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Pan K, Wang B, Xu X, Liang J, Tang Y, Ma S, Xia B, Zhu L. Hypofractionated stereotactic radiotherapy for brain metastases in lung cancer patients: dose‒response effect and toxicity. Discov Oncol 2024; 15:318. [PMID: 39078419 PMCID: PMC11289209 DOI: 10.1007/s12672-024-01191-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 07/24/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND Lung cancer is a common cause of brain metastases, approximately 40% of patients with lung cancer will develop brain metastases at some point during their disease. Hypofractionated stereotactic radiotherapy (HSRT) has been demonstrated to be effective in controlling limited brain metastases. However, there is still no conclusive on the optimal segmentation of HSRT. The aim of our study was to explore the correlation between the HSRT dosage and its treatment effect and toxicity. METHODS A retrospective analysis was conducted on patients with non-small cell lung cancer (NSCLC) brain metastasis at Hangzhou Cancer Hospital from 1 January 2019 to 1 January 2021. The number of brain metastases did not exceed 10 in all patients and the number of fractions of HSRT was 5. The prescription dose ranges from 25 to 40 Gy. The Kaplan-Meier method was used for estimation of the localised intracranial control rate (iLC). Adverse radiation effects (AREs) were evaluated according to CTCAE 5.0. This study was approved by the Institutional Ethics Review Board of the Hangzhou Cancer Hospital (#73/HZCH-2022). RESULTS Forty eligible patients with a total of 70 brain metastases were included in this study. The 1-year iLC was 76% and 89% in the prescribed dose ≤ 30 Gy and > 30 Gy group, respectively (P < 0.05). For patients treated with HSRT combined with targeted therapy, immunotherapy and chemotherapy, the 1-year iLC was 89%, 100%, and 45%, respectively. No significant associations were observed between the number, maximum diameter, location, and type of pathology of brain metastases. The rate of all-grade AREs was 33%. Two patients who received a total dose of 40 Gy developed grade 3 headache, the rest of the AREs were grade 1-2. CONCLUSIONS Increasing the prescription dose of HSRT improves treatment effect but may also exacerbate the side effects. Systemic therapy might impact the iLC rate, and individualized treatment regimens need to be developed.
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Affiliation(s)
- Kaicheng Pan
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China
| | - Bing Wang
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China
| | - Xiao Xu
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China
| | - Jiafeng Liang
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China
| | - Yi Tang
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China
| | - Shenglin Ma
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China
| | - Bing Xia
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China.
| | - Lucheng Zhu
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China.
- Department of Oncology, Affiliated Hangzhou Cancer Hospital, Zhejiang Chinese Medical University, Hangzhou, China.
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Upadhyay R, Palmer JD, Klamer BG, Perlow HK, Schoenhals JE, Ghose J, Rajappa P, Blakaj DM, Beyer S, Grecula JC, Sim AJ, Lu L, Zoller W, Elder JB, Chakravarti A, Thomas E, Raval RR. Safety and Feasibility of Stereotactic Radiosurgery for Patients with 15 or more Brain Metastases. Adv Radiat Oncol 2024; 9:101509. [PMID: 38799108 PMCID: PMC11127210 DOI: 10.1016/j.adro.2024.101509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 04/01/2024] [Indexed: 05/29/2024] Open
Abstract
Background Current standard of care treatment for patients with ≥15 brain metastases (BM) is whole brain radiation therapy (WBRT), despite poor neurocognitive outcomes. We analyzed our institutional experience of treating these patients with stereotactic radiosurgery (SRS), with the aim of evaluating safety, cognitive outcomes, and survival metrics. Methods Patients who received SRS for ≥15 BMs in 1 to 5 fractions from 2014 to 2022 were included. Cognitive outcomes were objectively evaluated using serial Patient-Reported Outcome Measurement Information System (PROMIS) scores. The Kaplan-Meier method was used for survival analysis and log-rank test for intergroup comparisons. Results Overall, 118 patients underwent 124 courses of LINAC-based SRS. The median number of lesions treated per course was 20 (range, 15-94). Most patients received fractionated SRS to a dose of 24 Gy in 3 fractions (81.5%). At the time of SRS, 19.4% patients had received prior WBRT, and 24.2% had received prior SRS. The rate of any grade radiation necrosis (RN) and grade ≥3 RN were 15.3% and 3.2%, respectively. When evaluating longitudinal PROMIS score trends, 25 of 31 patients had a stable/improved PROMIS score. Patients who did not receive prior brain RT had a longer median survival (7.4 months vs 4.6 months, P = .034). The 12m local control was 97.6%, and the cumulative incidence of distant intracranial failure, with death as a competing event, was 46% (95% CI, 36%, 55%). One year freedom from neurologic death, leptomeningeal disease, and salvage WBRT were 89%, 94.6%, and 84%, respectively. Conclusion We present here one of the largest studies evaluating SRS for patients with ≥15 BMs. SRS was safe, had favorable cognitive outcomes, and had comparable survival outcomes to contemporary studies evaluating WBRT in this population. Treatment-naïve patients had a median survival of >6 months, long enough to benefit from cognitive sparing with SRS. Our study supports randomized studies comparing SRS and hippocampal avoidance WBRT approaches for these patients.
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Affiliation(s)
- Rituraj Upadhyay
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Joshua D. Palmer
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Brett G. Klamer
- Center for Biostatistics, The Ohio State University, Columbus, Ohio
| | - Haley K. Perlow
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Jonathan E. Schoenhals
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Jayeeta Ghose
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Prajwal Rajappa
- Department of Pediatrics and Neurological Surgery, The Ohio State University James Cancer Center, Columbus, OH and Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Dukagjin M. Blakaj
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Sasha Beyer
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - John C. Grecula
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Austin J. Sim
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Lanchun Lu
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Wesley Zoller
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - James B. Elder
- Department of Neurological Surgery, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Arnab Chakravarti
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Evan Thomas
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
| | - Raju R. Raval
- Department of Radiation Oncology, The Ohio State University James Cancer Center, Columbus, Ohio
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Kanakarajan H, De Baene W, Gehring K, Eekers DBP, Hanssens P, Sitskoorn M. Factors associated with the local control of brain metastases: a systematic search and machine learning application. BMC Med Inform Decis Mak 2024; 24:177. [PMID: 38907265 PMCID: PMC11191176 DOI: 10.1186/s12911-024-02579-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/17/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Enhancing Local Control (LC) of brain metastases is pivotal for improving overall survival, which makes the prediction of local treatment failure a crucial aspect of treatment planning. Understanding the factors that influence LC of brain metastases is imperative for optimizing treatment strategies and subsequently extending overall survival. Machine learning algorithms may help to identify factors that predict outcomes. METHODS This paper systematically reviews these factors associated with LC to select candidate predictor features for a practical application of predictive modeling. A systematic literature search was conducted to identify studies in which the LC of brain metastases is assessed for adult patients. EMBASE, PubMed, Web-of-Science, and the Cochrane Database were searched up to December 24, 2020. All studies investigating the LC of brain metastases as one of the endpoints were included, regardless of primary tumor type or treatment type. We first grouped studies based on primary tumor types resulting in lung, breast, and melanoma groups. Studies that did not focus on a specific primary cancer type were grouped based on treatment types resulting in surgery, SRT, and whole-brain radiotherapy groups. For each group, significant factors associated with LC were identified and discussed. As a second project, we assessed the practical importance of selected features in predicting LC after Stereotactic Radiotherapy (SRT) with a Random Forest machine learning model. Accuracy and Area Under the Curve (AUC) of the Random Forest model, trained with the list of factors that were found to be associated with LC for the SRT treatment group, were reported. RESULTS The systematic literature search identified 6270 unique records. After screening titles and abstracts, 410 full texts were considered, and ultimately 159 studies were included for review. Most of the studies focused on the LC of the brain metastases for a specific primary tumor type or after a specific treatment type. Higher SRT radiation dose was found to be associated with better LC in lung cancer, breast cancer, and melanoma groups. Also, a higher dose was associated with better LC in the SRT group, while higher tumor volume was associated with worse LC in this group. The Random Forest model predicted the LC of brain metastases with an accuracy of 80% and an AUC of 0.84. CONCLUSION This paper thoroughly examines factors associated with LC in brain metastases and highlights the translational value of our findings for selecting variables to predict LC in a sample of patients who underwent SRT. The prediction model holds great promise for clinicians, offering a valuable tool to predict personalized treatment outcomes and foresee the impact of changes in treatment characteristics such as radiation dose.
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Affiliation(s)
- Hemalatha Kanakarajan
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands.
| | - Wouter De Baene
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
| | - Karin Gehring
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Daniëlle B P Eekers
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Patrick Hanssens
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Margriet Sitskoorn
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands.
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Hao Y, Tang T, Ren J, Li G. Prognostic analysis of stereotactic radiosurgery for brain metastases: a single-center retrospective study. LA RADIOLOGIA MEDICA 2023; 128:1271-1283. [PMID: 37648956 DOI: 10.1007/s11547-023-01698-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 08/09/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVES Brain metastasis (BM) is a common event during the development of many cancers, and is also one of the main causes of death of patients. Stereotactic radiosurgery (SRS) is an effective treatment for BM. The prognostic effects of various clinical factors on local control (LC) and overall survival (OS) after SRS treatment are still unclear. The purpose of this study is to retrospectively analyze the intracranial progression free survival (iPFS) and OS of patients receiving SRS treatment, and explore the relationship between various clinical characteristics and patient prognosis. MATERIALS AND METHODS We collected the clinical information of patients who were diagnosed with BM and received SRS treatment in our center between 2018 and 2021. Univariate and multivariate Cox regression analysis and KM analysis for iPFS and OS were conducted in R software to investigate the prognostic effects of clinical characteristics. RESULTS In total, 183 patients that received SRS in our center were enrolled in the cohort. The median iPFS for all patients was 8.87 months (95% CI 6.9-10.6), and the median OS was 16.5 months (95% CI 12.9-20.7). BM number > = 5 (HR 1.965 [95% CI 1.381-2.796], p < 0.001, FDR-corrected p < 0.001) was found to be strong predictor for shorter iPFS and OS. Subgroup analysis showed that patients with cumulative intracranial tumor volume (CITV) > = 2.14 cm3 and number > = 5 had shortest iPFS (P < 0.001) and OS (P = 0.007), compared with other subgroups. For patients with more than 5 BMs, SRS plus whole brain radiotherapy (WBRT) could achieve better local control, compared with SRS alone group (P = 0.0357). Peripheral blood inflammation indicators were associated with the prognosis of BM patients in univariate Cox analysis, but not in multivariate Cox analysis. CONCLUSIONS BM number is an independent prognostic factor for BM patients. The prognosis of patients in the subgroup with larger CITV and more BM is the worst. For patients with more than 5 BM, the combination of SRS and WBRT can improve the local control, but cannot prolong the OS.
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Affiliation(s)
- Yongping Hao
- Department of Radiation Oncology, The First Affiliated Hospital of China Medical University, No.155 North NanJing Street, Heping District, Shenyang, 110001, Liaoning, China
| | - Ting Tang
- Department of Radiation Oncology, The First Affiliated Hospital of China Medical University, No.155 North NanJing Street, Heping District, Shenyang, 110001, Liaoning, China
| | - Jing Ren
- Department of Radiation Oncology, The First Affiliated Hospital of China Medical University, No.155 North NanJing Street, Heping District, Shenyang, 110001, Liaoning, China
| | - Guang Li
- Department of Radiation Oncology, The First Affiliated Hospital of China Medical University, No.155 North NanJing Street, Heping District, Shenyang, 110001, Liaoning, China.
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Levis M, Gastino A, De Giorgi G, Mantovani C, Bironzo P, Mangherini L, Ricci AA, Ricardi U, Cassoni P, Bertero L. Modern Stereotactic Radiotherapy for Brain Metastases from Lung Cancer: Current Trends and Future Perspectives Based on Integrated Translational Approaches. Cancers (Basel) 2023; 15:4622. [PMID: 37760591 PMCID: PMC10526239 DOI: 10.3390/cancers15184622] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/01/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
Brain metastases (BMs) represent the most frequent metastatic event in the course of lung cancer patients, occurring in approximately 50% of patients with non-small-cell lung cancer (NSCLC) and in up to 70% in patients with small-cell lung cancer (SCLC). Thus far, many advances have been made in the diagnostic and therapeutic procedures, allowing improvements in the prognosis of these patients. The modern approach relies on the integration of several factors, such as accurate histological and molecular profiling, comprehensive assessment of clinical parameters and precise definition of the extent of intracranial and extracranial disease involvement. The combination of these factors is pivotal to guide the multidisciplinary discussion and to offer the most appropriate treatment to these patients based on a personalized approach. Focal radiotherapy (RT), in all its modalities (radiosurgery (SRS), fractionated stereotactic radiotherapy (SRT), adjuvant stereotactic radiotherapy (aSRT)), is the cornerstone of BM management, either alone or in combination with surgery and systemic therapies. We review the modern therapeutic strategies available to treat lung cancer patients with brain involvement. This includes an accurate review of the different technical solutions which can be exploited to provide a "state-of-art" focal RT and also a detailed description of the systemic agents available as effective alternatives to SRS/SRT when a targetable molecular driver is present. In addition to the validated treatment options, we also discuss the future perspective for focal RT, based on emerging clinical reports (e.g., SRS for patients with many BMs from NSCLC or SRS for BMs from SCLC), together with a presentation of innovative and promising findings in translational research and the combination of novel targeted agents with SRS/SRT.
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Affiliation(s)
- Mario Levis
- Radiation Oncology Unit, Department of Oncology, University of Turin, 10126 Turin, Italy; (M.L.); (A.G.); (G.D.G.); (C.M.); (U.R.)
| | - Alessio Gastino
- Radiation Oncology Unit, Department of Oncology, University of Turin, 10126 Turin, Italy; (M.L.); (A.G.); (G.D.G.); (C.M.); (U.R.)
| | - Greta De Giorgi
- Radiation Oncology Unit, Department of Oncology, University of Turin, 10126 Turin, Italy; (M.L.); (A.G.); (G.D.G.); (C.M.); (U.R.)
| | - Cristina Mantovani
- Radiation Oncology Unit, Department of Oncology, University of Turin, 10126 Turin, Italy; (M.L.); (A.G.); (G.D.G.); (C.M.); (U.R.)
| | - Paolo Bironzo
- Oncology Unit, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, 10043 Orbassano, Italy;
| | - Luca Mangherini
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (L.M.); (A.A.R.); (P.C.)
| | - Alessia Andrea Ricci
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (L.M.); (A.A.R.); (P.C.)
| | - Umberto Ricardi
- Radiation Oncology Unit, Department of Oncology, University of Turin, 10126 Turin, Italy; (M.L.); (A.G.); (G.D.G.); (C.M.); (U.R.)
| | - Paola Cassoni
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (L.M.); (A.A.R.); (P.C.)
| | - Luca Bertero
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (L.M.); (A.A.R.); (P.C.)
