet well-defined. In this study of prospectively and retrospectively collected data we investigated the impact of histology and other host, tumour and treatment factors on overall survival (OS) and LC. We analysed 162 patients and 318 BM lesions from various histologies treated with SRS between 2005 and 2011. We included patients who received SRS as first-line treatment, as well as patients who received SRS for residual or recurrent BM following prior surgery, whole brain radiotherapy (WBRT) or both. Median OS for the entire cohort was 8.4 months. Median OS for tumour histologies of melanoma, lung and breast cancer were 5.1, 12.2, and 14.7 months, respectively. On multivariate analysis, melanoma predicted for worse OS (hazard ratio [HR] 1.515, p = 0.003) together with performance status (HR 1.662, p < 0.001) and uncontrolled systemic disease (HR 1.755, p = 0.003). Melanoma histology was also negatively predictive for LC (HR 1.828, p = 0.021) together with increasing tumour size (HR 1.038, p = 0.017). Other factors, including the use of WBRT with SRS, the use of planning treatment volume margins, and prescription dose were not significantly predictive for OS and LC. We conclude melanoma histology also portends poorer LC in the SRS setting. While survival depends significantly on the systemic behaviour of the disease, treatment refinements to reduce local failure still merit exploration, especially in the era of targeted therapies.
Collapse
Affiliation(s)
- Joseph Sia
- William Buckland Radiotherapy Centre Melbourne, South Block, The Alfred, 55 Commercial Road, Melbourne, VIC 3004, Australia.
| | - Eldho Paul
- Department of Epidemiology and Preventative Medicine, Monash University, The Alfred Centre (Alfred Hospital), Melbourne, VIC, Australia
| | - Michael Dally
- William Buckland Radiotherapy Centre Melbourne, South Block, The Alfred, 55 Commercial Road, Melbourne, VIC 3004, Australia; Department of Surgery, Monash University, The Alfred Centre (Alfred Hospital), Melbourne, VIC, Australia
| | - Jeremy Ruben
- William Buckland Radiotherapy Centre Melbourne, South Block, The Alfred, 55 Commercial Road, Melbourne, VIC 3004, Australia; Department of Surgery, Monash University, The Alfred Centre (Alfred Hospital), Melbourne, VIC, Australia
| |
Collapse
|
31
|
Sheehan JP, Yen CP, Lee CC, Loeffler JS. Cranial stereotactic radiosurgery: current status of the initial paradigm shifter. J Clin Oncol 2014; 32:2836-46. [PMID: 25113762 PMCID: PMC4152711 DOI: 10.1200/jco.2013.53.7365] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The concept of stereotactic radiosurgery (SRS) was first described by Lars Leksell in 1951. It was proposed as a noninvasive alternative to open neurosurgical approaches to manage a variety of conditions. In the following decades, SRS emerged as a unique discipline involving a collegial partnership among neurosurgeons, radiation oncologists, and medical physicists. SRS relies on the precisely guided delivery of high-dose ionizing radiation to an intracranial target. The focused convergence of multiple beams yields a potent therapeutic effect on the target and a steep dose fall-off to surrounding structures, thereby minimizing the risk of collateral damage. SRS is typically administered in a single session but can be given in as many as five sessions or fractions. By providing an ablative effect noninvasively, SRS has altered the treatment paradigms for benign and malignant intracranial tumors, functional disorders, and vascular malformations. Literature on extensive intracranial radiosurgery has unequivocally demonstrated the favorable benefit-to-risk profile that SRS affords for appropriately selected patients. In a departure from conventional radiotherapeutic strategies, radiosurgical principles have recently been extended to extracranial indications such as lung, spine, and liver tumors. The paradigm shift resulting from radiosurgery continues to alter the landscape of related fields.
