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Tozuka T, Noro R, Mizutani H, Kurimoto F, Hakozaki T, Hisakane K, Naito T, Takahashi S, Taniuchi N, Yajima C, Hosomi Y, Hirose T, Minegishi Y, Okano T, Kamio K, Yamaguchi T, Seike M. Osimertinib plus local treatment for brain metastases versus osimertinib alone in patients with EGFR-Mutant Non-Small Cell Lung Cancer. Lung Cancer 2024; 191:107540. [PMID: 38614069 DOI: 10.1016/j.lungcan.2024.107540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/14/2024] [Accepted: 03/20/2024] [Indexed: 04/15/2024]
Abstract
OBJECTIVES Osimertinib is a standard treatment for patients with EGFR-mutant non-small cell lung cancer (NSCLC) and is highly effective for brain metastases (BMs). However, it is unclear whether local treatment (LT) for BMs prior to osimertinib administration improves survival in EGFR-mutant NSCLC. We aimed to reveal the survival benefit of upfront local treatment (LT) for BMs in patients treated with osimertinib. MATERIALS AND METHODS This multicenter retrospective study included consecutive patients with EGFR mutation (19del or L858R)-positive NSCLC who had BMs before osimertinib initiation between August 2018 and October 2021. We compared overall survival (OS) and central nervous system progression-free survival (CNS-PFS) between patients who received upfront LT for BMs (the upfront LT group), and patients who received osimertinib only (the osimertinib-alone group). Inverse-probability treatment weighting (IPTW) analysis was performed to adjust for potential confounding factors. RESULTS Of the 121 patients analyzed, 57 and 64 patients had 19del and L858R, respectively. Forty-five and 76 patients were included in the upfront LT group and the osimertinib-alone groups, respectively. IPTW-adjusted Kaplan-Meier curves showed that the OS of the upfront LT group was significantly longer than that of the osimertinib-alone group (median, 95 % confidence intervals [95 %CI]: Not reached [NR], NR-NR vs. 31.2, 21.7-33.2; p = 0.021). The hazard ratio (HR) for OS and CNS-PFS was 0.37 (95 %CI, 0.16-0.87) and 0.36 (95 %CI, 0.15-0.87), respectively. CONCLUSIONS The OS and CNS-PFS of patients who received upfront LT for BMs followed by osimertinib were significantly longer than those of patients who received osimertinib alone. Upfront LT for BMs may be beneficial in patients with EGFR-mutant NSCLC treated with osimertinib.
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Affiliation(s)
- Takehiro Tozuka
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Rintaro Noro
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Hideaki Mizutani
- Department of Thoracic Oncology, Saitama Cancer Center, Saitama, Japan
| | - Futoshi Kurimoto
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Taiki Hakozaki
- Department of Thoracic Oncology and Respiratory Medicine, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Kakeru Hisakane
- Department of Pulmonary Medicine and Oncology, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Tomoyuki Naito
- Department of Respiratory Medicine, Mitsui Memorial Hospital, Tokyo, Japan
| | - Satoshi Takahashi
- Respiratory Disease Center, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Namiko Taniuchi
- Department of Pulmonary Medicine, Nippon Medical School Musashikosugi Hospital, Kanagawa, Japan
| | - Chika Yajima
- Department of Respiratory Medicine, Tokyo Rinkai Hospital, Tokyo, Japan
| | - Yukio Hosomi
- Department of Thoracic Oncology and Respiratory Medicine, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Takashi Hirose
- Department of Pulmonary Medicine and Oncology, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Yuji Minegishi
- Department of Respiratory Medicine, Mitsui Memorial Hospital, Tokyo, Japan
| | - Tetsuya Okano
- Respiratory Disease Center, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Koichiro Kamio
- Department of Pulmonary Medicine, Nippon Medical School Musashikosugi Hospital, Kanagawa, Japan
| | | | - Masahiro Seike
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan.
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Kübler J, Wester-Ebbinghaus M, Wenz F, Stieler F, Bathen B, Mai SK, Wolff R, Hänggi D, Blanck O, Giordano FA. Postoperative stereotactic radiosurgery and hypofractionated radiotherapy for brain metastases using Gamma Knife and CyberKnife: a dual-center analysis. J Neurosurg Sci 2024; 68:22-30. [PMID: 32031357 DOI: 10.23736/s0390-5616.20.04830-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
BACKGROUND Postoperative stereotactic radiosurgery (SRS) and hypofractionated stereotactic radiotherapy (hFSRT) to tumor cavities is emerging as a new standard of care after resection of brain metastases. Both Gamma Knife (GK) and CyberKnife (CK) are modalities commonly used for stereotactic radiotherapy, but fractional schemes are not consistent. The objective of this study was to evaluate outcomes in patients receiving postoperative stereotactic radiotherapy of resected brain metastases (BM) using different fractionation schedules and modalities in two large centers. METHODS Patients with newly diagnosed BM who underwent postoperative SRS or hFSRT with either GK or CK at two large cancer centers were retrospectively evaluated. We analyzed local control (LC), regional control (RC) and overall survival (OS). RESULTS From April 14th to May 18th, 2020, 79 patients with 81 resection cavities were treated. Forty-seven patients (59.5%) received GK and 32 patients (40.5%) received CK treatment. Fifty-four cavities (66.7%) were treated with hFSRT and 27 (33.3%) with SRS. The most common hFSRT and SRS scheme was 3x10 Gy and 1x16 Gy, respectively. Median OS was 11.7 months with survival rates of 44.7% at 1 year and 18.5% at 2 years. LC was 83.3% after 1 year. Median time to regional progression was 12.0 months with RC rates of 61.1% at 6 months and 41.0% at 12 months. There was no difference in OS, LC or RC between GK and CK treatments or SRS and hFSRT. CONCLUSIONS Both SRS and hFSRT provide high local control rates in resected BM regardless of the applied modality.
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Affiliation(s)
- Jens Kübler
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Michael Wester-Ebbinghaus
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Florian Stieler
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Bastian Bathen
- Saphir Radiosurgery Center Frankfurt, Frankfurt am Main, Germany
- Department of Radiation Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Sabine K Mai
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Robert Wolff
- Saphir Radiosurgery Center Frankfurt, Frankfurt am Main, Germany
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Oliver Blanck
- Saphir Radiosurgery Center Frankfurt, Frankfurt am Main, Germany
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany -
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Mallikarjun KS, Eldaya RW, Miller-Thomas MM, Orlowski HL, Parsons MS. Good Gone Bad: Complications of Chemotherapy, Immunotherapy, and Radiotherapy on the CNS. Curr Probl Diagn Radiol 2024; 53:133-149. [PMID: 37495483 DOI: 10.1067/j.cpradiol.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/24/2023] [Accepted: 06/28/2023] [Indexed: 07/28/2023]
Abstract
With recent advancements in cancer therapy, especially immunotherapy, overall survival of many cancers has increased and patient toxicity has been reduced. However, many complications of traditional cancer therapy are still prevalent and complications of novel therapies are just beginning to appear. The neuroradiologist may be the first to visualize signs of these complications on imaging. This article describes the notable imaging findings of several unique and characteristic complications of CNS cancer therapy, including toxicities of chemotherapies, immunotherapies, and radiotherapy. Complications of chemotherapeutic agents covered include methotrexate-induced and disseminated necrotizing leukoencephalopathy, and chemotherapy-induced myelopathy. Immunotherapy complications included are Tacrolimus-related Optic Neuropathy, Rituximab and Immune reconstitution inflammatory syndrome-associated Progressive Multifocal Leukoencephalopathy, Bevacizumab-associated late radiation-induced neurotoxicity, and Ipilimumab-induced hypophysitis. Lastly, radiation-induced neurotoxicities are covered, including myelopathy, radiation necrosis, cerebral atrophy, leukoencephalopathy, optic neuropathy, mineralizing microangiopathy, stroke-like migraine attacks, osteonecrosis, and vasculopathies. Neuroradiologists will increasingly encounter patients who have undergone treatment with more than 1 therapeutic modality, resulting in overlapping findings as well. Recognition of the common complications of these therapies on imaging is critical to minimizing the effects of these potential short- and long-term complications.