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Darréon J, Massabeau C, Geffroy C, Maroun P, Simon L. Surface-guided radiotherapy overview: Technical aspects and clinical applications. Cancer Radiother 2023; 27:504-510. [PMID: 37558608 DOI: 10.1016/j.canrad.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/05/2023] [Accepted: 07/07/2023] [Indexed: 08/11/2023]
Abstract
In radiotherapy, patient positioning has long been ensured by ionizing imaging (kV or MV). Over the past ten years, surface-guided radiotherapy has appeared in radiotherapy departments. It is a continuous three-dimensional acquisition of the surface of the patient, based on the use of several optical cameras. The acquired surface is compared to an expected surface (usually taken from the planning scanner). Operators can constantly appreciate poor position, anatomical deformity or patient shift. Thus, the system allows an aid to the positioning of the patient, possibly without tattooing, but also a follow-up of the patient during the duration of the session. The most obvious contribution of the system concerns the treatment of the breast. In fact, for this location, the bone registration is not ideal and the target is visible in surface-guided radiotherapy. These systems also make it possible to treat in deep inspiration breath hold. But several other locations can benefit from it (pelvis, thorax, etc.).
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Affiliation(s)
- J Darréon
- Medical Physics Department, institut Paoli-Calmettes, Marseille, France.
| | - C Massabeau
- Département de radiothérapie, Oncopole Claudius-Regaud (OCR), institut universitaire du cancer de Toulouse Oncopole (IUCT O), Toulouse, France
| | - C Geffroy
- Centre Eugène-Marquis, Rennes, France
| | - P Maroun
- Institut radiothérapie Sud de l'Oise, Creil, France
| | - L Simon
- Département de radiothérapie, Oncopole Claudius-Regaud (OCR), institut universitaire du cancer de Toulouse Oncopole (IUCT O), Toulouse, France; Inserm, équipe Radopt, CNRS, centre de recherches en cancérologie de Toulouse (CRCT), université Paul-Sabatier Toulouse III, Toulouse, France
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Theriault BC, Singh C, Yu J, Knisely J, Shepard M, Wegner RE, Warnick RE, Peker S, Samanci Y, Trifiletti DM, Lee CC, Yang HC, Bernstein K, Kondziolka D, Tripathi M, Mathieu D, Mantziaris G, Pikis S, Sheehan J, Chiang VL. Selected-Lesion Stereotactic Radiosurgery (SL-SRS) as a Novel Strategy in the Treatment of Patients With Multiple Brain Metastases. Cureus 2023; 15:e45457. [PMID: 37859877 PMCID: PMC10583225 DOI: 10.7759/cureus.45457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2023] [Indexed: 10/21/2023] Open
Abstract
INTRODUCTION With the diminishing use of whole-brain radiotherapy (WBRT), there is increasing debate regarding the maximum number of brain metastases that should be treated with stereotactic radiosurgery (SRS). In patients with >10-15 lesions, some groups are proposing a new approach - selected-lesion SRS (SL-SRS) - where only a subset of intracranial lesions are chosen for irradiation. This study is an initial look into this practice. METHODS This is a cross-sectional exploratory survey study. A survey of 19 questions was created by the International Radiosurgery Research Foundation (IRRF) using open-ended and multiple-choice style questions on SL-SRS practices and indications with the goal of qualitatively understanding how SL-SRS is being implemented worldwide. The survey was distributed to physicians in the United States (US) and internationally who are members of the IRRF and who perform SRS frequently. Ten out of 50 IRRF institutions provided responses reflecting the practices of 16 physicians. RESULTS SL-SRS is being performed at 8/10 institutions. The most common reasons for using SL-SRS included patients with prior WBRT, patients with progressing systemic disease with central nervous system (CNS)-penetrating or immunotherapies available, specific requests from medical oncology, and cooperative studies using this approach. Lesion size was cited as the most important factor when choosing to irradiate any single lesion. The majority of respondents reported 30 mm and 40 mm as size cutoffs (by largest dimension) for treatment of a lesion in eloquent and non-eloquent locations, respectively. Eloquence of lesion location and attributable symptoms were also considered important. Progression of untreated lesions was the most common reason reported for bringing patients back for additional treatment. CONCLUSION The responses to this survey show that SL-SRS is being used, allowing for small/asymptomatic brain metastases to be left safely unirradiated. It is currently used in patients who have >10-15 lesions with prior WBRT, those with progression of extracranial disease but with acceptable systemic treatment options, and those with poor functional status. The incorporation of this new approach into clinical trials should be considered for the safe study of the efficacy of new CNS-penetrating systemic therapies.
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Affiliation(s)
| | - Charu Singh
- Radiation Oncology, Yale School of Medicine, New Haven, USA
| | - James Yu
- Radiation Oncology, St. Francis Hospital, Trinity Health of New England, Hartford, USA
| | | | | | - Rodney E Wegner
- Radiation Oncology, Allegheny Health Network, Pittsburgh, USA
| | | | - Selcuk Peker
- Neurosurgery, Koç University School of Medicine, Istanbul, TUR
| | - Yavuz Samanci
- Neurosurgery, Koç University Hospital, Istanbul, TUR
| | | | - Cheng-Chia Lee
- Neurosurgery, Taipei Veterans General Hospital, New Taipei, TWN
| | - Huai-Che Yang
- Neurosurgery, Taipei Veterans General Hospital, New Taipei, TWN
| | | | | | - Manjul Tripathi
- Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - David Mathieu
- Neurosurgery, Université de Sherbrooke, Sherbrooke, CAN
| | - Georgios Mantziaris
- Neurosurgery, University of Virginia School of Medicine, Charlottesville, USA
| | - Stylianos Pikis
- Neurosurgery, University of Virginia School of Medicine, Charlottesville, USA
| | - Jason Sheehan
- Neurosurgery, University of Virginia School of Medicine, Charlottesville, USA
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Gutiérrez A, Gevaert T, Boussaer M, Everaert T, Ferro Teixeira C, De Ridder M. Gantry triggered x-ray verification during single-isocenter stereotactic radiosurgery: Increased certainty for a no-margin strategy. Radiother Oncol 2023; 186:109808. [PMID: 37468067 DOI: 10.1016/j.radonc.2023.109808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 07/05/2023] [Accepted: 07/07/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Single-isocenter linac-based stereotactic radiosurgery (SRS) has emerged as a dedicated treatment option for multiple brain metastases. Consequently, image-guidance for patient positioning and motion management has become very important. The purpose of this study was to analyze intra-fraction errors measured with stereoscopic x-rays and their impact on the dose distribution. MATERIALS AND METHODS Treatments were planned with non- coplanar dynamic conformal arcs for 33 patients corresponding to 127 brain lesions and 356 arcs. Intra-arc positioning errors were measuredusing stereoscopic x-rays (ExacTrac Dynamic, Brainlab), triggered during arc delivery. Couch corrections above 0.7 mm and 0.5° were always applied. Intra-arc positioning data was analyzed. The dose impact was evaluated by applying the measured errors to the dose given in each arc. RESULTS Median residual errors were 0.10 mm, 0.13 mm and 0.08 mm for the lateral, longitudinal and vertical directions and 0.10°, 0.08° and 0.13° for the pitch, roll and yaw angles respectively. 90% of the treatment arcs showed shifts of less than 0.4 mm and 0.4°in all directions. Dosimetric impact of motion showed the largest losses in coverage on small targets. All targets achieved at least 95% of the prescription dose to 95% of their volume, even when planned without margins. CONCLUSIONS Intra-fractional errors measured during beam delivery were found to be notably low with a dose impact that showed acceptable target coverage when applying these intra-arc errors to the dose distributions of the individual treatment arcs. Using an adequate immobilization and intra-fraction imaging prior to and during irradiation, no margins need to be added to compensate for intra-fraction motion.
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Affiliation(s)
- Adrián Gutiérrez
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium.
| | - Thierry Gevaert
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Marlies Boussaer
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Tim Everaert
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Mark De Ridder
- Department of Radiotherapy, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Bankole NDA, Melhaoui A, Arkha Y, Afaf S, Bouyakhlef K, Boutarbouch M, Jiddane M, El Khamlichi A. Outcome of Brain Metastases Treated with Gamma Knife Stereotactic Radiosurgery: A Retrospective Cohort Study of 205 Cases. World Neurosurg 2023; 176:e462-e475. [PMID: 37257645 DOI: 10.1016/j.wneu.2023.05.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/21/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Brain metastases (BMs) are the most common expansive intracranial lesions in adults. Approximately 50% of patients diagnosed with new BMs will have >1 BM at the diagnosis. We report our experience with BMs treated with Leksell Gamma Knife stereotactic radiosurgery (GKSR) and evaluate the outcomes. METHODS Patients treated by GKSR in our institution between 2008 and 2021 for BMs were evaluated retrospectively. RESULTS A total of 205 patients (56.6% women) were included, with a median age of 59 years (range, 25-83 years). The breast (n = 85; 42.5%) and lung (n = 76; 38%) were the most common original locations for the primary tumors. Of the 205 patients, 103 (50.3%) had a single BM and 102 (49.7%) had ≥2 BMs. The median number of multiple BMs treated was 4 (range, 2-43). The mean overall survival (OS) time was 6.00 months (95% confidence interval [CI], 5.07-6.93 months) for all BMs. The median rate of tumor control after radiosurgery was 65% (range, 20%-99%) during a median follow-up of 6.00 months (95% CI, 3-84 months). In the overall population, the 1-, 2-, and 5-year OS rate was 37.55%, 25.12%, and 18.51%, respectively. The mean OS time was longer for those with multiple BMs than for those with a single BM (mean, 10 months [95% CI, 6.67-13.33 months] vs. mean, 5 months [95% CI, 4.21-5.70 months]; P = 0.03). Retreatment, tumor stability (control), and progression influenced the OS of patients with BMs, whether single or multiple (P < 0.001). CONCLUSIONS GKSR provides good results in terms of OS and better quality of life for patients with BMs, whether single or multiple. Tumor stability and retreatment influenced the OS of patients with BMs.
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Affiliation(s)
- Nourou Dine Adeniran Bankole
- Gamma Knife Radiosurgery Unit, National Center for Rehabilitation and Neuroscience, Mohamed V University of Rabat, Rabat, Morocco.
| | - Adyl Melhaoui
- Gamma Knife Radiosurgery Unit, National Center for Rehabilitation and Neuroscience, Mohamed V University of Rabat, Rabat, Morocco
| | - Yasser Arkha
- Gamma Knife Radiosurgery Unit, National Center for Rehabilitation and Neuroscience, Mohamed V University of Rabat, Rabat, Morocco
| | - Semmar Afaf
- Gamma Knife Radiosurgery Unit, National Center for Rehabilitation and Neuroscience, Mohamed V University of Rabat, Rabat, Morocco
| | - Khalid Bouyakhlef
- Gamma Knife Radiosurgery Unit, National Center for Rehabilitation and Neuroscience, Mohamed V University of Rabat, Rabat, Morocco
| | - Mahjouba Boutarbouch
- Gamma Knife Radiosurgery Unit, National Center for Rehabilitation and Neuroscience, Mohamed V University of Rabat, Rabat, Morocco
| | - Mohamed Jiddane
- Gamma Knife Radiosurgery Unit, National Center for Rehabilitation and Neuroscience, Mohamed V University of Rabat, Rabat, Morocco
| | - Abdeslam El Khamlichi
- Gamma Knife Radiosurgery Unit, National Center for Rehabilitation and Neuroscience, Mohamed V University of Rabat, Rabat, Morocco
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Gaito S, Marvaso G, Ortiz R, Crellin A, Aznar MC, Indelicato DJ, Pan S, Whitfield G, Alongi F, Jereczek-Fossa BA, Burnet N, Li MP, Rothwell B, Smith E, Colaco RJ. Proton Beam Therapy in the Oligometastatic/Oligorecurrent Setting: Is There a Role? A Literature Review. Cancers (Basel) 2023; 15:cancers15092489. [PMID: 37173955 PMCID: PMC10177340 DOI: 10.3390/cancers15092489] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Stereotactic ablative radiotherapy (SABR) and stereotactic radiosurgery (SRS) with conventional photon radiotherapy (XRT) are well-established treatment options for selected patients with oligometastatic/oligorecurrent disease. The use of PBT for SABR-SRS is attractive given the property of a lack of exit dose. The aim of this review is to evaluate the role and current utilisation of PBT in the oligometastatic/oligorecurrent setting. METHODS Using Medline and Embase, a comprehensive literature review was conducted following the PICO (Patients, Intervention, Comparison, and Outcomes) criteria, which returned 83 records. After screening, 16 records were deemed to be relevant and included in the review. RESULTS Six of the sixteen records analysed originated in Japan, six in the USA, and four in Europe. The focus was oligometastatic disease in 12, oligorecurrence in 3, and both in 1. Most of the studies analysed (12/16) were retrospective cohorts or case reports, two were phase II clinical trials, one was a literature review, and one study discussed the pros and cons of PBT in these settings. The studies presented in this review included a total of 925 patients. The metastatic sites analysed in these articles were the liver (4/16), lungs (3/16), thoracic lymph nodes (2/16), bone (2/16), brain (1/16), pelvis (1/16), and various sites in 2/16. CONCLUSIONS PBT could represent an option for the treatment of oligometastatic/oligorecurrent disease in patients with a low metastatic burden. Nevertheless, due to its limited availability, PBT has traditionally been funded for selected tumour indications that are defined as curable. The availability of new systemic therapies has widened this definition. This, together with the exponential growth of PBT capacity worldwide, will potentially redefine its commissioning to include selected patients with oligometastatic/oligorecurrent disease. To date, PBT has been used with encouraging results for the treatment of liver metastases. However, PBT could be an option in those cases in which the reduced radiation exposure to normal tissues leads to a clinically significant reduction in treatment-related toxicities.