Collapse
Affiliation(s)
- Jason P Sheehan
- Jason P. Sheehan, Chun-Po Yen, Cheng-Chia Lee, University of Virginia, Charlottesville, VA; Jay S. Loeffler, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Chun-Po Yen
- Jason P. Sheehan, Chun-Po Yen, Cheng-Chia Lee, University of Virginia, Charlottesville, VA; Jay S. Loeffler, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Cheng-Chia Lee
- Jason P. Sheehan, Chun-Po Yen, Cheng-Chia Lee, University of Virginia, Charlottesville, VA; Jay S. Loeffler, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jay S Loeffler
- Jason P. Sheehan, Chun-Po Yen, Cheng-Chia Lee, University of Virginia, Charlottesville, VA; Jay S. Loeffler, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
32
|
Esmaeilzadeh M, Majlesara A, Faridar A, Hafezi M, Hong B, Esmaeilnia-Shirvani H, Neyazi B, Mehrabi A, Nakamura M. Brain metastasis from gastrointestinal cancers: a systematic review. Int J Clin Pract 2014; 68:890-9. [PMID: 24666726 DOI: 10.1111/ijcp.12395] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Brain metastases (BM) from the gastrointestinal tract (GIT) cancers are relatively rare. Despite those advances in diagnostic and treatment options, life expectancy and quality of life in these patients are still poor. In this review, we present an overview of the studies which have been previously performed as well as a comprehensive strategy for the assessment and treatment of BM from the GIT cancers. METHOD To obtain information on brain metastases from GIT, we performed a systematic review of Medline, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL). The collected data included patient characteristics, primary tumor data and brain metastases data. RESULT In our search of the literature, we found 74 studies between 1980 and 2011, which included 2538 patients with brain metastases originated from gastrointestinal cancer. Analysis of available data showed that among 2538 patients who had brain metastases from GIT, a total of 116 patients (4.57%) had esophageal cancer, 148 patients (5.83%) had gastric cancer, 233 patients (9.18%) had liver cancer, 13 patients had pancreas cancer (0.52%) and 2028 patients (79.90%) had colorectal cancer. The total median age of the patients was 58.9 years. CONCLUSION Brain metastases have been considered the most common structural neurological complication of systemic cancer. Due to poor prognosis they influence the survival rate as well as the quality of life of the patients. The treatment of cerebral metastasis depends on the patients' situation and the decisions of the treating physicians. The early awareness of a probable metastasis from GI to the brain will have a great influence on treatment outcomes as well as the survival rate and the quality-of-life of the patients.
Collapse
Affiliation(s)
- M Esmaeilzadeh
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Kocher M, Wittig A, Piroth MD, Treuer H, Seegenschmiedt H, Ruge M, Grosu AL, Guckenberger M. Stereotactic radiosurgery for treatment of brain metastases. A report of the DEGRO Working Group on Stereotactic Radiotherapy. Strahlenther Onkol 2014; 190:521-32. [PMID: 24715242 DOI: 10.1007/s00066-014-0648-7] [Citation(s) in RCA: 145] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 02/25/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND This report from the Working Group on Stereotaktische Radiotherapie of the German Society of Radiation Oncology (Deutsche Gesellschaft für Radioonkologie, DEGRO) provides recommendations for the use of stereotactic radiosurgery (SRS) on patients with brain metastases. It considers existing international guidelines and details them where appropriate. RESULTS AND DISCUSSION The main recommendations are: Patients with solid tumors except germ cell tumors and small-cell lung cancer with a life expectancy of more than 3 months suffering from a single brain metastasis of less than 3 cm in diameter should be considered for SRS. Especially when metastases are not amenable to surgery, are located in the brain stem, and have no mass effect, SRS should be offered to the patient. For multiple (two to four) metastases--all less than 2.5 cm in diameter--in patients with a life expectancy of more than 3 months, SRS should be used rather than whole-brain radiotherapy (WBRT). Adjuvant WBRT after SRS for both single and multiple (two to four) metastases increases local control and reduces the frequency of distant brain metastases, but does not prolong survival when compared with SRS and salvage treatment. As WBRT carries the risk of inducing neurocognitive damage, it seems reasonable to withhold WBRT for as long as possible. CONCLUSION A single (marginal) dose of 20 Gy is a reasonable choice that balances the effect on the treated lesion (local control, partial remission) against the risk of late side effects (radionecrosis). Higher doses (22-25 Gy) may be used for smaller (< 1 cm) lesions, while a dose reduction to 18 Gy may be necessary for lesions greater than 2.5-3 cm. As the infiltration zone of the brain metastases is usually small, the GTV-CTV (gross tumor volume-clinical target volume) margin should be in the range of 0-1 mm. The CTV-PTV (planning target volume) margin depends on the treatment technique and should lie in the range of 0-2 mm. Distant brain recurrences fulfilling the aforementioned criteria can be treated with SRS irrespective of previous WBRT.