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Kuntz L, Le Fèvre C, Jarnet D, Keller A, Meyer P, Thiery A, Cebula H, Noel G, Antoni D. Acute toxicities and cumulative dose to the brain of repeated sessions of stereotactic radiotherapy (SRT) for brain metastases: a retrospective study of 184 patients. Radiat Oncol 2023; 18:7. [PMID: 36627646 PMCID: PMC9830690 DOI: 10.1186/s13014-022-02194-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 12/28/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Stereotactic radiation therapy (SRT) is a focal treatment for brain metastases (BMs); thus, 20 to 40% of patients will require salvage treatment after an initial SRT session, either because of local or distant failure. SRT is not exempt from acute toxicity, and the acute toxicities of repeated SRT are not well known. The objective of this study was to analyze the acute toxicities of repeated courses of SRT and to determine whether repeated SRT could lead to cumulative brain doses equivalent to those of whole-brain radiotherapy (WBRT). MATERIAL AND METHODS Between 2010 and 2020, data from 184 patients treated for 915 BMs via two to six SRT sessions for local or distant BM recurrence without previous or intercurrent WBRT were retrospectively reviewed. Patients were seen via consultations during SRT, and the delivered dose, the use of corticosteroid therapy and neurological symptoms were recorded and rated according to the CTCAEv4. The dosimetric characteristics of 79% of BMs were collected, and summation plans of 76.6% of BMs were created. RESULTS 36% of patients developed acute toxicity during at least one session. No grade three or four toxicity was registered, and grade one or two cephalalgy was the most frequently reported symptom. There was no significant difference in the occurrence of acute toxicity between consecutive SRT sessions. In the multivariate analysis, acute toxicity was associated with the use of corticosteroid therapy before irradiation (OR = 2.6; p = 0.01), BMV grade (high vs. low grade OR = 5.17; p = 0.02), and number of SRT sessions (3 SRT vs. 2 SRT: OR = 2.64; p = 0.01). The median volume equivalent to the WBRT dose (VWBRT) was 47.9 ml. In the multivariate analysis, the VWBRT was significantly associated with the total GTV (p < 0.001) and number of BMs (p < 0.001). Even for patients treated for more than ten cumulated BMs, the median BED to the brain was very low compared to the dose delivered during WBRT. CONCLUSION Repeated SRT for local or distant recurrent BM is well tolerated, without grade three or four toxicity, and does not cause more acute neurological toxicity with repeated SRT sessions. Moreover, even for patients treated for more than ten BMs, the VWBRT is low.
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Affiliation(s)
- L. Kuntz
- grid.512000.6Radiation Therapy University Department, Institut de Cancérologie Strasbourg Europe (ICANS), 17 rue Albert Calmette, 67200 Strasbourg, France
| | - C. Le Fèvre
- grid.512000.6Radiation Therapy University Department, Institut de Cancérologie Strasbourg Europe (ICANS), 17 rue Albert Calmette, 67200 Strasbourg, France
| | - D. Jarnet
- grid.512000.6Medical Physics Unit, Institut de Cancérologie Strasbourg Europe (ICANS), 17 rue Albert Calmette, 67200 Strasbourg, France
| | - A. Keller
- grid.512000.6Radiation Therapy University Department, Institut de Cancérologie Strasbourg Europe (ICANS), 17 rue Albert Calmette, 67200 Strasbourg, France
| | - P. Meyer
- grid.512000.6Medical Physics Unit, Institut de Cancérologie Strasbourg Europe (ICANS), 17 rue Albert Calmette, 67200 Strasbourg, France
| | - A. Thiery
- grid.512000.6Medical Information Department, Institut de Cancérologie Strasbourg Europe (ICANS), 3 rue de la Porte de L’Hôpital, 67065 Strasbourg Cedex, France
| | - H. Cebula
- grid.412220.70000 0001 2177 138XDepartment of Neurosurgery, University Hospitals of Strasbourg, 1 Avenue Molière, 67200 Strasbourg, France
| | - G. Noel
- grid.512000.6Radiation Therapy University Department, Institut de Cancérologie Strasbourg Europe (ICANS), 17 rue Albert Calmette, 67200 Strasbourg, France
| | - D. Antoni
- grid.512000.6Radiation Therapy University Department, Institut de Cancérologie Strasbourg Europe (ICANS), 17 rue Albert Calmette, 67200 Strasbourg, France
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Liu CW, Yang HC, Chiang CL, Shen CI, Wu HM, Luo YH, Hu YS, Lin CJ, Chung WY, Shiau CY, Guo WY, Pan DHC, Lee CC. Leukoencephalopathy in patients with brain metastases who received radiosurgery with or without whole brain radiotherapy. J Neurooncol 2023; 161:85-95. [PMID: 36544061 DOI: 10.1007/s11060-022-04210-5] [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: 08/21/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Whole brain radiation therapy (WBRT) for brain metastases (BMs) is a common cause of radiation-induced leukoencephalopathy; however the safety of alternative stereotactic radiosurgery (SRS) remains unclear. This study examined the incidence of leukoencephalopathy in patients treated with SRS alone versus WBRT plus SRS for BMs with a focus on the relationship between prognostic factors and leukoencephalopathy. METHODS Analysis was performed between 2002 and 2021. The total enrollment was 993 patients with the distribution: WBRT plus SRS (n = 291) and SRS only (n = 702). Leukoencephalopathy was graded from 0 to 3 for changes in white matter indicated by the MRI after WBRT or SRS. Patient characteristics and SRS dosimetric parameters were reviewed to identify factors that contributed to the incidence of leukoencephalopathy or overall survival. RESULTS The incidence of leukoencephalopathy was consistently higher in WBRT plus SRS group than in SRS alone group (p < 0.001). Leukoencephalopathy was also associated with a larger total tumor volume (≧28cm3; p = 0.028) and age (> 77 years; p = 0.025). Nonetheless, the SRS integral dose to skull in the subgroup of WBRT plus SRS treatment was not demonstrated significance in development of leukoencephalopathy (p = 0.986 for integral dose 1-2 J, p = 0.776 for integral dose > 2 J). CONCLUSIONS This study revealed that SRS is safe for oligo-BMs in terms of leukoencephalopathy development. Patient age and total tumor volume were identified as important factors in assessing the development of leukoencephalopathy. The additional of SRS (even at an integral dose > 2 J) did not increase the incidence of leukoencephalopathy.
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Affiliation(s)
- Chan-Wei Liu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chi-Lu Chiang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-I Shen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yung-Hung Luo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yong-Sin Hu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Ying Shiau
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan.,Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, 17F, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan. .,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan. .,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Chiou GY, Chiang CL, Yang HC, Shen CI, Wu HM, Chen YW, Chen CJ, Luo YH, Hu YS, Lin CJ, Chung WY, Shiau CY, Guo WY, Pan DHC, Lee CC. Combined stereotactic radiosurgery and tyrosine kinase inhibitor therapy versus tyrosine kinase inhibitor therapy alone for the treatment of non-small cell lung cancer patients with brain metastases. J Neurosurg 2022; 137:563-570. [PMID: 34920439 DOI: 10.3171/2021.9.jns211373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/23/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Whether combined radiation and tyrosine kinase inhibitor (TKI) therapy in non-small cell lung cancer (NSCLC) patients with brain metastases (BMs) and epidermal growth factor receptor (EGFR) mutations confers additional benefits over TKI therapy alone remains a matter of debate. The goal of this study was to compare outcomes between combined TKI therapy with stereotactic radiosurgery (SRS) versus TKI therapy alone in NSCLC patients with BMs and EGFR mutations. METHODS Consecutive cases of NSCLC patients with EGFR mutations and BMs treated with TKIs were selected for inclusion in this study. Patients were categorized into two groups based on SRS: TKI therapy alone (group I) and combined SRS and TKI therapy (group II). Patients who had SRS or TKI as salvage therapy and those with prior radiation treatment for BMs were excluded. Tumor control (< 10% increase in tumor volume) and overall survival (OS) rates were compared using Kaplan-Meier analyses. Independent predictors of tumor control and OS were identified using multivariable Cox regression analyses. RESULTS The study cohort comprised 280 patients (n = 90 in group I and n = 190 in group II). Cumulative tumor control rates were higher in group II than in group I (79.8% vs 31.2% at 36 months, p < 0.0001). Cumulative OS rates were comparable between groups I and II (43.8% vs 59.4% at 36 months, p = 0.3203). Independent predictors of tumor control were older age (p < 0.01, HR 1.03), fewer BMs (p < 0.01, HR 1.09), lack of extracranial metastasis (p < 0.02, HR 0.70), and combined SRS and TKI therapy (p < 0.01, HR 0.25). Independent predictors of OS were fewer BMs (p < 0.01, HR 1.04) and a higher Karnofsky Performance Status score (p < 0.01, HR 0.97). CONCLUSIONS Although the OS rate did not differ between TKI therapy with and without SRS, the addition of SRS to TKI therapy resulted in improvement of intracranial tumor control. The lack of effect on survival rate with the addition of SRS may be attributable to extracranial disease progression. The addition of SRS to TKI therapy is recommended for intracranial disease control in NSCLC patients with BMs and EGFR mutations. Potential benefits may include prevention of neurological deficits and seizures. Future prospective studies may help clarify the clinical outcome benefits of SRS in these patients.