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Affiliation(s)
- Simona Gaito
- Proton Clinical Outcomes Unit, The Christie NHS Proton Beam Therapy Centre, Manchester M20 4BX, UK
- Division of Clinical Cancer Science, School of Medical Sciences, The University of Manchester, Manchester M13 9PL, UK
| | - Giulia Marvaso
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
- Department of Radiation Oncology, IEO European Institute of Oncology IRCCS, 20126 Milan, Italy
| | - Ramon Ortiz
- Department of Radiation Oncology, University of California, San Francisco, CA 94720, USA
| | - Adrian Crellin
- National Lead Proton Beam Therapy NHSe, Manchester M20 4BX, UK
| | - Marianne C Aznar
- Division of Clinical Cancer Science, School of Medical Sciences, The University of Manchester, Manchester M13 9PL, UK
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida, Jacksonville, FL 32206, USA
| | - Shermaine Pan
- Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester M20 3DA, UK
| | - Gillian Whitfield
- Division of Clinical Cancer Science, School of Medical Sciences, The University of Manchester, Manchester M13 9PL, UK
- Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester M20 3DA, UK
| | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Ospedale Sacro Cuore don Calabria, 37024 Verona, Italy
- Division of Radiology and Radiotherapy, University of Brescia, 25121 Brescia, Italy
| | - Barbara Alicja Jereczek-Fossa
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
- Department of Radiation Oncology, IEO European Institute of Oncology IRCCS, 20126 Milan, Italy
| | - Neil Burnet
- Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester M20 3DA, UK
| | - Michelle P Li
- Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester M20 3DA, UK
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC 3010, Australia
| | - Bethany Rothwell
- Division of Physics, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Ed Smith
- Proton Clinical Outcomes Unit, The Christie NHS Proton Beam Therapy Centre, Manchester M20 4BX, UK
- Division of Clinical Cancer Science, School of Medical Sciences, The University of Manchester, Manchester M13 9PL, UK
- Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester M20 3DA, UK
| | - Rovel J Colaco
- Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester M20 3DA, UK
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11
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Roh H, Lee SY, Lee J, Hwang SY, Kim JH. Use of thyroid transcription factor 1 and napsin A to predict local failure and survival after Gamma Knife radiosurgery in patients with brain metastases from lung adenocarcinoma. J Neurosurg 2023; 138:663-673. [PMID: 35962961 DOI: 10.3171/2022.6.jns22450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/09/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS), combined with contemporary targeted therapies and immunotherapies, has improved the overall survival of patients with lung adenocarcinoma (ADC). Given that histological subtypes reflect prognosis in patients with primary ADC, it is important to integrate pathological biomarkers to predict clinical outcomes after SRS in patients with brain metastases from lung ADC. Therefore, the authors investigated the prognostic relevance of various biomarkers of primary lung ADC for clinical outcomes after SRS. METHODS A total of 95 patients with 136 brain metastases (1-4 oligometastases) who were treated with Gamma Knife radiosurgery between January 2017 and December 2020 were included. The Kaplan-Meier method and univariate and multivariate analyses using Cox proportional hazard regression models were used to identify prognostic factors for local control, survival, and distant brain control. RESULTS Multivariate analysis revealed thyroid transcription factor 1 as an independent prognostic factor for local control (HR 0.098, 95% CI 0.014-0.698, p = 0.0203) and napsin A as a significant predictor of overall survival after SRS (HR 0.080, 95% CI 0.017-0.386, p < 0.01). In a subset analysis of epidermal growth factor receptor (EGFR) mutation, patients with EGFR exon 19 mutations showed better distant brain control than those with EGFR exon 21 mutations (p < 0.01). CONCLUSIONS Pathological biomarkers of primary cancer should be considered to predict clinical outcomes after SRS in patients with lung ADC. Use of such biomarkers may help to provide personalized treatment to each patient, improving clinical outcomes after SRS.
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Affiliation(s)
- Haewon Roh
- 1Department of Neurosurgery, Armed Forces Capital Hospital, Seongnam.,Departments of2Neurosurgery
| | | | - Jinhwan Lee
- 4Pathology, Guro Hospital, Korea University of Medicine, Seoul; and
| | - Soon-Young Hwang
- 5Department of Biostatistics, Korea University of Medicine, Seoul, Republic of Korea
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12
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Ung TH, Meola A, Chang SD. Metastatic Lesions of the Brain and Spine. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1405:545-564. [PMID: 37452953 DOI: 10.1007/978-3-031-23705-8_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Brain and spinal metastases are common in cancer patients and are associated with significant morbidity and mortality. Continued advancement in the systemic care of cancer has increased the life expectancy of patients, and consequently, the incidence of brain and spine metastasis has increased. There has been an increase in the understanding of oncogenic mutations, and research has also demonstrated spatial and temporal mutations in patients that may drive overall treatment resistance and failure. Combinatory treatments with radiation, surgery, and newer systemic therapies have continued to increase the life expectancy of patients with brain and spine metastases. Given the overall complexity of brain and spine metastases, this chapter aims to give a comprehensive overview and cover important topics concerning brain and spine metastases. This will include the molecular, genetic, radiographic, surgical, and non-surgical treatments of brain and spinal metastases.
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Affiliation(s)
- Timothy H Ung
- Center for Academic Medicine, Department of Neurosurgery, MC: 5327, Stanford University School of Medicine, 453 Quarry Road, Palo Alto, CA, 94304, USA
| | - Antonio Meola
- Center for Academic Medicine, Department of Neurosurgery, MC: 5327, Stanford University School of Medicine, 453 Quarry Road, Palo Alto, CA, 94304, USA.
| | - Steven D Chang
- Center for Academic Medicine, Department of Neurosurgery, MC: 5327, Stanford University School of Medicine, 453 Quarry Road, Palo Alto, CA, 94304, USA
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13
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The Lung Graded Prognostic Assessment: Continued Evolution of Brain Metastases Prognostication. Int J Radiat Oncol Biol Phys 2022; 114:75-77. [PMID: 35964633 DOI: 10.1016/j.ijrobp.2022.05.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/15/2022] [Accepted: 05/28/2022] [Indexed: 11/24/2022]
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Sita TL, Gopalakrishnan M, Rooney MK, Ho A, Savoor R, Sonabend AM, Tate MC, Chandler JP, Lesniak MS, Kruser TJ, Kalapurakal JA, Sachdev S. Mean Brain Dose Remains Uninfluenced by the Lesion Number for Gamma Knife Stereotactic Radiosurgery for 10+ Metastases. World Neurosurg 2022; 165:e380-e385. [PMID: 35724885 DOI: 10.1016/j.wneu.2022.06.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/10/2022] [Accepted: 06/11/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Gamma Knife (GK) stereotactic radiosurgery (SRS) is increasingly used as an initial treatment for patients with 10 or more brain metastases. However, the clinical and dosimetric consequences of this practice are not well established. METHODS We performed a single-institution, retrospective analysis of 30 patients who received Gamma Knife SRS for 10 or more brain metastases in 1 session. We utilized MIM Software to contour the whole brain and accumulated the doses from all treated lesions to determine the mean dose delivered to the whole brain. Patient outcomes were determined from chart review. RESULTS Our cohort had a median number of 13 treated lesions (range 10-26 lesions) for a total of 427 treated lesions. The mean dose to the whole brain was determined to be 1.8 ± 0.91 Gy (range 0.70-3.8 Gy). The mean dose to the whole brain did not correlate with the number of treated lesions (Pearson r = 0.23, P = 0.21), but was closely associated with tumor volume (Pearson r = 0.95, P < 0.0001). There were no significant correlations between overall survival and number of lesions or aggregate tumor volume. Fourteen patients (47%) underwent additional SRS sessions and 6 patients (20%) underwent whole-brain radiotherapy with a median of 6.6 months (range 3.0-50 months) after SRS. Two patients (6.6%) developed grade 2 radionecrosis following SRS beyond earlier whole-brain radiotherapy. CONCLUSION The mean dose to the whole brain in patients treated with Gamma Knife SRS for 10 or more brain metastases remained low with an acceptable rate of radionecrosis. This strategy allowed the majority of patients to avoid subsequent whole-brain radiotherapy.
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Affiliation(s)
- Timothy L Sita
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mahesh Gopalakrishnan
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael K Rooney
- Department of Radiation Oncology, M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Alexander Ho
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rohan Savoor
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Adam M Sonabend
- Department of Neurological Surgery, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew C Tate
- Department of Neurological Surgery, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - James P Chandler
- Department of Neurological Surgery, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Maciej S Lesniak
- Department of Neurological Surgery, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tim J Kruser
- Turville Bay Radiation Oncology Center, SSM Health, Madison, Wisconsin, USA
| | - John A Kalapurakal
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sean Sachdev
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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Calvo-Ortega JF, Moragues-Femenía S, Laosa-Bello C, Hermida-López M, Pozo-Massó M, Zamora-Pérez A. Monte Carlo-based independent dose verification of radiosurgery HyperArc plans. Phys Med 2022; 102:19-26. [PMID: 36037748 DOI: 10.1016/j.ejmp.2022.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 08/07/2022] [Accepted: 08/17/2022] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To investigate the feasibility of using the free PRIMO Monte Carlo software for independent dose check of cranial SRS plans designed with the Varian HyperArc (HA) technique. MATERIALS AND METHODS In this study, the PRIMO Monte Carlo software v. 0.3.64.1800 was used with the phase-space files (v. 2, Feb. 27, 2013) provided by Varian for 6 MV flattening-filter-free (FFF) photon beams from a Varian TrueBeam linear accelerator (linac), equipped with a Millennium 120 multileaf collimator (MLC). This configuration was validated by comparing the percentage depth doses (PDDs), lateral profiles and relative output factors (OFs) simulated in a water phantom against measurements for field sizes from 1 × 1 to 40 × 40 cm2. The agreement between simulated and experimental relative dose curves was evaluated using a global (G) gamma index analysis. In addition, the accuracy of PRIMO to model the MLC was investigated (dosimetric leaf gap, tongue and groove, leaf transmission and interleaf leakage). Thirty-five HA SRS plans computed in the Eclipse treatment planning system (TPS) were simulated in PRIMO. The Acuros XB algorithm v. 16.10 (dose to medium) was used in Eclipse. Sixty targets with diameters ranging from 6 to 33 mm were included. Agreement between the dose distributions given by Eclipse and PRIMO was evaluated in terms of 3D global gamma passing rates (GPRs) for the 2 %/2 mm criteria. RESULTS Average GPR greater than 95 % with the 2 %(G)/1 mm criteria were obtained over the PDD and profiles of each field size. Differences between PRIMO calculated and measured OFs were within 0.5 % in all fields, except for the 1 × 1 cm2 with a discrepancy of 1.5 %. Regarding the MLC modeling in PRIMO, an agreement within 3 % was achieved between calculated and experimental doses. Excellent agreement between PRIMO and Eclipse was found for the 35 HA plans. The 3D global GPRs (2 %/2 mm) for the targets and external patient contour were 99.6 % ± 1.1 % and 99.8 % ± 0.5 %, respectively. CONCLUSIONS According to the results described in this study, the PRIMO Monte Carlo software, in conjunction with the 6X FFF Varian phase-space files, can be used as secondary dose calculation software to check stereotactic radiosurgery plans from Eclipse using the HyperArc technique.
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Affiliation(s)
- Juan-Francisco Calvo-Ortega
- Servicio de Oncología Radioterápica, Hospital Quirónsalud, Barcelona, Spain; Servicio de Oncología Radioterápica, Hospital Quirónsalud, Málaga, Spain.
| | | | - Coral Laosa-Bello
- Servicio de Oncología Radioterápica, Hospital Quirónsalud, Barcelona, Spain
| | - Marcelino Hermida-López
- Marcelino Hermida-López. Servei de Física i Protecció Radiològica, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Miguel Pozo-Massó
- Servicio de Oncología Radioterápica, Hospital Quirónsalud, Barcelona, Spain
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Analysis of Key Clinical Variables and Radiological Manifestations Associated with the Treatment Response of Patients with Brain Metastases to Stereotactic Radiosurgery. J Clin Med 2022; 11:jcm11154529. [PMID: 35956144 PMCID: PMC9369562 DOI: 10.3390/jcm11154529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/25/2022] [Accepted: 08/01/2022] [Indexed: 01/27/2023] Open
Abstract
Background: Stereotactic radiosurgery (SRS) is considered a promising treatment for brain metastases (BM) with better healing efficacy, relatively faster treatment time, and lower neurotoxicity, which can achieve local control rates above 70%. Although SRS improves the local control of BM, this may not translate into improvements in survival time. Thus, screening out the key factors influencing the treatment response to SRS, instead of the survival time following SRS, might be of more significance. This may assist doctors when making adjustments to treatment strategies for patients with BM. Methods: This is a retrospective review of 696 patients with BM who were treated with SRS at Huashan Hospital, Fudan University between June 2015 and February 2020. According to the patients’ treatment response to SRS, the patients were divided into an improved group (IG) and a progressive group (PG). The clinical data and magnetic resonance imaging (MRI) performed pre- and post-treatment were collected for the two groups. Five clinical variables (gender, age, Karnofsky performance status (KPS), primary tumor type, and extracranial lesion control) and seven radiological manifestations (location, number, volume, maximum diameter, edema index (EI), diffusion weighted imaging (DWI) sequence signal, and enhanced pattern) were selected and compared. A stepwise regression analysis was performed in order to obtain the best prediction effect of a group of variables and their regression coefficients, and finally to build an SRS treatment response scoring model based on the coefficients. The performance of the model was evaluated by calculating the AUC and performing the Hosmer–Lemeshow test. Results: A total of 323 patients were enrolled in the study based on the inclusion and exclusion criteria, including 209 patients in the IG and 114 patients in the PG. In the Chi-square test and t-test analysis, the significant p values of KPS, extracranial lesion control, volume, and EI were less than 0.05. Moreover, the cut-off values for volume and EI were 1801.145 mm3 and 3.835, respectively. The scoring model that was based on multivariate logistic regression coefficients performed better, achieving AUCs of 0.755 ± 0.062 and 0.780 ± 0.061 for the internal validation and validation cohorts, with p values of 0.168 and 0.073 for the Hosmer–Lemeshow test. Conclusions: KPS, extracranial lesion control, tumor volume, and EI had a certain correlation with the treatment response to SRS. Scoring models that are based on these variables can accurately predict the treatment response of patients with BM to SRS, thereby assisting doctors to make an appropriate first treatment strategy for patients with BM to a certain degree.