Collapse
Affiliation(s)
- Martin Kocher
- Department of Radiation Oncology, University Hospital Cologne, Joseph-Stelzmann-Str. 9, 50924, Köln, Germany,
| | | | | | | | | | | | | | | |
Collapse
|
34
|
Komaki RU, Ghia AJ. Brain Metastasis from Lung Cancer. Lung Cancer 2014. [DOI: 10.1002/9781118468791.ch38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
35
|
Rodrigues G, Warner A, Zindler J, Slotman B, Lagerwaard F. A clinical nomogram and recursive partitioning analysis to determine the risk of regional failure after radiosurgery alone for brain metastases. Radiother Oncol 2014; 111:52-8. [DOI: 10.1016/j.radonc.2013.11.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 10/18/2013] [Accepted: 11/03/2013] [Indexed: 11/30/2022]
|
36
|
Rades D, Hornung D, Blanck O, Martens K, Khoa MT, Trang NT, Hüppe M, Terheyden P, Gliemroth J, Schild SE. Stereotactic radiosurgery for newly diagnosed brain metastases. Strahlenther Onkol 2014; 190:786-91. [DOI: 10.1007/s00066-014-0625-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 01/22/2014] [Indexed: 11/30/2022]
|
37
|
Hasan S, Shah AH, Bregy A, Albert T, Markoe A, Stoyanova R, Thambuswamy M, Komotar RJ. The role of whole-brain radiation therapy after stereotactic radiation surgery for brain metastases. Pract Radiat Oncol 2013; 4:306-315. [PMID: 25194099 DOI: 10.1016/j.prro.2013.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 09/20/2013] [Accepted: 09/27/2013] [Indexed: 11/19/2022]
Abstract
The benefit of whole-brain radiation therapy (WBRT) following stereotactic radiation surgery (SRS) for brain metastases is controversial. We conducted a systematic analysis of published literature to explore the outcome of brain metastases treated with SRS and WBRT versus SRS alone using PubMed and MEDLINE. Outcomes including survival, control, salvage therapy, and other quality of life measures were reported. Three randomized controlled trials involving 389 patients with 1 to 4 brain metastases were selected. In 2 of these trials (n = 190), the mean 1-year survival was 33.2% for SRS + WBRT and 38.7% for SRS alone (P = .5233); 1-year local control was 89% for SRS + WBRT and 71% for SRS alone (P < .001). Mean crude distant recurrence rate for SRS + WBRT was 36.6% and 54% for SRS alone (P < .001). Patients without WBRT were over 3 times more likely to require salvage therapy (P < .001). The addition of WBRT was associated with a decreased health-related quality of life assessment, mini mental status exam, and Hopkins Verbal Learning Test (P < .05). Five retrospective studies (n = 1122) were also included in a separate analysis and yielded findings that supported results from the randomized trials. Our systematic analysis demonstrates that adjuvant WBRT following SRS for the treatment of oligometastases in the brain is more effective at controlling local and distant recurrence than SRS alone, but there is no apparent benefit for survival or symptomology. The proven cognitive decline and neurotoxicity present with WBRT should be weighed against the benefit of local control. Prognosis of brain metastasis is poor regardless of current treatment and further exploration for alternative adjuvant treatment for SRS is warranted.