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Affiliation(s)
- Guan-Ying Chiou
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
| | - Chi-Lu Chiang
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 5Department of Chest Medicine, Taipei Veterans General Hospital, Taipei
- 8Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; and
| | - Huai-Che Yang
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Chia-I Shen
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 5Department of Chest Medicine, Taipei Veterans General Hospital, Taipei
- 8Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; and
| | - Hsiu-Mei Wu
- 2Department of Radiology, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Yu-Wei Chen
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
- 2Department of Radiology, Taipei Veterans General Hospital, Taipei
| | - Ching-Jen Chen
- 9Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Yung-Hung Luo
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 5Department of Chest Medicine, Taipei Veterans General Hospital, Taipei
- 8Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; and
| | - Yong-Sin Hu
- 2Department of Radiology, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Chung-Jung Lin
- 2Department of Radiology, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Wen-Yuh Chung
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Cheng-Ying Shiau
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 4Cancer Center, Taipei Veterans General Hospital, Taipei
| | - Wan-Yuo Guo
- 2Department of Radiology, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - David Hung-Chi Pan
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
- 7Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei
| | - Cheng-Chia Lee
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 6Brain Research Center, National Yang Ming Chiao Tung University, Taipei
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Clinical outcomes of patients with multiple courses of radiosurgery for brain metastases from non-small cell lung cancer. Sci Rep 2022; 12:10712. [PMID: 35739135 PMCID: PMC9226031 DOI: 10.1038/s41598-022-13853-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/30/2022] [Indexed: 11/18/2022] Open
Abstract
We investigated the long-term clinical outcomes of patients who underwent multiple courses (≥ 5) of gamma knife radiosurgery (GKRS) due to recurrent brain metastases (BM) from non-small cell lung cancer (NSCLC). Between December 2001 and July 2019, consecutive 2571 patients underwent GKRS for BM from NSCLC. Clinical and radiological outcomes were investigated in 76 patients who underwent GKRS ≥ 5 times. The median follow-up period after the diagnosis of NSCLC was 54.6 months (range 14.5–159.1 months). The median number of GKRS procedures per patient was six (range 5–15). Actuarial post-GKRS survival rates at 1, 2, 3, 4, and 5 years following initial GKRS were 88.1%, 79.5%, 65.3%, 51.4%, and 37.3%, respectively. No significant difference in overall survival was observed between patients (n = 22) with whole-brain radiotherapy (WBRT) and patients (n = 54) without WBRT (p = 0.076). The incidence of radiation-induced leukoencephalopathy was 64% and 18% in patients with and without WBRT, respectively (p < 0.0001). Multiple courses of SRS are a tolerable and effective treatment option for recurrent BM from NSCLC. Repeat SRS may be an alternative treatment option to avoid or delay WBRT.
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Memantine in the Prevention of Radiation-Induced Brain Damage: A Narrative Review. Cancers (Basel) 2022; 14:cancers14112736. [PMID: 35681716 PMCID: PMC9179311 DOI: 10.3390/cancers14112736] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/25/2022] [Accepted: 05/30/2022] [Indexed: 12/03/2022] Open
Abstract
Simple Summary Decline in cognitive function is a major problem for patients undergoing whole-brain radiotherapy (WBRT). Scientific interest has increased due to the high dropout rate of patients in the first months after WBRT and the early onset of cognitive decline. Therefore, the study of antiglutamatergic pharmacological prophylaxis and hippocampal-sparing WBRT techniques has been deepened based on the knowledge of the mechanisms of hyperglutamatergic neurotoxicity and the role of some hippocampal areas in cognitive decline. In order to provide a summary of the evidence in this field, and to foster future research in this setting, this literature review presents current evidence on the prevention of radiation-induced cognitive decline and particularly on the role of memantine. Abstract Preserving cognitive functions is a priority for most patients with brain metastases. Knowing the mechanisms of hyperglutamatergic neurotoxicity and the role of some hippocampal areas in cognitive decline (CD) led to testing both the antiglutamatergic pharmacological prophylaxis and hippocampal-sparing whole-brain radiotherapy (WBRT) techniques. These studies showed a relative reduction in CD four to six months after WBRT. However, the failure to achieve statistical significance in one study that tested memantine alone (RTOG 0614) led to widespread skepticism about this drug in the WBRT setting. Moreover, interest grew in the reasons for the strong patient dropout rates in the first few months after WBRT and for early CD onset. In fact, the latter can only partially be explained by subclinical tumor progression. An emerging interpretation of the (not only) cognitive impairment during and immediately after WBRT is the dysfunction of the limbic and hypothalamic system with its immune and hormonal consequences. This new understanding of WBRT-induced toxicity may represent the basis for further innovative trials. These studies should aim to: (i) evaluate in greater detail the cognitive effects and, more generally, the quality of life impairment during and immediately after WBRT; (ii) study the mechanisms producing these early effects; (iii) test in clinical studies, the modern and advanced WBRT techniques based on both hippocampal-sparing and hypothalamic-pituitary-sparing, currently evaluated only in planning studies; (iv) test new timings of antiglutamatergic drugs administration aimed at preventing not only late toxicity but also acute effects.
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Ramos A, Giantini-Larsen A, Pannullo SC, Brandmaier A, Knisely J, Magge R, Wilcox JA, Pavlick AC, Ma B, Pisapia D, Ashamalla H, Ramakrishna R. A multidisciplinary management algorithm for brain metastases. Neurooncol Adv 2022; 4:vdac176. [PMID: 36532509 PMCID: PMC9749403 DOI: 10.1093/noajnl/vdac176] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
The incidence of brain metastases continues to present a management issue despite the advent of improved systemic control and overall survival. While the management of oligometastatic disease (ie, 1-4 brain metastases) with surgery and radiation has become fairly straightforward in the era of radiosurgery, the management of patients with multiple metastatic brain lesions can be challenging. Here we review the available evidence and provide a multidisciplinary management algorithm for brain metastases that incorporates the latest advances in surgery, radiation therapy, and systemic therapy while taking into account the latest in precision medicine-guided therapies. In particular, we argue that whole-brain radiation therapy can likely be omitted in most patients as up-front therapy.
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Affiliation(s)
- Alexander Ramos
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Alexandra Giantini-Larsen
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Susan C Pannullo
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Andrew Brandmaier
- Department of Radiation Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Jonathan Knisely
- Department of Radiation Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Rajiv Magge
- Department of Neurology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Jessica A Wilcox
- Department of Neurology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anna C Pavlick
- Department of Oncology, Weill Cornell Medicine, New York Presbyterian, New York, New York, USA
| | - Barbara Ma
- Department of Oncology, Weill Cornell Medicine, New York Presbyterian, New York, New York, USA
| | - David Pisapia
- Department of Pathology, Weill Cornell Medicine, New York Presbyterian, New York, New York, USA
| | - Hani Ashamalla
- Department of Neurology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Rohan Ramakrishna
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
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10
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Outcomes in Patients With 4 to 10 Brain Metastases Treated With Dose-Adapted Single-Isocenter Multitarget Stereotactic Radiosurgery: A Prospective Study. Adv Radiat Oncol 2021; 6:100760. [PMID: 34934856 PMCID: PMC8655418 DOI: 10.1016/j.adro.2021.100760] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/13/2021] [Indexed: 12/20/2022] Open
Abstract
Purpose To examine the effectiveness and safety of single-isocenter multitarget stereotactic radiosurgery using a volume-adapted dosing strategy in patients with 4 to 10 brain metastases. Methods and Materials Adult patients with 4 to 10 brain metastases were eligible for this prospective trial. The primary endpoint was overall survival. Secondary endpoints were local recurrence, distant brain failure, neurologic death, and rate of adverse events. Exploratory objectives were neurocognition, quality of life, dosimetric data, salvage rate, and radionecrosis. Dose was prescribed in a single fraction per RTOG 90-05 or as 5 Gy × 5 fractions for lesions ≥3 cm diameter, lesions involving critical structures, or single-fraction brain V12Gy >20 mL. Results Forty patients were treated with median age of 61 years, Karnofsky performance status 90, and 6 brain metastases. Twenty-two patients survived longer than expected from the time of protocol SRS, with 1 living patient who has not reached that milestone. Median overall survival was 8.1 months with a 1-year overall survival of 35.7%. The 1-year local recurrence rate was 5% (10 of 204 of evaluable lesions) in 12.5% (4 of 32) of the patients. Distant brain failure was observed in 19 of 32 patients with a 1-year rate of 35.8%. Grade 1-2 headache was the most common complaint, with no grade 3-5 treatment-related adverse events. Radionecrosis was observed in only 5 lesions, with a 1-year rate of 1.5%. Rate of neurologic death was 20%. Neurocognition and quality of life did not significantly change 3 months after SRS compared with pretreatment. Conclusions These results suggest that volume-adapted dosing single-isocenter multitarget stereotactic radiosurgery is an effective and safe treatment for patients with 4 to 10 brain metastases.