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Benjamin CG, Gurewitz J, Kavi A, Bernstein K, Silverman J, Mureb M, Donahue B, Kondziolka D. Survival and outcomes in patients with ≥ 25 cumulative brain metastases treated with stereotactic radiosurgery. J Neurosurg 2022; 137:571-581. [PMID: 34952524 DOI: 10.3171/2021.9.jns21882] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 09/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In the era in which more patients with greater numbers of brain metastases (BMs) are being treated with stereotactic radiosurgery (SRS) alone, it is critical to understand how patient, tumor, and treatment factors affect functional status and overall survival (OS). The authors examined the survival outcomes and dosimetry to critical structures in patients treated with Gamma Knife radiosurgery (GKRS) for ≥ 25 metastases in a single session or cumulatively over the course of their disease. METHODS A retrospective analysis was conducted at a single institution. The institution's prospective Gamma Knife (GK) SRS registry was queried to identify patients treated with GKRS for ≥ 25 cumulative BMs between June 2013 and April 2020. Ninety-five patients were identified, and their data were used for analysis. Treatment plans for dosimetric analysis were available for 89 patients. Patient, tumor, and treatment characteristics were identified, and outcomes and OS were evaluated. RESULTS The authors identified 1132 patients with BMs in their institutional registry. Ninety-five patients were treated for ≥ 25 cumulative metastases, resulting in a total of 3596 tumors treated during 373 separate treatment sessions. The median number of SRS sessions per patient was 3 (range 1-12 SRS sessions), with nearly all patients (n = 93, 98%) having > 1 session. On univariate analysis, factors affecting OS in a statistically significant manner included histology, tumor volume, tumor number, diagnosis-specific graded prognostic assessment (DS-GPA), brain metastasis velocity (BMV), and need for subsequent whole-brain radiation therapy (WBRT). The median of the mean WB dose was 4.07 Gy (range 1.39-10.15 Gy). In the top quartile for both the highest cumulative number and highest cumulative volume of treated metastases, the median of the mean WB dose was 6.14 Gy (range 4.02-10.15 Gy). Seventy-nine patients (83%) had all treated tumors controlled at last follow-up, reflecting the high and durable control rate. Corticosteroids for tumor- or treatment-related effects were prescribed in just over one-quarter of the patients. Of the patients with radiographically proven adverse radiation effects (AREs; 15%), 4 were symptomatic. Four patients required subsequent craniotomy for hemorrhage, progression, or AREs. CONCLUSIONS In selected patients with a large number of cumulative BMs, multiple courses of SRS are feasible and safe. Together with new systemic therapies, the study results demonstrate that the achieved survival rates compare favorably to those of larger contemporary cohorts, while avoiding WBRT in the majority of patients. Therefore, along with the findings of other series, this study supports SRS as a standard practice in selected patients with larger numbers of BMs.
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Affiliation(s)
| | - Jason Gurewitz
- 2Department of Radiation Oncology, NYU Langone Medical Center, New York
| | - Ami Kavi
- 2Department of Radiation Oncology, NYU Langone Medical Center, New York
| | - Kenneth Bernstein
- 2Department of Radiation Oncology, NYU Langone Medical Center, New York
| | - Joshua Silverman
- 2Department of Radiation Oncology, NYU Langone Medical Center, New York
| | - Monica Mureb
- 3Department of Neurosurgery, Westchester Medical Center, Valhalla
| | - Bernadine Donahue
- 2Department of Radiation Oncology, NYU Langone Medical Center, New York
- 5Department of Radiation Oncology, Maimonides Medical Center, Brooklyn, New York
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Significant survival improvements for patients with melanoma brain metastases: can we reach cure in the current era? J Neurooncol 2022; 158:471-480. [PMID: 35665462 DOI: 10.1007/s11060-022-04036-1] [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: 04/21/2022] [Accepted: 05/12/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE New therapies for melanoma have been associated with increasing survival expectations, as opposed to the dismal outcomes of only a decade ago. Using a prospective registry, we aimed to define current survival goals for melanoma patients with brain metastases (BM), based on state-of-the-art multimodality care. METHODS We reviewed 171 melanoma patients with BM receiving stereotactic radiosurgery (SRS) who were followed with point-of-care data collection between 2012 and 2020. Clinical, molecular and imaging data were collected, including systemic treatment and radiosurgical parameters. RESULTS Mean age was 63 ± 15 years, 39% were female and 29% had BRAF-mutated tumors. Median overall survival after radiosurgery was 15.7 months (95% Confidence Interval 11.4-27.7) and 25 months in patients managed since 2015. Thirty-two patients survived [Formula: see text] 5 years from their initial SRS. BRAF mutation-targeted therapies showed a survival advantage in comparison to chemotherapy (p = 0.009), but not to immunotherapy (p = 0.09). In a multivariable analysis, both immunotherapy and the number of metastases at 1st SRS were predictors of long-term survival ([Formula: see text] 5 years) from initial SRS (p = 0.023 and p = 0.018, respectively). Five patients (16%) of the long-term survivors required no active treatment for [Formula: see text] 5 years. CONCLUSION Long-term survival in patients with melanoma BM is achievable in the current era of SRS combined with immunotherapies. For those alive [Formula: see text] 5 years after first SRS, 16% had been also off systemic or local brain therapy for over 5 years. Given late recurrences of melanoma, caution is warranted, however prolonged survival off active treatment in a subset of our patients raises the potential for cure.
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Grabowski MM, Srinivasan ES, Vaios EJ, Sankey EW, Otvos B, Krivosheya D, Scott A, Olufawo M, Ma J, Fomchenko EI, Herndon JE, Kim AH, Chiang VL, Chen CC, Leuthardt EC, Barnett GH, Kirkpatrick JP, Mohammadi AM, Fecci PE. Combination Laser Interstitial Thermal Therapy Plus Stereotactic Radiotherapy (SRT) Increases Time to Progression for Biopsy-Proven Recurrent Brain Metastases. Neurooncol Adv 2022; 4:vdac086. [PMID: 35795470 PMCID: PMC9248774 DOI: 10.1093/noajnl/vdac086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Improved survival for patients with brain metastases has been accompanied by a rise in tumor recurrence after stereotactic radiotherapy (SRT). Laser interstitial thermal therapy (LITT) has emerged as an effective treatment for SRT failures as an alternative to open resection or repeat SRT. We aimed to evaluate the efficacy of LITT followed by SRT (LITT+SRT) in recurrent brain metastases. Methods A multicenter, retrospective study was performed of patients who underwent treatment for biopsy-proven brain metastasis recurrence after SRT at an academic medical center. Patients were stratified by “planned LITT+SRT” versus “LITT alone” versus “repeat SRT alone.” Index lesion progression was determined by modified Response Assessment in Neuro-Oncology Brain Metastases (RANO-BM) criteria. Results Fifty-five patients met inclusion criteria, with a median follow-up of 7.3 months (range: 1.0–30.5), age of 60 years (range: 37–86), Karnofsky Performance Status (KPS) of 80 (range: 60–100), and pre-LITT/biopsy contrast-enhancing volume of 5.7 cc (range: 0.7–19.4). Thirty-eight percent of patients underwent LITT+SRT, 45% LITT alone, and 16% SRT alone. Median time to index lesion progression (29.8, 7.5, and 3.7 months [P = .022]) was significantly improved with LITT+SRT. When controlling for age in a multivariate analysis, patients treated with LITT+SRT remained significantly less likely to have index lesion progression (P = .004). Conclusions These data suggest that LITT+SRT is superior to LITT or repeat SRT alone for treatment of biopsy-proven brain metastasis recurrence after SRT failure. Prospective trials are warranted to validate the efficacy of using combination LITT+SRT for treatment of recurrent brain metastases.
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Affiliation(s)
- Matthew M Grabowski
- Corresponding Author: Matthew M. Grabowski, MD, Cleveland Clinic, 9500 Euclid Ave. S4, Cleveland, OH 44195, USA ()
| | - Ethan S Srinivasan
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Eugene J Vaios
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Eric W Sankey
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Balint Otvos
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic & Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Daria Krivosheya
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic & Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Alex Scott
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael Olufawo
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jun Ma
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Elena I Fomchenko
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - James E Herndon
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Albert H Kim
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Veronica L Chiang
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Eric C Leuthardt
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Gene H Barnett
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic & Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - John P Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina, USA
- Duke Center for Brain and Spine Metastasis, Durham, North Carolina, USA
| | - Alireza M Mohammadi
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic & Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
- Duke Center for Brain and Spine Metastasis, Durham, North Carolina, USA
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20
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Rogers SJ, Lomax N, Alonso S, Lazeroms T, Riesterer O. Radiosurgery for Five to Fifteen Brain Metastases: A Single Centre Experience and a Review of the Literature. Front Oncol 2022; 12:866542. [PMID: 35619914 PMCID: PMC9128547 DOI: 10.3389/fonc.2022.866542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose Stereotactic radiosurgery (SRS) is now mainstream for patients with 1-4 brain metastases however the management of patients with 5 or more brain metastases remains controversial. Our aim was to evaluate the clinical outcomes of patients with 5 or more brain metastases and to compare with published series as a benchmarking exercise. Methods Patients with 5 or more brain metastases treated with a single isocentre dynamic conformal arc technique on a radiosurgery linac were identified from the institutional database. Endpoints were local control, distant brain failure, leptomeningeal disease and overall survival. Dosimetric data were extracted from the radiosurgery plans. Series reporting outcomes following SRS for multiple brain metastases were identified by a literature search. Results 36 patients, of whom 35 could be evaluated, received SRS for 5 or more brain metastases between February 2015 and October 2021. 25 patients had 5-9 brain metastases (group 1) and 10 patients had 10-15 brain metastases (group 2). The mean number of brain metastases in group 1 was 6.3 (5-9) and 12.3 (10-15) in group 2. The median cumulative irradiated volume was 4.6 cm3 (1.25-11.01) in group 1 and 7.2 cm3 (2.6-11.1) in group 2. Median follow-up was 12 months. At last follow-up, local control rates per BM were 100% and 99.8% as compared with a median of 87% at 1 year in published series. Distant brain failure was 36% and 50% at a median interval of 5.2 months and 7.4 months after SRS in groups 1 and 2 respectively and brain metastasis velocity at 1 year was similar in both groups (9.7 and 11). 8/25 patients received further SRS and 7/35 patients received whole brain radiotherapy. Median overall survival was 10 months in group 1 and 15.7 months in group 2, which compares well with the 7.5 months derived from the literature. There was one neurological death in group 2, leptomeningeal disease was rare (2/35) and there were no cases of radionecrosis. Conclusion With careful patient selection, overall survival following SRS for multiple brain metastases is determined by the course of the extracranial disease. SRS is an efficacious and safe modality that can achieve intracranial disease control and should be offered to patients with 5 or more brain metastases and a constellation of good prognostic factors.
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Affiliation(s)
- Susanne J Rogers
- Radiation Oncology Center KSA-KSB, Canton Hospital Aarau, Aarau, Switzerland
| | - Nicoletta Lomax
- Radiation Oncology Center KSA-KSB, Canton Hospital Aarau, Aarau, Switzerland
| | - Sara Alonso
- Radiation Oncology Center KSA-KSB, Canton Hospital Aarau, Aarau, Switzerland
| | - Tessa Lazeroms
- Radiation Oncology Center KSA-KSB, Canton Hospital Aarau, Aarau, Switzerland
| | - Oliver Riesterer
- Radiation Oncology Center KSA-KSB, Canton Hospital Aarau, Aarau, Switzerland
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21
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Utility of expanded anterior column resection versus decompression-alone for local control in the management of carcinomatous vertebral column metastases undergoing adjuvant stereotactic radiotherapy. Spine J 2022; 22:835-846. [PMID: 34718175 DOI: 10.1016/j.spinee.2021.10.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/03/2021] [Accepted: 10/19/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT With improvements in adjuvant radiotherapy and minimally invasive surgical techniques, separation surgery has become the default surgical intervention for spine metastases at many centers. However, it is unclear if there is clinical benefit from anterior column resection in addition to simple epidural debulking prior to stereotactic body radiotherapy (SBRT). PURPOSE To examine the effect of anterior column debulking versus epidural disease resection alone in the local control of metastases to the bony spine. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE Ninety-seven patients who underwent open surgery followed by SBRT for spinal metastases at a single comprehensive cancer center. OUTCOME MEASURES Local tumor recurrence following surgery and SBRT. METHODS Data were collected regarding radiation dose, cancer histology, extent of anterior column resection, and recurrence. Tumor involvement was categorized using the International Spine Radiosurgery Consortium guidelines. Univariable analyses were conducted to determine predictors of local recurrence and time to local recurrence. RESULTS Among the 97 included patients, mean age was 60.5±11.4 years and 51% of patients were male. The most common primary tumor types were lung (20.6%), breast (17.5%), kidney (13.4%) and prostate (12.4%). Recurrence was seen in 17 patients (17.5%) and local control rates were: 85.5% (1-year), 81.1% (2-year), and 54.9% (5-year). Overall predictors of local recurrence were tumor pathology (p<.01; renal cell carcinoma and colorectal adenocarcinoma associated with poorest PFS) and undergoing anterior column debulking versus epidural decompression-alone (p=.03). Only tumor pathology predicted time to local recurrence (p<.01), though inspection of Kaplan-Meier functions showed superior long-term local control in patients with radiosensitive tumor pathologies, no previous irradiation of the metastasis, and who underwent anterior column resection versus epidural removal alone. Median time to recurrence was 288 days with 100% of lesions showing anterior column recurrence and recurrence in the epidural space. CONCLUSIONS With the increasing shift towards surgery as a neoadjuvant to radiotherapy for patients with spinal column metastases, the role for surgical debulking has become less clear. In the present study, we find that anterior column debulking as opposed to epidural debulking-alone decreases the odds of local recurrence and improves long-term local control.