Collapse
Affiliation(s)
- Shaakir Hasan
- Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, Florida
| | - Ashish H Shah
- University of Miami Miller School of Medicine, Department of Neurological Surgery, Miami, Florida
| | - Amade Bregy
- University of Miami Miller School of Medicine, Department of Neurological Surgery, Miami, Florida
| | - Trevine Albert
- Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, Florida
| | - Arnold Markoe
- University of Miami Miller School of Medicine, Department of Radiation Oncology, Miami, Florida
| | - Radka Stoyanova
- University of Miami Miller School of Medicine, Department of Radiation Oncology, Miami, Florida
| | - Michael Thambuswamy
- University of Miami Miller School of Medicine, Department of Neurological Surgery, Miami, Florida
| | - Ricardo J Komotar
- University of Miami Miller School of Medicine, Department of Neurological Surgery, Miami, Florida.
| |
Collapse
|
38
|
Ruzevick J, Kleinberg L, Rigamonti D. Imaging changes following stereotactic radiosurgery for metastatic intracranial tumors: differentiating pseudoprogression from tumor progression and its effect on clinical practice. Neurosurg Rev 2013; 37:193-201; discussion 201. [PMID: 24233257 DOI: 10.1007/s10143-013-0504-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 08/18/2013] [Accepted: 08/24/2013] [Indexed: 02/07/2023]
Abstract
Stereotactic radiosurgery has become standard adjuvant treatment for patients with metastatic intracranial lesions. There has been a growing appreciation for benign imaging changes following radiation that are difficult to distinguish from true tumor progression. These imaging changes, termed pseudoprogression, carry significant implications for patient management. In this review, we discuss the current understanding of pseudoprogression in metastatic brain lesions, research to differentiate pseudoprogression from true progression, and clinical implications of pseudoprogression on treatment decisions.
Collapse
Affiliation(s)
- Jacob Ruzevick
- Department of Neurological Surgery, The Johns Hopkins University School of Medicine, Phipps Building, Room 126, 600 N. Wolfe Street, Baltimore, MD, 21287, USA,
| | | | | |
Collapse
|
39
|
Abstract
The use of stereotactic body radiotherapy for metastatic spinal tumours is increasing. Serious adverse events for this treatment include vertebral compression fracture (VCF) and radiation myelopathy. Although VCF is a fairly low-risk adverse event (approximately 5% risk) after conventional radiotherapy, crude risk estimates for VCF after spinal SBRT range from 11% to 39%. In this Review, we summarise the evidence and predictive factors for VCF induced by spinal SBRT, review the pathophysiology of VCF in the metastatic spine, and discuss strategies used to prevent and manage this potentially disabling complication.
Collapse
|
40
|
Brem S, Meyers CA, Palmer G, Booth-Jones M, Jain S, Ewend MG. Preservation of neurocognitive function and local control of 1 to 3 brain metastases treated with surgery and carmustine wafers. Cancer 2013; 119:3830-8. [PMID: 24037801 PMCID: PMC4209121 DOI: 10.1002/cncr.28307] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 07/11/2013] [Indexed: 11/23/2022]
Abstract
Background Neurosurgical resection and whole-brain radiation therapy (WBRT) are accepted treatments for single and oligometastatic cancer to the brain. To avoid the decline in neurocognitive function (NCF) linked to WBRT, the authors conducted a prospective, multicenter, phase 2 study to determine whether surgery and carmustine wafers (CW), while deferring WBRT, could preserve NCF and achieve local control (LC). Methods NCF and LC were measured in 59 patients who underwent resection and received CW for a single (83%) or dominant (oligometastatic, 2 to 3 lesions) metastasis and received stereotactic radiosurgery (SRS) for tiny nodules not treated with resection plus CW. Preservation of NCF was defined as an improvement or a decline ≤1 standard deviation from baseline in 3 domains: memory, executive function, and fine motor skills, evaluated at 2-month intervals. Results Significant improvements in executive function and memory occurred throughout the 1-year follow-up. Preservation or improvement of NCF occurred in all 3 domains for the majority of patients at each of the 2-month intervals. NCF declined in only 1 patient. The chemowafers were well tolerated, and serious adverse events were reversible. There was local recurrence in 28% of the patients at 1-year follow-up. Conclusions Patients with brain metastases had improvements in their cognitive trajectory, especially memory and executive function, after treatment with resection plus CW. The rate of LC (78%) was comparable to historic rates of surgery with WBRT and superior to reports of WBRT alone. For patients who undergo resection for symptomatic or large-volume metastasis or for tissue diagnosis, the addition of CW can be considered as an option.