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11
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Beltaifa Y, Hamdi H, Spatola G, Balossier A, Merly L, Castillo L, Cretol A, Regis J. Is Real-Time Inverse Planning Optimizing Dose to the Normal Brain? A Prospective Comparative Trial in a Series of Brain Metastases Treated by Stereotactic Radiosurgery. Stereotact Funct Neurosurg 2021; 100:53-60. [PMID: 34818656 DOI: 10.1159/000519024] [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: 02/02/2021] [Accepted: 08/12/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Radiosurgery has demonstrated good safety and efficacy in the treatment of multiple brain metastases (BMs). However, multi-target dose planning can be challenging and time-consuming. A recently developed real-time inverse treatment planning (IP) by convex optimization has been demonstrated to produce high-quality treatment plans with good conformity and selectivity in single-target plans. We intended to test the capacity of this IP to rapidly generate efficient plans while optimizing the preservation of normal tissue in multiple BM. METHODS Seventy-nine patients (mean age 62.4, age range 22-85) with a total of 272 BMs were treated by Gamma Knife Radiosurgery. All subjects were treated using a forward planning (FP) technique by an expert neurosurgeon. The new Intuitive Plan was applied and able to automatically generate an alternative plan for each patient. All planning variables were collected from the IP to be compared with the corresponding measurements obtained from the FP. A paired sample t test was applied to compare the 2 plans for the following variables: brain volumes receiving 10 Gy (V10) (primary endpoint), and 12 Gy (V12), planning indices (selectivity, coverage, gradient, and Paddick Conformity Index [PCI]), beam-on time (BOT), and integral doses. Additionally, the noninferiority margin for each item was calculated, and the 2 plans were compared for noninferiority using a paired t test. RESULTS The mean age of patients was 62.4 years old (age range 22-85), with a sex ratio of 1.02. The average number of lesions per patient was 3.4 (range 1-12). The mean prescription dose was 21.46 Gy (range 14-24 Gy). Noninferiority of the IP was concluded for V10, V12, prescription isodose volume, BOT, PCI, and selectivity. The V10 (and V12) was significantly lower with the IP (p < 0.001). These volumes were 8.69 cm3 ± 11.39 and 5.47 cm3 ± 7.03, respectively, for the FP and 7.57 cm3 ± 9.44 and 4.78 cm3 ± 5.86 for the IP. Only the coverage was significantly lower with the IP (-2.3%, p < 0.001), but both selectivity (+17%) and PCI (+15%) were significantly higher with the IP than FP (p < 0.001). CONCLUSION This IP demonstrated its capacity to generate multi-target plans rapidly, with a dose to the brain (V10) and BOT noninferior to the one of a human expert planner. These results would benefit from confirmation in a larger prospective series.
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Affiliation(s)
- Yassine Beltaifa
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix Marseille Université, Marseille, France.,Inserm, L'Institut de Neurosciences des Systèmes (INS, UMR1106), Aix Marseille Université, Marseille, France.,Faculty of Medicine, University of Sousse, Sousse, Tunisia
| | - Hussein Hamdi
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix Marseille Université, Marseille, France.,Inserm, L'Institut de Neurosciences des Systèmes (INS, UMR1106), Aix Marseille Université, Marseille, France.,Neurosurgery Department, Tanta University, Tanta, Egypt
| | - Giorgio Spatola
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix Marseille Université, Marseille, France.,Inserm, L'Institut de Neurosciences des Systèmes (INS, UMR1106), Aix Marseille Université, Marseille, France
| | - Anne Balossier
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix Marseille Université, Marseille, France.,Inserm, L'Institut de Neurosciences des Systèmes (INS, UMR1106), Aix Marseille Université, Marseille, France
| | - Louise Merly
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix Marseille Université, Marseille, France
| | - Laura Castillo
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix Marseille Université, Marseille, France
| | - Axelle Cretol
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix Marseille Université, Marseille, France
| | - Jean Regis
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix Marseille Université, Marseille, France.,Inserm, L'Institut de Neurosciences des Systèmes (INS, UMR1106), Aix Marseille Université, Marseille, France
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12
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Tan AP, Yeo TT, Yong HRC, Karlsson B. Dynamic radiation-induced imaging changes more than 20 years following gamma knife surgery. Acta Neurochir (Wien) 2021; 163:1935-1939. [PMID: 33999264 DOI: 10.1007/s00701-021-04865-5] [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: 08/15/2020] [Accepted: 04/22/2021] [Indexed: 11/28/2022]
Abstract
Gamma knife radiosurgery (GKS), a technique which involves delivery of a high dose of radiation to a precisely defined target, has become the predominant treatment option for brain metastases (BM) because of its high effectiveness and relatively minimal toxicity. Herein, we report a case of late-onset radiation-induced edema around an asymptomatic cyst, more than 20 years after salvage GKS, with 27 years of imaging follow-up, allowing the description of the evolutionary trajectory of these relatively rare complications. Our reported case also demonstrated the benign nature of delayed cyst formation (DCF), emphasizing that observation alone is reasonable for asymptomatic patients.
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Affiliation(s)
- Ai Peng Tan
- Department of Diagnostic Imaging, National University Hospital, 1E Kent Ridge Rd, Singapore, 119228, Singapore.
- Singapore Institute for Clinical Sciences (SICS), A*STAR Research Entities (ARES), 30 Medical Dr, Singapore, 117609, Singapore.
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), 21 Lower Kent Ridge Road, Singapore, 119077, Singapore.
| | - Tseng Tsai Yeo
- Division of Neurosurgery, Department of Surgery, National University Hospital, 1E Kent Ridge Rd, Singapore, 119228, Singapore
| | - Hsiang Rong Clement Yong
- Department of Diagnostic Imaging, National University Hospital, 1E Kent Ridge Rd, Singapore, 119228, Singapore
| | - Bengt Karlsson
- Division of Neurosurgery, Department of Surgery, National University Hospital, 1E Kent Ridge Rd, Singapore, 119228, Singapore
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13
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Carr CM, Benson JC, DeLone DR, Diehn FE, Kim DK, Merrell KW, Nagelschneider AA, Madhavan AA, Johnson DR. Intracranial long-term complications of radiation therapy: an image-based review. Neuroradiology 2021; 63:471-482. [PMID: 33392738 DOI: 10.1007/s00234-020-02621-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/08/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Radiation therapy is commonly utilized in the majority of solid cancers and many hematologic malignancies and other disorders. While it has an undeniably major role in improving cancer survival, radiation therapy has long been recognized to have various negative effects, ranging from mild to severe. In this manuscript, we review several intracranial manifestations of therapeutic radiation, with particular attention to those that may be encountered by radiologists. METHODS We conducted an extensive literature review of known complications of intracranial radiation therapy. Based on this review, we selected complications that had salient, recognizable imaging findings. We searched our imaging database for illustrative examples of these complications, focusing only on patients who had a history of intracranial radiation therapy. We then selected cases that best exemplified expected imaging findings in these entities. RESULTS Based on our initial literature search and imaging database review, we selected cases of radiation-induced meningioma, radiation-induced glioma, cavernous malformation, enlarging perivascular spaces, leukoencephalopathy, stroke-like migraine after radiation therapy, Moyamoya syndrome, radiation necrosis, radiation-induced labyrinthitis, optic neuropathy, and retinopathy. Although retinopathy is not typically apparent on imaging, it has been included given its clinical overlap with optic neuropathy. CONCLUSIONS We describe the clinical and imaging features of selected sequelae of intracranial radiation therapy, with a focus on those most relevant to practicing radiologists. Knowledge of these complications and their imaging findings is important, because radiologists play a key role in early detection of these entities.