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22
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Tsui DCC, Camidge DR, Rusthoven CG. Managing Central Nervous System Spread of Lung Cancer: The State of the Art. J Clin Oncol 2022; 40:642-660. [PMID: 34985937 DOI: 10.1200/jco.21.01715] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Brain metastases (BrM) are common in both non-small-cell lung cancer and small-cell lung cancer. Substantial progress in BrM management has occurred in the past decade related to advances in both radiation and medical oncology. Recent and ongoing radiation trials have focused on increasing the candidacy for focal therapy of BrM with stereotactic radiosurgery; reducing the toxicity and improving patient selection for whole brain radiotherapy; and, in small-cell lung cancer, evaluating brain magnetic resonance imaging surveillance without prophylactic cranial irradiation, hippocampal avoidance in prophylactic cranial irradiation and whole brain radiotherapy, and the role of upfront stereotactic radiosurgery for BrM. In medical oncology, the development of multiple tyrosine kinase inhibitors with encouraging CNS activity and emerging data on the CNS activity of immune checkpoint inhibitors in some patients have opened the door to novel systemic and multidisciplinary treatment strategies for the management of BrM. Future research will focus on more robust characterizations of the CNS activity of targeted therapy and immunotherapies, as well as optimal integration and patient selection for multidisciplinary strategies involving CNS-active drugs, radiation therapy, and CNS surveillance.
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Affiliation(s)
- David Chun Cheong Tsui
- Division of Medical Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
| | - D Ross Camidge
- Division of Medical Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
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23
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Ferini G, Viola A, Valenti V, Tripoli A, Molino L, Marchese VA, Illari SI, Rita Borzì G, Prestifilippo A, Umana GE, Martorana E, Mortellaro G, Ferrera G, Cacciola A, Lillo S, Pontoriero A, Pergolizzi S, Parisi S. Whole Brain Irradiation or Stereotactic RadioSurgery for five or more brain metastases (WHOBI-STER): A prospective comparative study of neurocognitive outcomes, level of autonomy in daily activities and quality of life. Clin Transl Radiat Oncol 2021; 32:52-58. [PMID: 34926839 PMCID: PMC8649107 DOI: 10.1016/j.ctro.2021.11.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 11/18/2021] [Accepted: 11/21/2021] [Indexed: 02/07/2023] Open
Abstract
The main aim of MBM treatment is to palliate neurological symptoms and to maintain an adequate QoL. SRT could be the “new standard” over WBI in the management of MBM patients. Neurocognitive functions could deteriorate more after WBI than after SRT.
Aims To evaluate neurocognitive performance, daily activity and quality of life (QoL), other than usual oncologic outcomes, among patients with brain metastasis ≥5 (MBM) from solid tumors treated with Stereotactic Brain Irradiation (SBI) or Whole Brain Irradiation (WBI). Methods This multicentric randomized controlled trial will involve the enrollment of 100 patients (50 for each arm) with MBM ≥ 5, age ≥ 18 years, Karnofsky Performance Status (KPS) ≥ 70, life expectancy > 3 months, known primary tumor, with controlled or controllable extracranial disease, baseline Montreal Cognitive Assessment (MoCA) score ≥ 20/30, Barthel Activities of Daily Living score ≥ 90/100, to be submitted to SBI by LINAC with monoisocentric technique and non-coplanar arcs (experimental arm) or to WBI (control arm). The primary endpoints are neurocognitive performance, QoL and autonomy in daily-life activities variations, the first one assessed by MoCa Score and Hopkins Verbal Learning Test-Revised, the second one through the EORTC QLQ-C15-PAL and QLQ-BN-20 questionnaires, the third one through the Barthel Index, respectively. The secondary endpoints are time to intracranial failure, overall survival, retreatment rate, acute and late toxicities, changing of KPS. It will be considered significant a statistical difference of at least 30% between the two arms (statistical power of 80% with a significance level of 95%). Discussion Several studies debate what is the decisive factor accountable for the development of neurocognitive decay among patients undergoing brain irradiation for MBM: radiation effect on clinically healthy brain tissue or intracranial tumor burden? The answer to this question may come from the recent technological advancement that allows, in a context of a significant time saving, improved patient comfort and minimizing radiation dose to off-target brain, a selective treatment of MBM simultaneously, otherwise attackable only by WBI. The achievement of a local control rate comparable to that obtained with WBI remains the fundamental prerequisite. Trial registration NCT number: NCT04891471.
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Key Words
- 3D-CRT, 3Dimensional-ConformalRadioTherapy
- Autonomy in daily activities
- BSC, Best Supportive Care
- Brain metastases
- CRF, Case Report Form
- CT, Computerized Tomography
- CTV, Clinical Target Volume
- EORTC QLQ-C15-PAL, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 for Palliative Care
- FSRT, Fractionated Stereotactic Radiation Therapy
- GTV, Gross Tumor Volume
- KPS, Karnofsky Performance Status
- LINAC, Linear Accelerator
- MBM, Multiple Brain Metastastes
- MRI, Magnetic Resonance Imaging
- MoCA, Montreal Cognitive Assessment
- NCCN, National Comprehensive Cancer Network
- Neurocognitive decay
- Neurocognitive performance
- Neurocognitive tests
- OAR, Organ At Risk
- OS, Overall Survival
- PTV, Planning Target Volume
- Palliative care
- QLQ-BN20, Quality of Life Questionnaire - Brain Neoplasm 20
- QoL, Quality of Life
- Quality of life
- RT, Radiation Therapy
- RTOG, Radiation Therapy Oncology Group
- Radiotherapy for multiple brain metastases
- SBI, Stereotactic Brain Irradiation
- SRS, Stereotactic RadioSurgery
- SRT, Stereotactic Radiation Therapy
- Stereotactic Brain RadioSurgery
- Stereotactic Brain Radiotherapy
- Supportive care in cancer patients
- VEGF, Vascular Endothelial Growth Factor
- Whole Brain Radiotherapy
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Affiliation(s)
| | - Anna Viola
- Fondazione IOM, Viagrande, I-95029 Catania, Italy
| | - Vito Valenti
- REM Radioterapia srl, Viagrande, I-95029 Catania, Italy
| | | | - Laura Molino
- Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali Università di Messina, I-98100 Messina, Italy
| | | | | | | | - Angela Prestifilippo
- Medical Oncology Unit, Mediterranean Institute of Oncology, Viagrande, I-95029 Catania, Italy
| | - Giuseppe Emmanuele Umana
- Trauma Center, Gamma Knife Center, Department of Neurosurgery, Cannizzaro Hospital, I-95125 Catania, Italy
| | | | - Gianluca Mortellaro
- Department of Radiation Oncology, ARNAS Ospedale Civico, I-90127 Palermo, Italy
| | - Giuseppe Ferrera
- Department of Radiation Oncology, ARNAS Ospedale Civico, I-90127 Palermo, Italy
| | - Alberto Cacciola
- Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali Università di Messina, I-98100 Messina, Italy
| | - Sara Lillo
- Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali Università di Messina, I-98100 Messina, Italy
| | - Antonio Pontoriero
- Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali Università di Messina, I-98100 Messina, Italy
| | - Stefano Pergolizzi
- Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali Università di Messina, I-98100 Messina, Italy
| | - Silvana Parisi
- Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali Università di Messina, I-98100 Messina, Italy
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Tsui SSW, Wu VWC, Cheung JSC. Comparison of dosimetric impact of intra-fractional setup discrepancy between multiple- and single-isocenter approaches in linac-based stereotactic radiotherapy of multiple brain metastases. J Appl Clin Med Phys 2021; 23:e13484. [PMID: 34931447 PMCID: PMC8833285 DOI: 10.1002/acm2.13484] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 04/23/2021] [Accepted: 11/09/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction Treatment of multiple brain metastases by linac‐based stereotactic radiotherapy (SRT) can employ either a multiple‐isocenter (MI) or single‐isocenter (SI) approach. The purposes of this study were to evaluate the dosimetric results of MI and SI approaches and compare the impacts of intra‐fractional setup discrepancies on the robustness of respective approaches using isocenter shifts, whether the same magnitude of translational and rotational effects could lead to a significant difference between the two approaches. Methods Twenty‐two patients with multiple brain metastases treated by linac‐based SRT were recruited. Treatment plans were computed with both the MI and SI approaches. For the MI approach, the isocenter was located at the geometric center of each planning target volumes (PTVs), whereas the isocenter of the SI approach was located midway between the PTV centroids. To simulate the intra‐fractional errors, isocenter displacements including translational and rotational shifts were hypothetically applied. Apart from the dosimetric outcomes of the two approaches, the impact of the isocenter shifts on PTVs and organs at risk (OARs) were recorded in terms of the differences (δ) in dose parameters relative to the reference plan and was then compared between the MI and SI approaches. Results Both MI and SI plans met the plan acceptance criteria. The mean Paddick conformity index (Paddick CI) and Dmax of most OARs between MI and SI plans did not show a significant difference, except that higher doses to the left optic nerve and optic chiasm were found in SI plans (p = 0.03). After the application of the isocenter shifts, δCI increased with an increase in the magnitude of the isocenter shift. When comparing between MI and SI plans, the δCIs were similar (p > 0.05) for all extents of translational shifts, but δCIs were significantly higher in SI plans after application of all rotations particularly ±1.5° and ±2.0° shifts. Despite the result that the majority of δDMax of OARs were higher in the SI plans, only the differences in the left optic nerve and chiasm showed generally consistent significance after both translational ≥±1 mm and rotational shifts of ≥±1∘. Conclusion Both MI and SI approaches could produce clinically acceptable plans. However, isocenter shifts brought dosimetric impacts to both MI and SI approaches and the effects increased with the increase of the shift magnitude. Although similar impacts were shown in plans of both approaches after translational isocenter shift, SI plans were relatively more vulnerable than MI plans to rotational shifts.
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Affiliation(s)
- Sylvia S W Tsui
- Department of Clinical Oncology, Prince of Wales Hospital, Shatin, Hong Kong
| | - Vincent W C Wu
- Department of Health Technology & Informatics, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Jerry S C Cheung
- Department of Clinical Oncology, Queen Mary Hospital, Pok Fu Lam, Hong Kong
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25
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Mantovani C, Gastino A, Cerrato M, Badellino S, Ricardi U, Levis M. Modern Radiation Therapy for the Management of Brain Metastases From Non-Small Cell Lung Cancer: Current Approaches and Future Directions. Front Oncol 2021; 11:772789. [PMID: 34796118 PMCID: PMC8593461 DOI: 10.3389/fonc.2021.772789] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/18/2021] [Indexed: 12/19/2022] Open
Abstract
Brain metastases (BMs) represent the most frequent event during the course of Non-Small Cell Lung Cancer (NSCLC) disease. Recent advancements in the diagnostic and therapeutic procedures result in increased incidence and earlier diagnosis of BMs, with an emerging need to optimize the prognosis of these patients through the adoption of tailored treatment solutions. Nowadays a personalized and multidisciplinary approach should rely on several clinical and molecular factors like patient’s performance status, extent and location of brain involvement, extracranial disease control and the presence of any “druggable” molecular target. Radiation therapy (RT), in all its focal (radiosurgery and fractionated stereotactic radiotherapy) or extended (whole brain radiotherapy) declinations, is a cornerstone of BMs management, either alone or combined with surgery and systemic therapies. Our review aims to provide an overview of the many modern RT solutions available for the treatment of BMs from NSCLC in the different clinical scenarios (single lesion, oligo and poly-metastasis, leptomeningeal carcinomatosis). This includes a detailed review of the current standard of care in each setting, with a presentation of the literature data and of the possible technical solutions to offer a “state-of-art” treatment to these patients. In addition to the validated treatment options, we will also discuss the future perspectives on emerging RT technical strategies (e.g., hippocampal avoidance whole brain RT, simultaneous integrated boost, radiosurgery for multiple lesions), and present the innovative and promising findings regarding the combination of novel targeted agents such as tyrosine kinase inhibitors and immune checkpoint inhibitors with brain irradiation.
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Affiliation(s)
| | | | - Marzia Cerrato
- Department of Oncology, University of Torino, Torino, Italy
| | | | | | - Mario Levis
- Department of Oncology, University of Torino, Torino, Italy
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26
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Skourou C, Hickey D, Rock L, Houston P, Sturt P, O' Sullivan S, Faul C, Paddick I. Treatment of multiple intracranial metastases in radiation oncology: a contemporary review of available technologies. BJR Open 2021; 3:20210035. [PMID: 34877458 PMCID: PMC8611687 DOI: 10.1259/bjro.20210035] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 08/06/2021] [Indexed: 12/31/2022] Open
Abstract
The use of stereotactic radiosurgery to treat multiple intracranial metastases, frequently concurrently, has become increasingly common. The ability to accurately and safely deliver stereotactic radiosurgery treatment to multiple intracranial metastases (MIM) relies heavily on the technology available for targeting, planning, and delivering the dose. A number of platforms are currently marketed for such applications, each with intrinsic capabilities and limitations. These can be broadly categorised as cobalt-based, linac-based, and robotic. This review describes the most common representative technologies for each type along with their advantages and current limitations as they pertain to the treatment of multiple intracranial metastases. Each technology was used to plan five clinical cases selected to represent the clinical breadth of multiple metastases cases. The reviewers discuss the different strengths and limitations attributed to each technology in the case of MIM as well as the impact of disease-specific characteristics (such as total number of intracranial metastases, their size and relative proximity) on plan and treatment quality.
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Affiliation(s)
| | | | | | | | | | | | - Clare Faul
- St. Luke’s Radiation Oncology Network, Dublin, Ireland
| | - Ian Paddick
- Queen Square Radiosurgery Centre, National Hospital for Neurology and Neurosurgery, London, UK
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27
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Williams GR, Manjunath SH, Butala AA, Jones JA. Palliative Radiotherapy for Advanced Cancers: Indications and Outcomes. Surg Oncol Clin N Am 2021; 30:563-580. [PMID: 34053669 DOI: 10.1016/j.soc.2021.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Palliative radiotherapy (PRT) is well-tolerated, effective treatment for pain, bleeding, obstruction, and other symptoms/complications of advanced cancer. It is an important component of multidisciplinary management. It should be considered even for patients with poor prognosis, because it can offer rapid symptomatic relief. Furthermore, expanding indications for treatment of noncurable disease have shown that PRT can extend survival for select patients. For those with good prognosis, advanced PRT techniques may improve the therapeutic ratio, maximizing tumor control while limiting toxicity. PRT referral should be considered for any patient with symptomatic or asymptomatic sites of disease where local control is desired.