Collapse
Affiliation(s)
- Steven Brem
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, Florida; Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania and the Abramson Cancer Center, Philadelphia, Pennsylvania
| | | | | | | | | | | |
Collapse
|
41
|
Clinical outcomes of patients treated with a second course of stereotactic radiosurgery for locally or regionally recurrent brain metastases after prior stereotactic radiosurgery. J Neurooncol 2013; 115:37-43. [DOI: 10.1007/s11060-013-1191-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 06/22/2013] [Indexed: 10/26/2022]
|
42
|
Telera S, Fabi A, Pace A, Vidiri A, Anelli V, Carapella CM, Marucci L, Crispo F, Sperduti I, Pompili A. Radionecrosis induced by stereotactic radiosurgery of brain metastases: results of surgery and outcome of disease. J Neurooncol 2013; 113:313-25. [PMID: 23525948 DOI: 10.1007/s11060-013-1120-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Accepted: 03/16/2013] [Indexed: 11/24/2022]
Abstract
Sterotactic radiosurgery (SRS) is an effective and commonly employed therapy for metastatic brain tumors. Among complication of this treatment, symptomatic focal cerebral radionecrosis (RN) occurs in 2-10 % of cases. The large diffusion of combined therapies as SRS followed by WBRT and/or CHT, has significantly amplified the number of patients who potentially might be affected by this pathology and neurosurgeons are increasingly called to treat suspected area of RN. Results of surgery of RN in patients with brain metastases are rarely reported in literature, a standardization of diagnostic work-up to correctly identify RN is still lacking and the timing and indications in favour of surgical therapy over medical treatments are not clear as well. In this retrospective study, we review current concept related to RN and analyze the outcome of surgical treatment in a series of 15 patients previously submitted to SRS for brain metastases and affected by suspected radionecrotic lesions. After surgery, all patients except one neurologically improved. No intra-operative complications occurred. Brain edema improved in all patients allowing a reduction or even suspension of corticosteroid therapy. Pure RN was histologically determined in 7 cases; RN and tumor recurrence in the other 8. Overall median survival was 19 months. An aggressive surgical attitude may be advisable in symptomatic patients with suspected cerebral RN, to have histologic confirmation of the lesion, to obtain a long-lasting relief from the mass effect and brain edema and to improve the overall quality of life, sparing a prolonged corticosteroid therapy.
Collapse
Affiliation(s)
- Stefano Telera
- Division of Neurosurgery, Istituto Nazionale Tumori Regina Elena, via Elio Chianesi 53, 00144, Rome, Italy.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Hippocampal avoidance with volumetric modulated arc therapy in melanoma brain metastases - the first Australian experience. Radiat Oncol 2013; 8:62. [PMID: 23497418 PMCID: PMC3608934 DOI: 10.1186/1748-717x-8-62] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 03/07/2013] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Volumetric modulated arc therapy (VMAT) can deliver intensity modulated radiotherapy (IMRT) like dose distributions in a short time; this allows the expansion of IMRT treatments to palliative situations like brain metastases (BMs). VMAT can deliver whole brain radiotherapy (WBRT) with hippocampal avoidance and a simultaneous integrated boost (SIB) to achieve stereotactic radiotherapy (SRT) for BMs. This study is an audit of our experience in the treatment of brain metastases with VMAT in our institution. METHODS AND MATERIALS Metastases were volumetrically contoured on fused diagnostic gadolinium enhanced T1 weighted MRI/planning CT images. Risk organs included hippocampus, optic nerve, optic chiasm, eye, and brain stem. The hippocampi were contoured manually as one paired organ with assistance from a neuroradiologist. WBRT and SIB were integrated into a single plan. RESULTS Thirty patients with 73 BMs were treated between March 2010 and February 2012 with VMAT. Mean follow up time was 3.5 months. For 26 patients, BMs arose from primary melanoma and for the remaining four patients from non-small cell lung cancer (n= 2), primary breast cancer, and sarcoma. Mean age was 60 years. The male to female ratio was 2:1. Five patients were treated without hippocampal avoidance (HA) intent. The median WBRT dose was 31 Gy with a median SIB dose for BMs of 50 Gy, given over a median of 15 fractions. Mean values for BMs were as follows: GTV = 6.9 cc, PTV = 13.3 cc, conformity index = 8.6, homogeneity index = 1.06. Mean and maximum hippocampus dose was 20.4 Gy, and 32.4 Gy, respectively, in patients treated with HA intent. Mean VMAT treatment time from beam on to beam off for one fraction was 3.43 minutes, which compared to WBRT time of 1.3 minutes. Twenty out of 25 assessable lesions at the time of analysis were controlled. Treatment was well tolerated; grade 4 toxicity was reported in one patient. The median overall survival was 9.40 months CONCLUSIONS VMAT for BMs is feasible, safe and associated with a similar survival times and toxicities to conventional SRT+/-WBRT. The advantage of VMAT is that WBRT and SRT can be delivered at the same time on one machine.