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Affiliation(s)
- Carrie M Carr
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - John C Benson
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David R DeLone
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Felix E Diehn
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Dong Kun Kim
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Alex A Nagelschneider
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ajay A Madhavan
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Derek R Johnson
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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14
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Neurologic Complications of Cranial Radiation Therapy and Strategies to Prevent or Reduce Radiation Toxicity. Curr Neurol Neurosci Rep 2020; 20:34. [DOI: 10.1007/s11910-020-01051-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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15
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Bowden GN, Kim JO, Faramand A, Fallon K, Flickinger J, Lunsford LD. Clinical dose profile of Gamma Knife stereotactic radiosurgery for extensive brain metastases. J Neurosurg 2020; 134:1430-1434. [PMID: 32384280 DOI: 10.3171/2020.3.jns193369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The use of Gamma Knife stereotactic radiosurgery (GKSRS) for the treatment of extensive intracranial metastases has been expanding due to its superior dosimetry and efficacy. However, there remains a dearth of data regarding the dose parameters in actual clinical scenarios. The authors endeavored to calculate the radiation dose to the brain when treating ≥ 15 brain metastases with GKSRS. METHODS This retrospective analysis reviewed dosage characteristics for patients requiring single-session GKSRS for the treatment of ≥ 15 brain metastases. Forty-two patients met the inclusion criteria between 2008 and 2017. The median number of tumors at the initial GKSRS procedure was 20 (range 15-39 tumors), accounting for 865 tumors in this study. The median aggregate tumor volume was 3.1 cm3 (range 0.13-13.26 cm3), and the median marginal dose was 16 Gy (range 14-19 Gy). RESULTS The median of the mean brain dose was 2.58 Gy (range 0.95-3.67 Gy), and 79% of patients had a dose < 3 Gy. The 12-Gy dose volume was a median of 12.45 cm3, which was equivalent to 0.9% of the brain volume. The median percentages of brain receiving 5 Gy and 3 Gy were 6.7% and 20.4%, respectively. There was no correlation between the number of metastases and the mean dose to the brain (p = 0.8). A greater tumor volume was significantly associated with an increased mean brain dose (p < 0.001). The median of the mean dose to the bilateral hippocampi was 2.3 Gy. Sixteen patients had supplementary GKSRS, resulting in an additional mean dose of 1.4 Gy (range 0.2-3.8 Gy) to the brain. CONCLUSIONS GKSRS is a viable means of managing extensive brain metastases. This procedure provides a relatively low dose of radiation to the brain, especially when compared with traditional whole-brain radiation protocols.
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Affiliation(s)
- Gregory Neil Bowden
- 1Department of Neurological Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Jong Oh Kim
- Departments of2Radiation Oncology (Medical Physics) and
| | - Andrew Faramand
- 3Neurological Surgery and the Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania; and
| | - Kevin Fallon
- 4Department of Radiation Oncology (Medical Physics), Medical University of South Carolina, Charleston, South Carolina
| | | | - L Dade Lunsford
- 3Neurological Surgery and the Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania; and
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16
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Nakazaki K, Yomo S, Kondoh T, Serizawa T, Kenai H, Kawagishi J, Sato S, Nagano O, Aiyama H, Kawai H, Hasegawa T, Iwai Y, Nagatomo Y, Kida Y, Nishigaki M. Salvage gamma knife radiosurgery for active brain metastases from small-cell lung cancer after whole-brain radiation therapy: a retrospective multi-institutional study (JLGK1701). J Neurooncol 2020; 147:67-76. [PMID: 31933257 DOI: 10.1007/s11060-020-03397-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 01/08/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the efficacy of gamma knife radiosurgery (GKS) for brain metastases (BMs) from small-cell lung cancer after whole-brain radiotherapy (WBRT). METHODS We retrospectively analyzed the usefulness and safety of GKS in 163 patients from 15 institutions with 1-10 active BMs after WBRT. The usefulness and safety of GKS were evaluated using statistical methods. RESULTS The median age was 66 years, and 79.1% of patients were men. The median number and largest diameter of BM were 2.0 and 1.4 cm, respectively. WBRT was administered prophylactically in 46.6% of patients. The median overall survival (OS) was 9.3 months, and the neurologic mortality was 20.0%. Crude incidences of local control failure and new lesion appearance were 36.6% and 64.9%, respectively. A BM diameter ≥ 1.0 cm was a significant risk factor for local progression (hazard ratio [HR] 2.556, P = 0.039) and neurologic death (HR 4.940, P = 0.031). Leukoencephalopathy at the final follow-up was more prevalent in the therapeutic WBRT group than in the prophylactic group (P = 0.019). The symptom improvement rate was 61.3%, and neurological function was preserved for a median of 7.6 months. Therapeutic WBRT was not a significant risk factor for OS, neurological death, local control, or functional deterioration (P = 0.273, 0.490, 0.779, and 0.560, respectively). Symptomatic radiation-related adverse effects occurred in 7.4% of patients. CONCLUSIONS GKS can safely preserve neurological function and prevent neurologic death in patients with 1-10 small, active BMs after prophylactic and therapeutic WBRT.
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Affiliation(s)
- Kiyoshi Nakazaki
- Department of Neurosurgery, Brain Attack Center Ota Memorial Hospital, 3-6-28 Okinogami, Fukuyama, Hiroshima, 7200825, Japan.
| | - Shoji Yomo
- Department of Neurosurgery, Aizawa Hospital, Matsumoto, Nagano, Japan
| | - Takeshi Kondoh
- Department of Neurosurgery, Shinsuma General Hospital, Kobe, Hyogo, Japan
| | - Toru Serizawa
- Tokyo Gamma Unit Center, Tsukiji Neurological Clinic, Tokyo, Japan
| | - Hiroyuki Kenai
- Department of Neurosurgery, Nagatomi Neurosurgical Hospital, Oita, Japan
| | - Jun Kawagishi
- Jiro Suzuki Memorial GammaHouse, Furukawa Seiryo Hospital, Osaki, Miyagi, Japan
| | - Sonomi Sato
- Department of Neurosurgery, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital, Koriyama, Fukushima, Japan
| | - Osamu Nagano
- Gamma Knife House, Chiba Cerebral and Cardiovascular Center, Ichihara, Chiba, Japan
| | - Hitoshi Aiyama
- Katsuta Hospital Mito GammaHouse, Hitachi-naka, Ibaraki, Japan
| | - Hideya Kawai
- Department of Neurosurgery, Research Institute for Brain and Blood-Vessels-Akita, Akita, Japan
| | | | - Yoshiyasu Iwai
- Department of Neurosurgery, Osaka City General Hospital, Osaka, Japan
| | - Yasushi Nagatomo
- Department of Neurosurgery, Kouseikai Takai Hospital, Tenri, Nara, Japan
| | - Yoshihisa Kida
- Department of Neurosurgery, Ookuma Hospital, Nagoya, Japan
| | - Masakazu Nishigaki
- Department of Human Health Sciences, School of Medicine, Kyoto University, Kyoto, Japan
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17
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Shrivastava A, Mohammed N, Hung YC, Xu Z, Schlesinger D, Heinrichs T, Kearns K, Li CE, Lavezzo K, Narayan A, Sheehan JP. Impact of Integral Dose on the Maintenance of Pain Relief in Patients with Idiopathic Trigeminal Neuralgia Treated with Upfront Gamma Knife Radiosurgery. World Neurosurg 2019; 129:e375-e380. [PMID: 31132503 DOI: 10.1016/j.wneu.2019.05.155] [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: 04/24/2019] [Revised: 05/16/2019] [Accepted: 05/17/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Integral dose (ID) defined as the product of mean dose and target volume, is a measure of the absorbed radiation energy. OBJECTIVE To evaluate the effect of ID on the duration of pain relief after primary Gamma knife stereotactic radiosurgery (GKSRS) in trigeminal neuralgia. PATIENTS AND METHODS A total of 78 patients who achieved initial pain response of I-III on the Barrow Neurological Institute Pain Scale (BNI-PS) following primary GKSRS for idiopathic trigeminal neuralgia were included in this study. A Cox regression model was used to compute the prognostic factor with respect to the ID within the 50% isodose line. Facial pain relief maintenance interval was defined as time interval between the day of improved BNI-PS grade and pain level back to the BNI-PS IV or V. The median duration of follow-up was 42 months (range 6-108 months). RESULTS After the initial GKSRS, patients achieved pain relief at a median of 0.5 months (range, 7 days to 6 months); 28 patients developed recurrence of pain. There was a positive correlation between the pain relief maintenance and increasing ID within 50% isodose line (hazard ratio 1.85, P = 0.04) on multivariable Cox-regression analysis. Using logistic regression analysis, we found that ID was not predictive of developing post-stereotactic radiosurgery hypoesthesia (P = 0.64, hazard ratio 1.057). CONCLUSIONS Stereotactic radiosurgery can be individualized based on trigeminal nerve morphology to achieve durable pain relief in patients with trigeminal neuralgia. ID calculation aids in planning an optimal radiation dose based on the nerve morphology to provide durable pain relief of idiopathic trigeminal neuralgia.