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Affiliation(s)
- Graeme R Williams
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Boulevard, 2nd Floor West, Philadelphia, PA 19104, USA; Leonard Davis Institute of Healthcare Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Shwetha H Manjunath
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Boulevard, 2nd Floor West, Philadelphia, PA 19104, USA
| | - Anish A Butala
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Boulevard, 2nd Floor West, Philadelphia, PA 19104, USA
| | - Joshua A Jones
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Boulevard, 2nd Floor West, Philadelphia, PA 19104, USA
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28
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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.
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Milano MT, Chiang VLS, Soltys SG, Wang TJC, Lo SS, Brackett A, Nagpal S, Chao S, Garg AK, Jabbari S, Halasz LM, Gephart MH, Knisely JPS, Sahgal A, Chang EL. Executive summary from American Radium Society's appropriate use criteria on neurocognition after stereotactic radiosurgery for multiple brain metastases. Neuro Oncol 2021; 22:1728-1741. [PMID: 32780818 DOI: 10.1093/neuonc/noaa192] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The American Radium Society (ARS) Appropriate Use Criteria brain malignancies panel systematically reviewed (PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses]) published literature on neurocognitive outcomes after stereotactic radiosurgery (SRS) for patients with multiple brain metastases (BM) to generate consensus guidelines. METHODS The panel developed 4 key questions (KQs) to guide systematic review. From 11 614 original articles, 12 were selected. The panel developed model cases addressing KQs and potentially controversial scenarios not addressed in the systematic review (which might inform future ARS projects). Based upon quality of evidence, the panel confidentially voted on treatment options using a 9-point scale of appropriateness. RESULTS The panel agreed that SRS alone is usually appropriate for those with good performance status and 2-10 asymptomatic BM, and usually not appropriate for >20 BM. For 11-15 and 16-20 BM there was (between 2 case variants) agreement that SRS alone may be appropriate or disagreement on the appropriateness of SRS alone. There was no scenario (among 6 case variants) in which conventional whole-brain radiotherapy (WBRT) was considered usually appropriate by most panelists. There were several areas of disagreement, including: hippocampal sparing WBRT for 2-4 asymptomatic BM; WBRT for resected BM amenable to SRS; fractionated versus single-fraction SRS for resected BM, larger targets, and/or brainstem metastases; optimal treatment (WBRT, hippocampal sparing WBRT, SRS alone to all or select lesions) for patients with progressive extracranial disease, poor performance status, and no systemic options. CONCLUSIONS For patients with 2-10 BM, SRS alone is an appropriate treatment option for well-selected patients with good performance status. Future study is needed for those scenarios in which there was disagreement among panelists.
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Affiliation(s)
- Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, NY
| | - Veronica L S Chiang
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, CT
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, CT
| | - Tony J C Wang
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Alexandria Brackett
- Cushing/Whitney Medical Library, Yale School of Medicine, Yale University, New Haven, CT
| | - Seema Nagpal
- Department of Neurology, Stanford University School of Medicine, Stanford, CT
| | - Samuel Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Amit K Garg
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Albuquerque, NM
| | - Siavash Jabbari
- Laurel Amtower Cancer Institute and Neuro-oncology Center, Sharp Healthcare, San Diego, CA
| | - Lia M Halasz
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | | | - Jonathan P S Knisely
- Department of Radiation Oncology, Weill Cornell Medicine, Cornell University, New York, NY
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
| | - Eric L Chang
- Department of Radiation Oncology, Keck School of Medicine of University of Southern California, Los Angeles, CA
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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.
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Chen L, Chen E, Huang Y, Tian X. Rivaroxaban triggered multifocal intratumoral hemorrhage of the cabozantinib-treated diffuse brain metastases: A case report and review of literature. Open Med (Wars) 2021; 16:618-623. [PMID: 33869783 PMCID: PMC8035493 DOI: 10.1515/med-2021-0261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/27/2021] [Accepted: 03/01/2021] [Indexed: 12/21/2022] Open
Abstract
Brain metastases (BMs) are the most common intracranial malignancy with poor prognosis. Patients with intracranial tumors are at greater risk for thrombotic complications and intracranial hemorrhage. Rivaroxaban is a potent oral anticoagulant with the high selectivity of direct factor Xa inhibition. The incidence and severity of rivaroxaban-triggered intratumoral hemorrhage (ITH) in patients with BMs remain unknown. A 57-year-old woman was diagnosed with multiple lung, bone, and BMs from unknown primary cancer origin, and refused any invasive procedures to confirm tumor pathology. However, this patient had a relatively favorable outcome after treating with cabozantinib, an inhibitor of multiple tyrosine kinases. The patient survived over 2 years and developed deep vein thrombosis of right lower limb. Oral rivaroxaban was prescribed, and the multifocal catastrophic ITH was encountered after 1 week. The last head computed tomography imaging revealed a rare but typical image of diffuse hemorrhagic metastases. Hemorrhagic-prone BMs, therapeutic rivaroxaban, and cabozantinib treatment increase risks to develop ITH. In this case rivaroxaban was the trigger to this terminal event. This case is a miserable lesson and keeps reminding us to stay vigilant in clinical practice even when there is a potential benefit for anticoagulation in such population.
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Affiliation(s)
- Luyue Chen
- Department of Neurosurgery, Zhongshan Hospital Xiamen University, Xiamen, 361004, Fujian, People's Republic of China
| | - E Chen
- Department of Neurosurgery, Zhongshan Hospital Xiamen University, Xiamen, 361004, Fujian, People's Republic of China
| | - Yanlin Huang
- Department of Neurosurgery, Zhongshan Hospital Xiamen University, Xiamen, 361004, Fujian, People's Republic of China
| | - Xinhua Tian
- Department of Neurosurgery, Zhongshan Hospital Xiamen University, Xiamen, 361004, Fujian, People's Republic of China
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Yomo S, Oda K, Oguchi K. Safety and efficacy of upfront stereotactic radiosurgery for brain metastases with high cumulative intracranial tumor volume (> 7 ml): analysis of 233 consecutive patients. Acta Neurochir (Wien) 2021; 163:991-1001. [PMID: 33398539 DOI: 10.1007/s00701-020-04658-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 11/23/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The cumulative intracranial tumor volume (CITV) has recently been suggested to be a more relevant predictive factor for patients with brain metastases (BM) treated with stereotactic radiosurgery (SRS). We aimed to investigate the feasibility of upfront SRS for patients with BM having a high CITV, i.e., exceeding 7 ml. METHODS Two hundred thirty-three consecutive patients with BM having a CITV > 7 ml who underwent SRS as first-line treatment from 2011 to 2019 were retrospectively identified. The overall survival (OS) and intracranial disease control rates were analyzed. Multivariate proportional hazards models were used to identify prognostic factors associated with treatment outcome. Toxicity and salvage therapy were also investigated. RESULTS The median OS was 8.7 months (95% confidence interval: 7.1-10.4), and 6-month and 1-year OS rates were 60 and 40%, respectively. Systemic anticancer therapy (hazard ratio (HR): 0.45, p < 0.001), female sex (HR: 0.61, p = 0.001), synchronous SRS (HR: 0.57, p = 0.003), number of BM (HR: 1.04, p = 0.008), controlled extracranial disease (HR: 0.56, p = 0.009), Karnofsky performance status (HR: 0.87, p = 0.015), and staged SRS (HR: 0.71, p = 0.037) were found to be factors independently associated with OS. Post-SRS toxicities of CTCAE grades 3, 4, and 5 were observed in 14, 5, and 1 patient, respectively. As salvage management, repeat SRS, whole brain radiotherapy, and surgical resection were required for 84, 16, and 10 patients, respectively, CONCLUSIONS: With vigilant surveillance and appropriate salvage management, upfront SRS alone can be considered as a relatively safe and effective treatment strategy even for BM with CITV > 7 ml.
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Affiliation(s)
- Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, 2-5-1, Honjo, Matsumoto City, Nagano Prefecture, 390-0814, Japan.
| | - Kyota Oda
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, 2-5-1, Honjo, Matsumoto City, Nagano Prefecture, 390-0814, Japan
| | - Kazuhiro Oguchi
- Positron Imaging Center, Aizawa Hospital, Matsumoto City, Nagano Prefecture, Japan
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Kraft J, Mayinger M, Willmann J, Brown M, Tanadini-Lang S, Wilke L, Guckenberger M, Andratschke N. Management of multiple brain metastases: a patterns of care survey within the German Society for Radiation Oncology. J Neurooncol 2021; 152:395-404. [PMID: 33620657 PMCID: PMC7997832 DOI: 10.1007/s11060-021-03714-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 02/06/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The treatment of brain metastases (BM) has changed considerably in recent years and in particular, the management of multiple BM is currently undergoing a paradigm shift and treatment may differ from current guidelines. This survey was designed to analyze the patterns of care in the management of multiple BM. METHODS An online survey consisting of 36 questions was distributed to the members of the German Society for Radiation Oncology (DEGRO). RESULTS In total, 193 physicians out of 111 institutions within the German Society for Radiation oncology responded to the survey. Prognostic scores for decision making were not used regularly. Whole brain radiotherapy approaches (WBRT) are the preferred treatment option for patients with multiple BM, although stereotactic radiotherapy treatments are chosen by one third depending on prognostic scores and overall number of BM. Routine hippocampal avoidance (HA) in WBRT is only used by a minority. In multiple BM of driver-mutated non-small cell lung cancer origin up to 30% favor sole TKI therapy as upfront treatment and would defer upfront radiotherapy. CONCLUSION In multiple BM WBRT without hippocampal avoidance is still the preferred treatment modality of choice regardless of GPA and mutational status, while SRT is only used in patients with good prognosis. Evidence for both, SRS and hippocampal avoidance radiotherapy, is growing albeit the debate over the appropriate treatment in multiple BM is yet not fully clarified. Further prospective assessment of BM management-ideally as randomized trials-is required to align evolving concepts with the proper evidence and to update current guidelines.
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Affiliation(s)
- Johannes Kraft
- University Hospital Zurich: UniversitatsSpital Zurich, Zurich, Switzerland.
| | - Michael Mayinger
- University Hospital Zurich: UniversitatsSpital Zurich, Zurich, Switzerland
| | - Jonas Willmann
- University Hospital Zurich: UniversitatsSpital Zurich, Zurich, Switzerland
| | - Michelle Brown
- University Hospital Zurich: UniversitatsSpital Zurich, Zurich, Switzerland
| | | | - Lotte Wilke
- University Hospital Zurich: UniversitatsSpital Zurich, Zurich, Switzerland
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Asher AL, Alvi MA, Bydon M, Pouratian N, Warnick RE, McInerney J, Grills IS, Sheehan J. Local failure after stereotactic radiosurgery (SRS) for intracranial metastasis: analysis from a cooperative, prospective national registry. J Neurooncol 2021; 152:299-311. [PMID: 33481148 DOI: 10.1007/s11060-021-03698-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/08/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Stereotactic radiosurgery (SRS) has been increasingly employed to treat patients with intracranial metastasis, both as a salvage treatment after failed whole brain radiation therapy (WBRT) and as an initial treatment. "Several studies have shown that SRS may be as effective as WBRT with the added benefit of preserving neuro-cognition". However, some patients may have local failure following SRS for intracranial metastasis, defined as increase in total lesion volume by 25% after at least 3 months of follow up. METHODS The SRS registry, established by the Neuro point alliance (NPA) under the auspices of the American Association of Neurological Surgeons (AANS), was queried for patients with intracranial metastasis receiving SRS at the participating sites. Demographic, clinical symptoms, tumor, and treatment characteristics as well as follow up status were summarized for the cohort. A multivariable explanatory cox- regression was performed to evaluate the impact of each of the factors on time to local failure.at last follow-up. RESULTS A total of 441 patients with 1255 intracranial metastatic lesions undergoing SRS were identified. The most common primary cancer histology was non-small cell lung cancer (43.8%, n = 193). More than half of the cohort had more than 1 metastatic lesion (2-3 lesions: 29.5%, n = 130; more than 3 lesions: 25.2% (n = 111). The average duration of follow-up for the cohort was found to be 8.4 months (SD = 7.61). The mean clinical treatment volume (CTV), after adding together the volume of each lesion for each patient was 5.39 cc (SD = 7.6) at baseline. A total of 20.2% (n = 89) had local failure (increase in volume by > 25%) with a mean time to progression of 7.719 months (SD = 6.09). The progression free survival (PFS) for the cohort at 3, 6 and 12 months were found to be 94.9%, 84.3%, and 69.4%, respectively. On multivariable cox regression analysis, factors associated with increased hazard of local failure included male gender (HR 1.65, 95% CI 1.03-2.66, p = 0.037), chemotherapy at or before SRS (HR = 2.39, 95% CI 1.41-4.05, p = 0.001), WBRT at or before SRS (HR = 2.21, 95% CI 1.16- 4.22, p = 0.017), while surgical resection (HR 0.45, 95% CI 0.21-0. 97, p = 0.04) and immunotherapy (0.34, 95% CI 0.16-0.50, p = 0.014) were associated with lower hazard of local failure. CONCLUSION Factors found to be predictive of local failure included higher RPA score and those receiving chemotherapy, while patients undergoing surgical resection and those with occipital lobe lesions were less likely to experience local failure. Our analyses not only corroborate those previously reported but also demonstrate the utility of a multi-institutional registry to advance real-world SRS research for patients with intracranial metastatic lesions.
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Affiliation(s)
- Anthony L Asher
- Neuroscience Institute, Carolinas Healthcare System and Carolina, Neurosurgery & Spine Associates, Charlotte, NC, 28204, USA
| | - Mohammed Ali Alvi
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 55902, USA
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 55902, USA
| | - Nader Pouratian
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| | - Ronald E Warnick
- Department of Neurosurgery, The Jewish Hospital, Cincinnati, OH, USA
| | - James McInerney
- Department of Neurosurgery, Penn State Health, Hershey, PA, USA
| | - Inga S Grills
- Department of Neurological Surgery, Beaumont Health System, Royal Oak, MI, USA
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia Health System, 1300 Jefferson Park Ave, Charlottesville, VA, 22908, USA.