Collapse
|
44
|
Rodrigues G, Zindler J, Warner A, Lagerwaard F. Recursive partitioning analysis for the prediction of stereotactic radiosurgery brain metastases lesion control. Oncologist 2013; 18:330-5. [PMID: 23429647 DOI: 10.1634/theoncologist.2012-0316] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE The objective of this investigation was to identify independent pretreatment factors that predict for control of local brain metastases (BM) in a large single-institution series of patients receiving stereotactic radiosurgery (SRS). Recursive partitioning analysis was used to potentially identify a class of patients with durable lesion control characteristics. METHODS A retrospective SRS database containing baseline characteristics, treatment details, and follow-up data of newly diagnosed patients with 1-3 BM (on magnetic resonance imaging) treated with linear accelerator-based SRS was created. Three study endpoints were used: time to progression (primary endpoint, individual lesion progression; n = 536), time to first progression (secondary endpoint, first lesion progression on an individual patient basis; n = 380), and overall survival (secondary endpoint; n = 380). Recursive partitioning analysis (RPA) was performed to identify predictors of time to progression. RESULTS Multivariable analysis demonstrated that lesion aspect/phenotype and radiotherapy schedule were independent factors associated with both progression outcomes. Presence of tumor necrosis was found to be associated with a significant hazard of progression (hazard ratio >3), whereas use of the most intense radiotherapy fractionation schedule (21 Gy in one fraction) was associated with significant reductions in progression (hazard ratio <0.3). RPA using SRS dose and lesion aspect/phenotype was created and described three distinct prognostic groups. CONCLUSIONS RPA of a large retrospective database of patients receiving SRS confirmed previous observations regarding the importance of SRS dose and lesion aspect/phenotype in lesion control and overall survival. The SRS lesion analysis may help to stratify future clinical trials and better define patient care options and prognosis.
Collapse
Affiliation(s)
- George Rodrigues
- Department of Radiation Oncology, London Regional Cancer Program, London Health Sciences Centre, London, Ontario, Canada.
| | | | | | | |
Collapse
|
45
|
Märtens B, Janssen S, Werner M, Frühauf J, Christiansen H, Bremer M, Steinmann D. Hypofractionated stereotactic radiotherapy of limited brain metastases: a single-centre individualized treatment approach. BMC Cancer 2012; 12:497. [PMID: 23098039 PMCID: PMC3531248 DOI: 10.1186/1471-2407-12-497] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Accepted: 10/23/2012] [Indexed: 11/10/2022] Open
Abstract
Background We retrospectively report treatment results of our single-centre experience with hypofractionated stereotactic radiotherapy (hfSRT) of limited brain metastases in primary and recurrence disease situations. Our aim was to find the most effective and safe dose concept. Methods From 04/2006 to 12/2010, 75 patients, with 108 intracranial metastases, were treated with hfSRT.