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Affiliation(s)
- Adesh Shrivastava
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Nasser Mohammed
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA.
| | - Yi-Chieh Hung
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - David Schlesinger
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Trevor Heinrichs
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Kathryn Kearns
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Chelsea E Li
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Karen Lavezzo
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Aditya Narayan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
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18
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Dutta SW, Sheehan JP, Niranjan A, Lunsford LD, Trifiletti DM. Evolution in the role of stereotactic radiosurgery in patients with multiple brain metastases: An international survey. J Clin Neurosci 2018; 57:6-12. [DOI: 10.1016/j.jocn.2018.08.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 08/13/2018] [Indexed: 01/15/2023]
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19
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Marchan EM, Peterson J, Sio TT, Chaichana KL, Harrell AC, Ruiz-Garcia H, Mahajan A, Brown PD, Trifiletti DM. Postoperative Cavity Stereotactic Radiosurgery for Brain Metastases. Front Oncol 2018; 8:342. [PMID: 30234013 PMCID: PMC6127288 DOI: 10.3389/fonc.2018.00342] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 08/06/2018] [Indexed: 11/26/2022] Open
Abstract
During the past decade, tumor bed stereotactic radiosurgery (SRS) after surgical resection has been increasingly utilized in the management of brain metastases. SRS has risen as an alternative to adjuvant whole brain radiation therapy (WBRT), which has been shown in several studies to be associated with increased neurotoxicity. Multiple recent articles have shown favorable local control rates compared to those of WBRT. Specifically, improvements in local control can be achieved by adding a 2 mm margin around the resection cavity. Risk factors that have been established as increasing the risk of local recurrence after resection include: subtotal resection, larger treatment volume, lower margin dose, and a long delay between surgery and SRS (>3 weeks). Moreover, consensus among experts in the field have established the importance of (a) fusion of the pre-operative magnetic resonance imaging scan to aid in volume delineation (b) contouring the entire surgical tract and (c) expanding the target to include possible microscopic disease that may extend to meningeal or venous sinus territory. These strategies can minimize the risks of symptomatic radiation-induced injury and leptomeningeal dissemination after postoperative SRS. Emerging data has arisen suggesting that multifraction postoperative SRS, or alternatively, preoperative SRS could provide decreased rates of radiation necrosis and leptomeningeal disease. Future prospective randomized clinical trials comparing outcomes between these techniques are necessary in order to improve outcomes in these patients.
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Affiliation(s)
- Eduardo M Marchan
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Jennifer Peterson
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Kaisorn L Chaichana
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, United States
| | - Anna C Harrell
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States.,Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, United States
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Bragstad S, Flatebø M, Natvig GK, Eide GE, Skeie GO, Behbahani M, Pedersen PH, Enger PØ, Skeie BS. Predictors of quality of life and survival following Gamma Knife surgery for lung cancer brain metastases: a prospective study. J Neurosurg 2018; 129:71-83. [DOI: 10.3171/2017.2.jns161659] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVELung cancer (LC) patients who develop brain metastases (BMs) have a poor prognosis. Estimations of survival and risk of treatment-related deterioration in quality of life (QOL) are important when deciding on treatment. Although we know of several prognostic factors for LC patients with BMs, the role of QOL has not been established. Authors of this study set out to evaluate changes in QOL following Gamma Knife surgery (GKS) for BMs in LC patients and QOL as a prognostic factor for survival.METHODSForty-four of 48 consecutive LC patients with BMs underwent GKS in the period from May 2010 to September 2011, and their QOL was prospectively assessed before and 1, 3, 6, 9, and 12 months after GKS by using the Functional Assessment of Cancer Therapy–Brain (FACT-BR) questionnaire. A mixed linear regression model was used to identify potential predictive factors for QOL and to assess the effect of GKS and the disease course on QOL at follow-up.RESULTSMean QOL as measured by the brain cancer subscale (BRCS) of the FACT-BR remained stable from baseline (score 53.0) up to 12 months post-GKS (57.1; p = 0.624). The BRCS score improved for 32 patients (72.3%) with a total BM volume ≤ 5 cm3. Mean improvement in these patients was 0.45 points each month of follow-up, compared to a decline of 0.50 points each month despite GKS treatment in patients with BM volumes > 5 cm3 (p = 0.04). Asymptomatic BMs (p = 0.01), a lower recursive partitioning analysis (RPA) classification (p = 0.04), and a higher Karnofsky Performance Scale (KPS) score (p < 0.01) at baseline were predictors for a high, stable QOL after GKS. After multivariate analysis, a high KPS score (p < 0.01) remained the only positive predictor of a high, stable QOL post-GKS.Median survival post-GKS was 5.6 months (95% CI 1.0–10.3). A higher BRCS score (p = 0.01), higher KPS score (p = 0.01), female sex (p = 0.01), and the absence of liver (p = 0.02), adrenal (p = 0.02), and bone metastases (p = 0.03) predicted longer survival in unadjusted models. However, in multivariate analyses, a higher BRCS score (p < 0.01), female sex (p = 0.01), and the absence of bone metastases (p = 0.02) at GKS remained significant predictors. Finally, the BRCS score’s predictive value for survival was compared with the values for the variables behind well-known prognostic indices: age, KPS score, extracranial disease status, and number and volume of BMs. Both BRCS score (p = 0.01) and BM volume (p = 0.05) remained significant predictors for survival in the final model.CONCLUSIONSPatient-reported QOL according to the BRCS is a predictor of survival in patients with BMs and may be helpful in deciding on the optimal treatment. Gamma Knife surgery is a safe and effective therapeutic modality that improves QOL for LC patients with a BM volume ≤ 5 cm3 at treatment. Careful follow-up and salvage therapy on demand seem to prevent worsening of QOL due to relapse of BMs.
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Affiliation(s)
- Sidsel Bragstad
- Departments of 1Neurosurgery,
- 2Department of Global Public Health and Primary Care
| | | | | | - Geir Egil Eide
- 2Department of Global Public Health and Primary Care
- 4Centre for Clinical Research, Haukeland University Hospital
| | | | - Maziar Behbahani
- Departments of 1Neurosurgery,
- 6Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
| | | | - Per Øyvind Enger
- Departments of 1Neurosurgery,
- 8Oncomatrix, Institute of Biomedicine, University of Bergen; and
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21
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Bauer-Nilsen K, Trifiletti DM, Chatrath A, Ruiz-Garcia H, Marchan E, Peterson J, May BC, Sheehan JP. Stereotactic radiosurgery for brain metastases from malignant melanoma and the impact of hemorrhagic metastases. J Neurooncol 2018; 140:83-88. [PMID: 29926319 DOI: 10.1007/s11060-018-2933-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 06/14/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Stereotactic radiosurgery (SRS) is a common treatment modality among patients with brain metastases, particularly from malignant melanoma. Our objective was to investigate the difference in local control, toxicity, and survival among patients with hemorrhagic and solid melanoma brain metastases. METHODS We collected demographic, treatment, local control, toxicity, and survival for 134 patients with a total of 936 intracranial melanoma metastases who underwent SRS between 1998 and 2015. Pre-radiosurgical diagnostic imaging was reviewed for evidence of hemorrhage (melanin-containing or clearly hemorrhagic). RESULTS The cohort consisted of 92 men and 42 women with a mea age of 61.7 years (range 21.2-84.9) at the time of radiosurgery. Overall survival of patients with brain metastases from malignant melanoma was 42, 31, 12% at 12, 24, and 72 months from date of first SRS. At 6 months, 43% of the patients with hemorrhagic metastases had local tumor control compared to 83% of solid melanoma metastases (p < 0.001). No significant difference in toxicity was noted between the two groups. Factors that were significantly associated with time to local tumor progression on multivariate analysis include prior WBRT (HR 1.62, p = 0.003), prior chemotherapy (HR 0.69, p = 0.011), margin dose (HR 0.88, p < 0.001) and radiographic features of melanin deposition (HR 3.73, p < 0.001), or clear hemorrhage (HR 2.20, p < 0.001). CONCLUSIONS Our findings demonstrate that hemorrhagic intracranial melanoma metastases are associated with inferior local tumor control when treated with SRS, as compared to solid tumors. These results highlight the importance of early radiosurgery among patients with melanoma brain metastases before hemorrhage occurs.