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Hirshman BR, Compton J, Carroll KT, Ali MA, Wang SG, Chen CC. Cumulative Intracranial Tumor Volume as a Prognostic Factor in Patients with Brain Metastases Undergoing Stereotactic Radiosurgery. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 128:57-69. [PMID: 34191062 DOI: 10.1007/978-3-030-69217-9_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Approximately 25-35% of all cancer patients suffer from brain metastases (BM), and many of them-in particular, those with a limited number of intracranial tumors-are treated with stereotactic radiosurgery (SRS). Accurate prediction of survival remains a key clinical challenge in this population. Several prognostic scales have been developed to facilitate this prognostication, including the Recursive Partitioning Analysis (RPA) classification, the modified Recursive Partitioning Analysis (mRPA) subclassifications, the Basic Score for Brain Metastases (BS-BM), the Score Index for Radiosurgery (SIR), the Graded Prognostic Assessment (GPA), and the diagnosis-specific Graded Prognostic Assessment (dsGPA). However, none of these scales include consideration of the cumulative intracranial tumor volume (CITV), which is defined as the sum of all intracranial tumor volumes. Since there is mounting evidence that the CITV carries significant prognostic value in SRS-treated patients with BM, this variable should be considered during survival prognostication, along with other pertinent clinical, pathological, and molecular characteristics.
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Affiliation(s)
- Brian R Hirshman
- Department of Neurosurgery, University of California San Diego (UCSD), La Jolla, CA, USA
| | - Jason Compton
- School of Medicine, University of California San Diego (UCSD), La Jolla, CA, USA
| | - Kate T Carroll
- School of Medicine, University of California San Diego (UCSD), La Jolla, CA, USA
| | - Mir Amaan Ali
- School of Medicine, University of California San Diego (UCSD), La Jolla, CA, USA
| | - Sonya G Wang
- Department of Neurology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN, USA.
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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.
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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
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Nabors LB, Portnow J, Ahluwalia M, Baehring J, Brem H, Brem S, Butowski N, Campian JL, Clark SW, Fabiano AJ, Forsyth P, Hattangadi-Gluth J, Holdhoff M, Horbinski C, Junck L, Kaley T, Kumthekar P, Loeffler JS, Mrugala MM, Nagpal S, Pandey M, Parney I, Peters K, Puduvalli VK, Robins I, Rockhill J, Rusthoven C, Shonka N, Shrieve DC, Swinnen LJ, Weiss S, Wen PY, Willmarth NE, Bergman MA, Darlow SD. Central Nervous System Cancers, Version 3.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2020; 18:1537-1570. [PMID: 33152694 DOI: 10.6004/jnccn.2020.0052] [Citation(s) in RCA: 242] [Impact Index Per Article: 60.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The NCCN Guidelines for Central Nervous System (CNS) Cancers focus on management of adult CNS cancers ranging from noninvasive and surgically curable pilocytic astrocytomas to metastatic brain disease. The involvement of an interdisciplinary team, including neurosurgeons, radiation therapists, oncologists, neurologists, and neuroradiologists, is a key factor in the appropriate management of CNS cancers. Integrated histopathologic and molecular characterization of brain tumors such as gliomas should be standard practice. This article describes NCCN Guidelines recommendations for WHO grade I, II, III, and IV gliomas. Treatment of brain metastases, the most common intracranial tumors in adults, is also described.
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Affiliation(s)
| | | | - Manmeet Ahluwalia
- 3Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | - Henry Brem
- 5The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Steven Brem
- 6Abramson Cancer Center at the University of Pennsylvania
| | | | - Jian L Campian
- 8Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | | | | | - Craig Horbinski
- 13Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | - Larry Junck
- 14University of Michigan Rogel Cancer Center
| | | | - Priya Kumthekar
- 13Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | - Manjari Pandey
- 19St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | | | - Vinay K Puduvalli
- 21The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Ian Robins
- 22University of Wisconsin Carbone Cancer Center
| | - Jason Rockhill
- 23Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | | | - Lode J Swinnen
- 5The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
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Donofrio CA, Cavalli A, Gemma M, Riccio L, Donofrio A, Panni P, Ferrari da Passano C, Del Vecchio A, Bolognesi A, Soffietti R, Mortini P. Cumulative intracranial tumour volume prognostic assessment: a new predicting score index for patients with brain metastases treated by stereotactic radiosurgery. Clin Exp Metastasis 2020; 37:499-508. [PMID: 32430649 DOI: 10.1007/s10585-020-10037-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 05/12/2020] [Indexed: 01/28/2023]
Abstract
Brain metastases (BM) represent the most common intracranial malignancy in adults. Limitations of existing prognostic models reduce their predictivity and clinical applicability. The aim of this study is to validate the cumulative intracranial tumour volume prognostic assessment (CITVPA) as a new prognostic score system for patients with BM treated by Stereotactic Radiosurgery (SRS). Between January 2001 and December 2015, 1894 patients underwent Gamma Knife SRS treatment. The CITVPA model was implemented and validated as follows: the CITV cut-offs were identified thanks to a receiver-operating characteristic (ROC) curve analysis; the survival predictive factors were selected through a Cox proportional hazard model; its prognostic power was compared to RPA, SIR and GPA through the Harrel concordance index (HCI). According to the ROC curve analysis, the CITV cut-off values were set at 1.5 and 4.0 cc. Based on the multivariate analysis, the CITVPA model included: age (OR 1.010, 95% CI 1.005-1.015, p < 0.001), KPS (OR 0.960, 95% CI 0.956-0.965, p < 0.001), extracranial metastases (OR 1.287, 95% CI 1.154-1.437, p < 0.001), BM number (OR 1.193, 95% CI 1.047-1.360, p = 0.008), and CITV (OR 1.028, 95% CI 1.020-1.036, p < 0.001). A score between 0 and 1 was attributed to each prognosticator; a global CITVPA score ranging from 0 to 5 was assigned with higher results corresponding to worse outcomes. The CITVPA (HCI = 0.64) exhibited a significantly (p < 0.001) higher prognostic power compared to RPA (HCI = 0.55), SIR (HCI = 0.55) and GPA (HCI = 0.61). The CITVPA represents a reliable prognostic system for patients with BM treated by SRS. However, further prospective and multicentric studies are necessary before its applicability in clinical practice.
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Affiliation(s)
- Carmine Antonio Donofrio
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | - Andrea Cavalli
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Marco Gemma
- Service of Anaesthesia and Intensive Care Unit, Fatebenefratelli Hospital, Milan, Italy
| | - Lucia Riccio
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Alessandra Donofrio
- Department of Radiation Oncology, Brescia University, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Pietro Panni
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Camillo Ferrari da Passano
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | | | - Angelo Bolognesi
- Service of Radiation Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
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Qie S, Ran Y, Yang H, Cui G, Liu M, Sun X, Tian Y, Sun W, Li N, Liu C. Brain metastases from esophageal cancer: A case report. Medicine (Baltimore) 2020; 99:e20223. [PMID: 32541449 PMCID: PMC7302628 DOI: 10.1097/md.0000000000020223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION At present, there is no uniform consensus on the treatment of brain metastases from esophageal cancer. The studies on the treatment of brain metastases from esophageal cancer by radiotherapy combined with temozolomide (TMZ) are even rarer. PATIENT CONCERNS A 69-year-old woman was admitted to our hospital for brain metastases from esophageal cancer after thoracic irradiation. DIAGNOSES Magnetic resonance imaging of the head showed a round, heterogeneous metastatic tumor in the left parietal lobe. Brain magnetic resonance imaging showed edema around brain metastasesInterventions: After radiotherapy plus TMZ in this patient's head, the brain metastatic tumor was significantly decreased. OUTCOMES At the end of radiotherapy, and 1 and 2 months after the end of radiotherapy, the metastatic tumor continued to shrink, and no obvious side effects were observed. LESSONS This study suggests that radiotherapy plus TMZ might be a feasible option for brain metastases from esophageal cancer.
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Alsuhaibani A, Elashwah A, Alkafi A, Constantinescus C, ALzorkany F. Stereotactic Body Radiation Therapy (SBRT) Using CyberKnife in Oligometastatic Cancer Patients; Retrospective Evaluation, Single Institution Experience. J Gastrointest Cancer 2020; 50:879-887. [PMID: 30291546 DOI: 10.1007/s12029-018-0170-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES We retrospectively evaluate local control rate at 6 months and 1 year in oligometastatic cancer patients treated with SBRT using CyberKnife. METHODS Total of 21 patients with 24 treatment sites from February 2014 till June 2017 who were treated with SBRT in our institution were included in this study. RESULTS Eleven patients were males, 10 patients were females, median age at diagnosis was 63 years, and colorectal cancer is the most commonly diagnosed cancer in 18 patients. The abdomino-pelvic lymph nodes were the commonest treatment site in 11 (45.8%), average PTV volume of 46.4 cc. All the patients received SBRT with average (BED) of 97 GY, 7 treatment sites received BED of < 100GYgroup 1, and 17 received BED ≥ 100GY group 2. No reported G3 or G4 acute or chronic toxicity. The 6 months and 1 year local control (LC) were 95.8 and 88.2%, respectively. After a median follow-up of 16.8 months, 19(90.5%) patients were alive; among them, local progression was observed in 1 (4.1%) treatment site, while systemic progression in 4 (16.6%), and two (9.5%) patients died; they had both local and systemic failures. The 1-year local PFS rate was 82%. In univariate analysis, PTV volume was significantly correlated with LC rate at 6 months (p = 0.001), while the site of metastasis appeared to significantly correlate with PFS (p = 0.03). CONCLUSION SBRT using CyberKnife is feasible, safe, and effective treatment for oligometastatic sites. Six months and 1 year local control rate is 95.8 and 88.2% respectively in our patients cohort, treatment regimens with higher BED resulting in better 1-year local PFS, although it was not statistically significant. A larger cohort of patients and longer follow up is required for better evaluation.
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Affiliation(s)
- Abdullah Alsuhaibani
- Oncology Center, University Medical City, King Saud University, Riyadh, Saudi Arabia.
| | - Ahmed Elashwah
- Radiation oncology department King Faisal specialized hospital and research center, Riyadh, Saudi Arabia
- Kasr Aleini center of clinical oncology and nuclear medicine (NEMROCK), Cairo University, Cairo, Egypt
| | - Abdullah Alkafi
- Radiation oncology department King Faisal specialized hospital and research center, Riyadh, Saudi Arabia
| | - Camelia Constantinescus
- Radiation oncology department King Faisal specialized hospital and research center, Riyadh, Saudi Arabia
| | - Faisal ALzorkany
- Radiation oncology department King Faisal specialized hospital and research center, Riyadh, Saudi Arabia
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Eastman BM, Venur VA, Lo SS, Graber JJ. Stereotactic radiosurgery in the treatment of adults with metastatic brain tumors. J Neurosurg Sci 2020; 64:272-286. [PMID: 32270945 DOI: 10.23736/s0390-5616.20.04952-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Brain metastasis is the most common type of intracranial tumor affecting a significant proportion of advanced cancer patients. In recent years, stereotactic radiosurgery (SRS) has become commonly utilized. It has contributed significantly to decreased toxicity, prolonged quality of life and general improvement in outcomes of patients with brain metastases. Frequent imaging and advanced treatment techniques have allowed for the treatment of more patients with large and numerous metastases extending their overall survival. The addition of targeted therapy and immunotherapy to SRS has introduced novel treatment paradigms and has further improved our ability to effectively treat brain lesions. In this review, we examined in detail the available evidence for the use of SRS alone or in combination with surgery and systemic therapies. Given our developing understanding of the importance of primary tumor histology, the use of different treatment strategies for different metastasis is evolving. Combining SRS with immunotherapy and targeted therapy in breast cancer, lung cancer and melanoma as well as the use of preoperative SRS have shown significant promise in recent years and are investigated in multiple ongoing prospective trials. Further research is needed to guide the optimal sequence of therapies and to identify specific patient subgroups that may benefit the most from aggressive, combined treatment approaches.
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Affiliation(s)
- Boryana M Eastman
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Vyshak A Venur
- Division of Medical Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Jerome J Graber
- Department of Neurology and Neurosurgery, Alvord Brain Tumor Center, University of Washington School of Medicine, Seattle, WA, USA -
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Hughes RT, McTyre ER, LeCompte M, Cramer CK, Munley MT, Laxton AW, Tatter SB, Ruiz J, Pasche B, Watabe K, Chan MD. Clinical Outcomes of Upfront Stereotactic Radiosurgery Alone for Patients With 5 to 15 Brain Metastases. Neurosurgery 2020; 85:257-263. [PMID: 29982831 DOI: 10.1093/neuros/nyy276] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 05/30/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The role of primary stereotactic radiosurgery (SRS) for patients with >4 brain metastases (BM) remains controversial. OBJECTIVE To compare the outcomes of patients treated with upfront SRS alone for 1, 2 to 4, and 5 to 15 BM and assess for predictors of clinical outcomes in the 5 to 15 BM group. METHODS A total of 478 patients treated with upfront SRS were stratified by number of lesions: 220 had 1 BM, 190 had 2 to 4 BM, and 68 patients had 5 to 15 BM. Overall survival and whole brain radiotherapy-free survival were estimated using the Kaplan-Meier method. The cumulative incidences of local failure and distant brain failure (DBF) were estimated using competing risks methodology. Clinicopathologic and dosimetric parameters were evaluated as predictors of survival and DBF in patients with 5 to 15 BM using Cox proportional hazards. RESULTS Median overall survival was 8.0, 6.3, and 4.7 mo for patients with 1, 2 to 4, and 5 to 15 BM, respectively (P = .14). One-year DBF was 27%, 44%, and 40%, respectively (P = .01). Salvage SRS and whole brain radiotherapy rates did not differ. Progressive extracranial disease and gastrointestinal primary were associated with poor survival while RCC primary was associated with increased risk of DBF. No evaluated dose-volume parameters predicted for death, neurologic death or toxicity. CONCLUSION SRS for 5 to 15 BM is well tolerated without evidence of an associated increase in toxicity, treatment failure, or salvage therapy. Further prospective, randomized studies are warranted to clarify the role of SRS for these patients.