52 newly diagnosed metastases (48%), without up-front whole brain radiotherapy (WBRT), received hfSRT as a primary treatment. 56 metastases (52%) received a prior WBRT and were treated in this study in a recurrence situation. Main fractionation concepts used for primary hfSRT were 6-7x5 Gy (61.5%) and 5x6 Gy (19.2%), for recurrent hfSRT 7-10x4 Gy (33.9%) and 5-6x5 Gy (33.9%). Results Median overall survival (OS) of all patients summed up to 9.1 months, actuarial 6-and 12-month-OS was 59% and 35%, respectively. Median local brain control (LC) was 11.9 months, median distant brain control (DC) 3.9 months and intracranial control (IC) 3.4 months, respectively. Variables with significant influence on OS were Gross Tumour Volume (GTV) (p = 0.019), the biological eqivalent dose (calculated on a 2 Gy single dose, EQD2, α/β = 10) < and ≥ median of 39 Gy (p = 0.012), extracerebral activity of the primary tumour (p < 0.001) and the steroid uptake during hfSRT (p = 0.03). LC was significantly influenced by the EQD2, ≤ and > 35 Gy (p = 0.004) in both
uni- and multivariate Cox regression analysis. Median LC was 14.9 months for EQD2 >35 Gy and 3.4 months for doses ≤35 Gy, respectively. Early treatment related side effects were usually mild. Nevertheless, patients with a EQD2 >35 Gy had higher rates of toxicity (31%) than ≤35 Gy (8.3%, p=0.026). Conclusion Comparing different dose concepts in hfSRT, a cumulative EQD2 of ≥35 Gy seems to be the most effective concept in patients with primary or recurrent limited brain metastases. Despite higher rates of only mild toxicity, this concept represents a safe treatment option.
Collapse
Affiliation(s)
- Bettina Märtens
- Radiation Oncology, Medical School Hannover, Carl-Neuberg-Str, 1, Hannover, 30625, Germany
| | | | | | | | | | | | | |
Collapse
|
46
|
A call for the aggressive treatment of oligometastatic and oligo-recurrent non-small cell lung cancer. Pulm Med 2012; 2012:480961. [PMID: 23125927 PMCID: PMC3483729 DOI: 10.1155/2012/480961] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 09/11/2012] [Indexed: 01/25/2023] Open
Abstract
Metastatic non-small cell lung cancer (NSCLC) carries a dismal prognosis. Clinical evidence suggests the existence of an intermediate, or oligometastatic, state when metastases are limited in number and/or location. In addition, following initial curative therapy, many patients present with limited metastatic disease, or oligo-recurrence. Metastasis-directed, anti-cancer therapies may benefit these patients. A growing evidence-base supports the use of hypofractionated, image-guided radiotherapy (HIGRT) for a variety of malignant conditions including inoperable stage I NSCLC and many metastatic sites. When surgical resection is not possible, HIGRT offers an effective alternative for local treatment of limited metastatic disease. Early studies have produced promising results when HIGRT was delivered to all known sites of disease in patients with oligometastatic/oligo-recurrent NSCLC. In a population of patients formerly considered rapidly terminal, these studies report five year overall survival rates of 13-22%. HIGRT for metastatic NSCLC warrants further study. We call for large, intergroup, and even international randomized trials incorporating HIGRT and other metastasis-directed therapies into the treatment of patients with oligometastatic/oligo-recurrent NSCLC.
Collapse
|
47
|
Chen X, Xiao J, Li X, Jiang X, Zhang Y, Xu Y, Dai J. Fifty percent patients avoid whole brain radiotherapy: stereotactic radiotherapy for multiple brain metastases: a retrospective analysis of a single center. Clin Transl Oncol 2012; 14:599-605. [PMID: 22855144 DOI: 10.1007/s12094-012-0849-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2011] [Accepted: 11/06/2011] [Indexed: 11/29/2022]
Abstract
PURPOSE To summarize the outcomes of stereotactic radiotherapy (SRT), with or without whole-brain radiotherapy (WBRT), in the treatment of multiple brain metastasis and to explore the status of WBRT and SRT in the management of multiple brain metastasis. METHODS From May 1995 to April 2010, 98 patients with newly diagnosed, multiple brain metastasis were treated in our center. Forty-four patients were treated with SRT alone for the initial treatment, and 54 were treated with SRT + WBRT. Kaplan-Meier and Cox proportional hazards regression analyses were used for the survival analysis. RESULTS The median survival time (MST) was 13.5 months. No difference was observed in MST between the SRT and the SRT + WBRT groups (p = 0.578). The Karnofsky Performance Score at the time of treatment (p = 0.025), the interval time between diagnosis of primary tumor and brain metastasis (P = 0.012) and the situation of extracranial disease (p = 0.018) were significant predictors of survival. The crude distant intracranial recurrence (DIR) rates were 47.7 % in the SRT group and 24.1 % in the SRT + WBRT group (p = 0.018). In addition, 52.3 % patients in the SRT group were free from DIR and did not require WBRT in their whole lives. CONCLUSIONS Our data suggest that use of SRT as the initial treatment while reserving WBRT as the salvage therapy in case of distant intracranial recurrence made about 50 % of the patients avoid WBRT throughout the course of their lives and may be another optional treatment modality for multiple brain metastases.