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Affiliation(s)
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA. .,Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA.
| | - Ajay Chatrath
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA
| | - Eduardo Marchan
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA
| | - Jennifer Peterson
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA.,Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Byron C May
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA
| | - Jason P Sheehan
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA.,Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
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22
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Franchino F, Rudà R, Soffietti R. Mechanisms and Therapy for Cancer Metastasis to the Brain. Front Oncol 2018; 8:161. [PMID: 29881714 PMCID: PMC5976742 DOI: 10.3389/fonc.2018.00161] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/30/2018] [Indexed: 12/12/2022] Open
Abstract
Advances in chemotherapy and targeted therapies have improved survival in cancer patients with an increase of the incidence of newly diagnosed brain metastases (BMs). Intracranial metastases are symptomatic in 60–70% of patients. Magnetic resonance imaging (MRI) with gadolinium is more sensitive than computed tomography and advanced neuroimaging techniques have been increasingly used in the detection, treatment planning, and follow-up of BM. Apart from the morphological analysis, the most effective tool for characterizing BM is immunohistochemistry. Molecular alterations not always reflect those of the primary tumor. More sophisticated methods of tumor analysis detecting circulating biomarkers in fluids (liquid biopsy), including circulating DNA, circulating tumor cells, and extracellular vesicles, containing tumor DNA and macromolecules (microRNA), have shown promise regarding tumor treatment response and progression. The choice of therapeutic approaches is guided by prognostic scores (Recursive Partitioning Analysis and diagnostic-specific Graded Prognostic Assessment-DS-GPA). The survival benefit of surgical resection seems limited to the subgroup of patients with controlled systemic disease and good performance status. Leptomeningeal disease (LMD) can be a complication, especially in posterior fossa metastases undergoing a “piecemeal” resection. Radiosurgery of the resection cavity may offer comparable survival and local control as postoperative whole-brain radiotherapy (WBRT). WBRT alone is now the treatment of choice only for patients with single or multiple BMs not amenable to surgery or radiosurgery, or with poor prognostic factors. To reduce the neurocognitive sequelae of WBRT intensity modulated radiotherapy with hippocampal sparing, and pharmacological approaches (memantine and donepezil) have been investigated. In the last decade, a multitude of molecular abnormalities have been discovered. Approximately 33% of patients with non-small cell lung cancer (NSCLC) tumors and epidermal growth factor receptor mutations develop BMs, which are targetable with different generations of tyrosine kinase inhibitors (TKIs: gefitinib, erlotinib, afatinib, icotinib, and osimertinib). Other “druggable” alterations seen in up to 5% of NSCLC patients are the rearrangements of the “anaplastic lymphoma kinase” gene TKI (crizotinib, ceritinib, alectinib, brigatinib, and lorlatinib). In human epidermal growth factor receptor 2-positive, breast cancer targeted therapies have been widely used (trastuzumab, trastuzumab-emtansine, lapatinib-capecitabine, and neratinib). Novel targeted and immunotherapeutic agents have also revolutionized the systemic management of melanoma (ipilimumab, nivolumab, pembrolizumab, and BRAF inhibitors dabrafenib and vemurafenib).
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Affiliation(s)
- Federica Franchino
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
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23
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Rivers C, Tranquilli M, Prasad S, Winograd E, Plunkett RJ, Fenstermaker RA, Fabiano AJ, Podgorsak MB, Prasad D. Impact of the Number of Metastatic Tumors Treated by Stereotactic Radiosurgery on the Dose to Normal Brain: Implications for Brain Protection. Stereotact Funct Neurosurg 2017; 95:352-358. [PMID: 29017157 DOI: 10.1159/000480666] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 08/23/2017] [Indexed: 11/19/2022]
Abstract
PURPOSE/OBJECTIVES The purpose of this study was to evaluate the effect of the number of brain lesions for which stereotactic radiosurgery (SRS) was performed on the dose volume relationships in normal brain. MATERIALS AND METHODS Brain tissue was segmented using the patient's pre-SRS MRI. For each plan, the following data points were recorded: total brain volume, number of lesions treated, volume of brain receiving 8 Gy (V8), V10, V12, and V15. RESULTS A total of 225 Gamma Knife® treatments were included in this retrospective analysis. The number of lesions treated ranged from 1 to 29. The isodose for prescription ranged from 40 to 95% (mean 55%). The mean prescription dose to tumor edge was 18 Gy. The mean coverage, selectivity, conformity, and gradient index were 97.5%, 0.63, 0.56, and 3.5, respectively. The mean V12 was 9.5 cm3 (ranging from 0.5 to 59.29). There was no correlation between the number of lesions and brain V8, V12, V10, or V15. There was a direct and statistically significant relationship between the brain volume treated (V8, V10, V12, and V15) and total volume of tumors treated (p < 0.001). In our study, the integral dose to the brain exceeded 3 J when the total tumor volume exceeded 25 cm3. CONCLUSIONS The number of metastatic brain lesions treated bears no significant relationship to total brain tissue volume treated when using SRS. The fact that the integral dose to the brain exceeded 3 J when the total tumor volume exceeded 25 cm3 is useful for establishing guidelines. Although standard practice has favored using whole brain radiation therapy in patients with more than 4 lesions, a significant amount of normal brain tissue may be spared by treating these patients with SRS. SRS should be carefully considered in patients with multiple brain lesions, with the emphasis on total brain volume involved rather than the number of lesions to be treated.
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Affiliation(s)
- Charlotte Rivers
- Department of Radiation Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
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24
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Villanueva-Meyer JE, Mabray MC, Cha S. Current Clinical Brain Tumor Imaging. Neurosurgery 2017; 81:397-415. [PMID: 28486641 PMCID: PMC5581219 DOI: 10.1093/neuros/nyx103] [Citation(s) in RCA: 194] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 02/23/2017] [Indexed: 01/12/2023] Open
Abstract
Neuroimaging plays an ever evolving role in the diagnosis, treatment planning, and post-therapy assessment of brain tumors. This review provides an overview of current magnetic resonance imaging (MRI) methods routinely employed in the care of the brain tumor patient. Specifically, we focus on advanced techniques including diffusion, perfusion, spectroscopy, tractography, and functional MRI as they pertain to noninvasive characterization of brain tumors and pretreatment evaluation. The utility of both structural and physiological MRI in the post-therapeutic brain evaluation is also reviewed with special attention to the challenges presented by pseudoprogression and pseudoresponse.