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Affiliation(s)
- Ryan T Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Emory R McTyre
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Michael LeCompte
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Christina K Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Michael T Munley
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Jimmy Ruiz
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Boris Pasche
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston Salem, North Carolina.,Department of Cancer Biology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
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Volume de-escalation in radiation therapy: state of the art and new perspectives. J Cancer Res Clin Oncol 2020; 146:909-924. [PMID: 32072318 DOI: 10.1007/s00432-020-03152-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 02/10/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE New RT techniques and data emerging from follow-up for several tumor sites suggest that treatment volume de-escalation may permit to minimize therapy-related side effects and/or obtain better clinical outcomes. Here, we summarize the main evidence about volume de-escalation in RT. METHOD The relevant literature from PubMed was reviewed in this article. The ClinicalTrials.gov database was searched for clinical trials related to the specific topic. RESULTS In Lymphoma, large-volume techniques (extended- and involved-field RT) are being successfully replaced by involved-site RT and involved-node RT. In head and neck carcinoma, spare a part of elective neck is controversial. In early breast cancer, partial breast irradiation has been established as a treatment option in low-risk patients. In pancreatic cancer stereotactic body radiotherapy may be used to dose escalation. Stereotactic radiosurgery should be the treatment choice for patients with oligometastatic brain disease and a life expectancy of more than 3 months, and it should be considered an alternative to WBRT for patients with multiple brain metastases. CONCLUSION Further clinical trials are necessary to improve the identification of suitable patient cohorts and the extent of possible volume de-escalation that does not compromise tumor control.
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Palmer JD, Trifiletti DM, Gondi V, Chan M, Minniti G, Rusthoven CG, Schild SE, Mishra MV, Bovi J, Williams N, Lustberg M, Brown PD, Rao G, Roberge D. Multidisciplinary patient-centered management of brain metastases and future directions. Neurooncol Adv 2020; 2:vdaa034. [PMID: 32793882 PMCID: PMC7415255 DOI: 10.1093/noajnl/vdaa034] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The incidence of brain metastasis is increasing as improvements in systemic therapy lead to increased survival. This provides new and challenging clinical decisions for patients who are trying to balance the risk of recurrence or progression with treatment-related side effects, and it requires appropriate management strategies from multidisciplinary teams. Improvements in prognostic assessment and systemic therapy with increasing activity in the brain allow for individualized care to better guide the use of local therapies and/or systemic therapy. Here, we review the current landscape of brain-directed therapy for the treatment of brain metastasis in the context of recent improved systemic treatment options. We also discuss emerging treatment strategies including targeted therapies for patients with actionable mutations, immunotherapy, modern whole-brain radiation therapy, radiosurgery, surgery, and clinical trials.
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Affiliation(s)
- Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Neurosurgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel M Trifiletti
- Departments of Radiation Oncology and Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Radiation Oncology Consultants LLC, Chicago, Illinois, USA
- Northwestern Medicine Chicago Proton Center Warrenville, Chicago, Illinois, USA
| | - Michael Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Giuseppe Minniti
- Radiation Oncology Unit, UPMC Hillman Cancer Center, San Pietro Hospital FBF, Rome, Italy
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic Scottsdale, Phoenix, Arizona, USA
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joseph Bovi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nicole Williams
- Department of Medical Oncology, The James Cancer Hospital and Solove Research Institute at The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Maryam Lustberg
- Department of Medical Oncology, The James Cancer Hospital and Solove Research Institute at The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ganesh Rao
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Roberge
- Department of Radiation Oncology, Centre Hospitalier de l’ Université de Montreal, Montreal, Quebec, Canada
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Siddiqui ZA, Squires BS, Johnson MD, Baschnagel AM, Chen PY, Krauss DJ, Olson RE, Meyer KD, Grills IS. Predictors of radiation necrosis in long-term survivors after Gamma Knife stereotactic radiosurgery for brain metastases. Neurooncol Pract 2019; 7:400-408. [PMID: 32765891 DOI: 10.1093/nop/npz067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background The long-term risk of necrosis after radiosurgery for brain metastases is uncertain. We aimed to investigate incidence and predictors of radiation necrosis for individuals with more than 1 year of survival after radiosurgery for brain metastases. Methods Patients who had a diagnosis of brain metastases treated between December 2006 and December 2014, who had at least 1 year of survival after first radiosurgery were retrospectively reviewed. Survival was analyzed using the Kaplan-Meier estimator, and the incidence of radiation necrosis was estimated with death or surgical resection as competing risks. Patient and treatment factors associated with radiation necrosis were also analyzed. Results A total of 198 patients with 732 lesions were analyzed. Thirty-four lesions required salvage radiosurgery and 10 required salvage surgical resection. Median follow-up was 24 months. The estimated median survival for this population was 25.4 months. The estimated per-lesion incidence of radiation necrosis at 4 years was 6.8%. Medical or surgical therapy was required for 60% of necrosis events. Tumor volume and male sex were significant factors associated with radiation necrosis. The per-lesions incidence of necrosis for patients undergoing repeat radiosurgery was 33.3% at 4 years. Conclusions In this large series of patients undergoing radiosurgery for brain metastases, patients continued to be at risk for radiation necrosis throughout their first 4 years of survival. Repeat radiosurgery of recurrent lesions greatly exacerbates the risk of radiation necrosis, whereas treatment of larger target volumes increases the risk modestly.
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Affiliation(s)
- Zaid A Siddiqui
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Bryan S Squires
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Matt D Johnson
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Andrew M Baschnagel
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Peter Y Chen
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Daniel J Krauss
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Ricky E Olson
- Department of Neurological Surgery, Beaumont Health System, Royal Oak, Michigan
| | - Kurt D Meyer
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
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Couñago F, Luna J, Guerrero LL, Vaquero B, Guillén-Sacoto MC, González-Merino T, Taboada B, Díaz V, Rubio-Viqueira B, Díaz-Gavela AA, Marcos FJ, del Cerro E. Management of oligometastatic non-small cell lung cancer patients: Current controversies and future directions. World J Clin Oncol 2019; 10:318-339. [PMID: 31799148 PMCID: PMC6885452 DOI: 10.5306/wjco.v10.i10.318] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/30/2019] [Accepted: 09/15/2019] [Indexed: 02/06/2023] Open
Abstract
Oligometastatic non-small cell lung cancer (NSCLC) describes an intermediate stage of NSCLC between localized and widely-disseminated disease. This stage of NSCLC is characterized by a limited number of metastases and a more indolent tumor biology. Currently, the management of oligometastatic NSCLC involves radical treatment (radiotherapy or surgery) that targets the metastatic lesions and the primary tumor to achieve disease control. This approach offers the potential to achieve prolonged survival in patients who, in the past, would have only received palliative measures. The optimal therapeutic strategies for the different scenarios of oligometastatic disease (intracranial vs extracranial disease, synchronous vs metachronous) remain undefined. Given the lack of head-to-head studies comparing radiotherapy to surgery in these patients, the decision to apply surgery or radiotherapy (with or without systemic treatment) must be based on prognostic factors that allow us to classify patients. This classification will allow us to select the most appropriate therapeutic strategy on an individualized basis. In the future, the molecular or microRNA profiles will likely improve the treatment selection process. The objective of the present article is to review the most relevant scientific evidence on the management of patients with oligometastatic NSCLC, focusing on the role of radiotherapy and surgery. We also discuss areas of controversy and future directions.
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Affiliation(s)
- Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid, Pozuelo de Alarcón, Madrid 28223, Spain
- Department of Radiation Oncology, Hospital La Luz, Madrid 28003, Spain
- Clinical Department, Faculty of Biomedicine, Universidad Europea, Madrid 28223, Spain
| | - Javier Luna
- Department of Radiation Oncology, Hospital Fundación Jiménez Díaz, Madrid 28040, Spain
| | | | - Blanca Vaquero
- Department of Radiation Oncology, Hospital La Luz, Madrid 28003, Spain
| | | | | | - Begoña Taboada
- Department of Radiation Oncology, Complexo Hospitalario Universitario Santiago de Compostela, Santiago de Compostela 15706, Spain
| | - Verónica Díaz
- Department of Radiation Oncology, Hospital Universitario Puerta del Mar, Cádiz 11009, Spain
| | - Belén Rubio-Viqueira
- Department of Medical Oncology, Hospital Universitario Quirónsalud Madrid, Pozuelo de Alarcón, Madrid 28223, Spain
| | - Ana Aurora Díaz-Gavela
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid, Pozuelo de Alarcón, Madrid 28223, Spain
- Department of Radiation Oncology, Hospital La Luz, Madrid 28003, Spain
- Clinical Department, Faculty of Biomedicine, Universidad Europea, Madrid 28223, Spain
| | - Francisco José Marcos
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid, Pozuelo de Alarcón, Madrid 28223, Spain
- Department of Radiation Oncology, Hospital La Luz, Madrid 28003, Spain
- Clinical Department, Faculty of Biomedicine, Universidad Europea, Madrid 28223, Spain
| | - Elia del Cerro
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid, Pozuelo de Alarcón, Madrid 28223, Spain
- Department of Radiation Oncology, Hospital La Luz, Madrid 28003, Spain
- Clinical Department, Faculty of Biomedicine, Universidad Europea, Madrid 28223, Spain
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Wang W, Sun X, Hui Z. Treatment Optimization for Brain Metastasis from Anaplastic Lymphoma Kinase Rearrangement Non-Small-Cell Lung Cancer. Oncol Res Treat 2019; 42:599-606. [PMID: 31527380 DOI: 10.1159/000502755] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 08/14/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Brain metastasis is common in non-small-cell lung cancer (NSCLC) with driver gene mutations. Anaplastic lymphoma kinase (ALK) gene rearrangement is one of the common driver mutations in NSCLC. Tyrosine kinase inhibitor (TKI) has been the research hotspot at present. However, there are relatively few studies specified on the treatment of brain metastasis from ALK gene rearrangement NSCLC. The prognosis of these patients, the role of ALK-TKI, and the proper combination model of ALK-TKI with radiotherapy are worth further exploring. This review focuses on new data on the prognosis of ALK-TKI and the proper combination model of ALK-TKI with radiotherapy. SUMMARY According to some retrospective trials, for ALKi-naïve ALK rearrangement NSCLC patients with brain metastasis, crizotinib together with radiotherapy seem to improve intracranial control rate, progression-free survival, and very likely improve overall survival; next-generation ALK-TKIs are now replacing crizotinib as first-line treatment. For patients with central nervous system progression during crizotinib application, combining radiotherapy could improve the local control rate while continuing crizotinib to control systemic disease. Second-/third-generation ALK inhibitors had higher intracranial ORR and DCR even after crizotinib-refractory situations, and they alone had a strong efficacy against intracranial tumors, in which situation radiotherapy might be omitted. Stereotactic radiosurgery (SRS) and whole-brain radiotherapy (WBRT) were both local treatment options for brain metastasis, and the preferred choice was hard to make. ALK resistance is complicated with a wide range of molecular changes, and future studies are needed to solve these problems. Anyway, further and larger prospective studied are worth exploring to offer a confirmed preferred choice of drugs and radiation. Key Messages: Next-generation ALK-TKIs are now replacing crizotinib as first-line treatment in ALKi-naïve ALK rearrangement NSCLC patients with brain metastasis, and they alone might have a strong efficacy against intracranial tumors in crizotinib-refractory situations in which occasion radiotherapy might be omitted. SRS and WBRT are both local treatment options for brain metastasis.
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Affiliation(s)
- Wenhui Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academic of Medical Science and Peking Union Medical College, Beijing, China
| | - Xin Sun
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academic of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhouguang Hui
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academic of Medical Science and Peking Union Medical College, Beijing, China, .,Department of VIP Medical Services, National Cancer Center/National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academic of Medical Science and Peking Union Medical College, Beijing, China,
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48
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Noel G, Keller A, Antoni D. [Stereotactic radiotherapy of brain metastases in complex situations]. Cancer Radiother 2019; 23:708-715. [PMID: 31477442 DOI: 10.1016/j.canrad.2019.07.146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 07/11/2019] [Indexed: 02/07/2023]
Abstract
Stereotactic radiation therapy of brain metastases is a treatment recognized as effective, well tolerated, applicable for therapeutic indications codified and validated by national and international guidelines. However, the effectiveness of this irradiation, the evolution of patient care and the technical improvements enabling its implementation make it possible to consider it in more complex situations: proximity of brain metastases to organs at risk; large, cystic, haemorrhagic or multiple brain metastases, combination with targeted therapies and immunotherapy, stereotactic radiotherapy in patients with a pacemaker. This article aims to put forward the arguments available to date in the literature and those resulting from clinical practice to provide decision support for the radiation oncologists.
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Affiliation(s)
- G Noel
- Department of radiotherapy, comprehensive cancer center Paul-Strauss, UNICANCER, 3, rue de la porte de l'Hôpital, 67065 Strasbourg cedex, France; Strasbourg University, CNRS, IPHC UMR 7178, Centre Paul-Strauss, UNICANCER, 67000 Strasbourg, France.
| | - A Keller
- Department of radiotherapy, comprehensive cancer center Paul-Strauss, UNICANCER, 3, rue de la porte de l'Hôpital, 67065 Strasbourg cedex, France
| | - D Antoni
- Department of radiotherapy, comprehensive cancer center Paul-Strauss, UNICANCER, 3, rue de la porte de l'Hôpital, 67065 Strasbourg cedex, France; Strasbourg University, CNRS, IPHC UMR 7178, Centre Paul-Strauss, UNICANCER, 67000 Strasbourg, France
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Gori S, Puglisi F, Moroso S, Fabi A, La Verde N, Frassoldati A, Tarenzi E, Garrone O, Vici P, Laudadio L, Cretella E, Turazza M, Foglietta J, Leonardi V, Cavanna L, Barni S, Galanti D, Russo A, Marchetti F, Valerio M, Lunardi G, Alongi F, Inno A. The HERBA Study: A Retrospective Multi-Institutional Italian Study on Patients With Brain Metastases From HER2-Positive Breast Cancer. Clin Breast Cancer 2019; 19:e501-e510. [DOI: 10.1016/j.clbc.2019.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/28/2019] [Accepted: 05/07/2019] [Indexed: 10/26/2022]
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Vellayappan B, Sahgal A, Chang EL, Lo SS. Commentary: Clinical Outcomes of Upfront Stereotactic Radiosurgery Alone for Patient With 5 to 15 Brain Metastases. Neurosurgery 2019; 85:E247-E248. [PMID: 29982791 DOI: 10.1093/neuros/nyy278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 05/30/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Science Centre, University of Toronto, Toronto, Canada
| | - Eric L Chang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
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