Collapse
Affiliation(s)
- Xiujun Chen
- Department of Radiation Oncology, Cancer Hospital (Institute), Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | | | | | | | | | | | | |
Collapse
|
48
|
Ogura K, Mizowaki T, Ogura M, Sakanaka K, Arakawa Y, Miyamoto S, Hiraoka M. Outcomes of hypofractionated stereotactic radiotherapy for metastatic brain tumors with high risk factors. J Neurooncol 2012; 109:425-32. [DOI: 10.1007/s11060-012-0912-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Accepted: 06/04/2012] [Indexed: 10/28/2022]
|
49
|
Noël G, Daisne JF, Thillays F. Radiothérapie en conditions stéréotaxiques des métastases cérébrales. Cancer Radiother 2012; 16 Suppl:S101-10. [DOI: 10.1016/j.canrad.2011.02.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2010] [Revised: 01/28/2011] [Accepted: 02/01/2011] [Indexed: 11/15/2022]
|
50
|
Elliott RE, Rush SC, Morsi A, Mehta N, Spriet J, Narayana A, Donahue B, Parker EC, Golfinos JG. Local control of newly diagnosed and distally recurrent, low-volume brain metastases with fixed-dose (20 gy) gamma knife radiosurgery. Neurosurgery 2012; 68:921-31; discussion 931. [PMID: 21221034 DOI: 10.1227/neu.0b013e318208f58e] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Metastases to the brain occur in 20% to 30% of patients with cancer and have been identified on autopsy in as many as 50% of patients. OBJECTIVE To analyze the efficacy of 20-Gy Gamma Knife radiosurgery (GKR) as initial treatment in patients with 1 to 3 brain metastases ≤ 2 cm in greatest diameter. METHODS A retrospective analysis of 114 consecutive adults with Karnofsky performance status ≥ 60 who received GKR for 1 to 3 brain metastases ≤ 2 cm in size was performed. Five patients lacked detailed follow-up and were excluded, leaving 109 for outcome analysis (34 men and 75 women; median age, 61.2 years). All metastases received 20 Gy to the 50% isodose line. RESULTS One hundred nine patients underwent treatment of 164 metastases at initial GKR. Twenty-six patients (23.9%) were alive at last follow-up (median time, 29.9 months; range, 6.6 months to 7.8 years). The median overall survival was 13.8 months (range, 1 day to 7.6 years). Among the 52 patients with distant failure, 33 patients received 20 Gy to 95 new lesions. A total of 259 metastases received 20 Gy, and 4 patients lacked imaging follow-up secondary to death before posttreatment imaging. Local failure occurred in 17 of 255 treated lesions (6.7%), yielding an overall local control rate of 93.3%. Actuarial local control at 6, 12, 24, and 36 months was 96%, 93%, 89%, and 88%, respectively. Permanent neurological complications occurred in 3 patients (2.8%). CONCLUSION Among patients with 1 to 3 brain metastases ≤ 2 cm in size who have not received whole-brain radiation therapy, GKR with 20 Gy provides high rates of local control with low morbidity and excellent neurological symptom-free survival.
Collapse
Affiliation(s)
- Robert E Elliott
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York 10016, USA
| | | | | | | | | | | | | | | | | |
Collapse
|