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Affiliation(s)
- Javier E. Villanueva-Meyer
- Department of Radiology and Biomedical Imaging, Neuroradiology Section, University of California San Francisco, San Francisco, California
| | - Marc C. Mabray
- Department of Radiology and Biomedical Imaging, Neuroradiology Section, University of California San Francisco, San Francisco, California
| | - Soonmee Cha
- Department of Radiology and Biomedical Imaging, Neuroradiology Section, University of California San Francisco, San Francisco, California
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Lamba N, Muskens IS, DiRisio AC, Meijer L, Briceno V, Edrees H, Aslam B, Minhas S, Verhoeff JJC, Kleynen CE, Smith TR, Mekary RA, Broekman ML. Stereotactic radiosurgery versus whole-brain radiotherapy after intracranial metastasis resection: a systematic review and meta-analysis. Radiat Oncol 2017. [PMID: 28646895 PMCID: PMC5483276 DOI: 10.1186/s13014-017-0840-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background In patients with one to three brain metastases who undergo resection, options for post-operative treatments include whole-brain radiotherapy (WBRT) or stereotactic radiosurgery (SRS) of the resection cavity. In this meta-analysis, we sought to compare the efficacy of each post-operative radiation modality with respect to tumor recurrence and survival. Methods Pubmed, Embase and Cochrane databases were searched through June 2016 for cohort studies reporting outcomes of SRS or WBRT after metastasis resection. Pooled effect estimates were calculated using fixed-effect and random-effect models for local recurrence, distant recurrence, and overall survival. Results Eight retrospective cohort studies with 646 patients (238 with SRS versus 408 with WBRT) were included in the analysis. Comparing SRS to WBRT, the overall crude risk ratio using the fixed-effect model was 0.59 for local recurrence (95%-CI: 0.32–1.09, I2: 3.35%, P-heterogeneity = 0.36, 3 studies), 1.09 for distant recurrence (95%-CI: 0.74–1.60, I2: 50.5%, P-heterogeneity = 0.13; 3 studies), and 2.99 for leptomeningeal disease (95% CI 1.55–5.76; I2: 14.4% p-heterogeneity: 0.28; 2 studies). For the same comparison, the risk ratio for median overall survival was 0.47 (95% CI: 0.41–0.54; I2: 79.1%, P-heterogeneity < 0.01; 4 studies) in a fixed-effect model, but was no longer significant (0.63; 95%-CI: 0.40–1.00) in a random-effect model. SRS was associated with a lower risk of leukoencephalopathy (RR: 0.15, 95% CI: 0.07–0.33, 1 study), yet with a higher risk of radiation-necrosis (RR: 19.4, 95% CI: 1.21–310, 1 study). Conclusion Based on retrospective cohort studies, the results of this study suggest that SRS of the resection cavity may offer comparable survival and similar local and distant control as adjuvant WBRT, yet may be associated with a higher risk for developing leptomeningeal disease. Future research on SRS should focus on achieving a better understanding of the various factors that may favor SRS over WBRT.
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Affiliation(s)
- Nayan Lamba
- Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Ivo S Muskens
- Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, HP G03.124, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Aislyn C DiRisio
- Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Louise Meijer
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, HP G03.124, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | | | - Heba Edrees
- School of Pharmacy, MCPHS University, Boston, MA, USA
| | - Bilal Aslam
- School of Pharmacy, MCPHS University, Boston, MA, USA
| | - Sadia Minhas
- School of Pharmacy, MCPHS University, Boston, MA, USA
| | - Joost J C Verhoeff
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Catharina E Kleynen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Timothy R Smith
- Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rania A Mekary
- Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,School of Pharmacy, MCPHS University, Boston, MA, USA
| | - Marike L Broekman
- Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. .,Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, HP G03.124, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
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26
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Trifiletti DM, Peach MS, Xu Z, Kersh R, Showalter TN, Sheehan JP. Evaluation of outcomes after stereotactic radiosurgery for pilocytic astrocytoma. J Neurooncol 2017; 134:297-302. [PMID: 28567590 DOI: 10.1007/s11060-017-2521-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 05/29/2017] [Indexed: 12/18/2022]
Abstract
Pilocytic astrocytomas are rare intracranial gliomas that are typically treated with surgical extirpation. Our aim was to report the radiologic and clinical outcomes of patients treated with stereotactic radiosurgery (SRS) for pilocytic astrocytoma in the primary and salvage setting. Patients with pilocytic astrocytoma treated at a single institution with SRS from 1990 to 2015 were reviewed. Patient, disease, and treatment characteristics were collected and overall survival, local control, and toxicity were evaluated. Twenty-eight consecutive patients (12 females and 16 males) with a median age of 17.4 years at SRS were identified. Overall, 46% of patients were treated with SRS as part of the initial treatment course after biopsy or subtotal resection, and the remainder as a salvage therapy. The most common location was the cerebellum (28%) followed by brainstem and basal ganglia (21 and 18%, respectively). Four patients received prior external beam radiation therapy (14%). Median tumor volume was 1.84 cc (0.19-15.94 cc), and 39% had a cystic component at SRS. Prescription dose ranged from 4 to 20 Gy (median 16 Gy) to a median isodose line of 50% (range 30-100%). With a median follow-up of 5.2 years (0.3-17.1 years), all patients remained alive at last follow-up. Two patients demonstrated evidence of local radiographic progression at last follow-up (7%). No toxicity could be directly attributed to SRS. In this SRS series, durable tumor control was achieved in 93% of patients with pilocytic astrocytoma, although continued follow up will be important giving the natural history of this disease. As demonstrated, SRS is an appropriate technique in the primary and recurrent treatment of pilocytic astrocytoma that offers favorable disease control and infrequent clinical toxicity.
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Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA. .,Department of Radiation Oncology, University of Virginia Health System, 1240 Lee Street, Box 800383, Charlottesville, VA, 22908, USA.
| | - M Sean Peach
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Ronald Kersh
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Jason P Sheehan
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA.,Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
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Romano KD, Trifiletti DM, Garda A, Xu Z, Schlesinger D, Watkins WT, Neal B, Larner JM, Sheehan JP. Choosing a Prescription Isodose in Stereotactic Radiosurgery for Brain Metastases: Implications for Local Control. World Neurosurg 2016; 98:761-767.e1. [PMID: 27867125 DOI: 10.1016/j.wneu.2016.11.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 11/04/2016] [Accepted: 11/07/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) achieves excellent local control (LC) with limited toxicity for most brain metastases. SRS dose prescription variables influence LC; therefore, we evaluated the impact of prescription isodose line (IDL) on LC after SRS. METHODS A retrospective analysis of patients with brain metastases treated on a Gamma Knife platform from 2004 to 2014 was conducted. Clinical, toxicity, radiographic, and dosimetric data were collected. Cox proportional hazards regression was used to determine progression-free survival (PFS) and competing risks analysis was used to determine predictive factors for LC. RESULTS A total of 134 patients with 374 brain metastases were identified with a median survival of 8.7 months (range, 0.2-64.8). The median tumor maximum dimension was 8 mm (range, 2-62 mm), median margin dose was 20 Gy (range, 5-24 Gy), and 12-month LC rate was 88.7%. On multivariate analysis, PFS improved with increasing IDL (P = 0.003) and decreased with non-non-small-cell lung cancer histology (P = 0.001). Margin dose, tumor size, conformality, and previous whole-brain irradiation failed to independently affect PFS. When adjusting for death as a competing risk, the cumulative likelihood of LC improved with higher IDL (P = 0.04). The rate of SRS-induced radiographic and clinical toxicity was low (16.6% and 1.5%, respectively), and neither was affected by IDL. CONCLUSIONS Our results confirm that SRS for brain metastases results in favorable LC, particularly for patients with smaller tumors. We noted that dose delivery to a higher prescription IDL is associated with small but measurable improvements in LC. This finding could be related to higher dose just beyond the radiographically apparent tumor.
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Affiliation(s)
- Kara D Romano
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA.
| | - Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA
| | - Allison Garda
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - David Schlesinger
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA; Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - William T Watkins
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA
| | - Brian Neal
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA
| | - James M Larner
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA
| | - Jason P Sheehan
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA; Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
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Cohen-Inbar O, Melmer P, Lee CC, Xu Z, Schlesinger D, Sheehan JP. Leukoencephalopathy in long term brain metastases survivors treated with radiosurgery. J Neurooncol 2016; 126:289-98. [PMID: 26468138 DOI: 10.1007/s11060-015-1962-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/10/2015] [Indexed: 12/28/2022]
Abstract
Brain metastases (BM) develop in 10-30 % of patients. Stereotactic radiosurgery (SRS) was shown to improve local control, and performance status, in certain cohorts of brain metastasis patients. The cumulative neurocognitive effect of numerous SRS sessions remains unknown. Leukoencephalopathy is significant diffuse white matter changes and it usually implies a neurocognitive decline. We report patients with BM who survived >2 years after SRS. Clinical and treatment parameters were analyzed for development of leukoencephalopathy. Multiple parameters as well as leukoencephalopathy grade changes were recorded. The median clinical and radiological follow-up was 42 and 41 months (range 24–115 and 24–115) respectively. The cohort included 92 patients and 704 lesions. The most common malignancies were non-small cell lung carcinoma (44.5 % n = 41), breast adenocarcinoma (23.9 %, n = 22) and melanoma (16.3 %,n = 15). 27.6 % (n = 26) of patients underwent adjuvant WBRT. At last follow up, local tumor control was achieved in 76.3 % (n = 61) of patients and 71.8 % (n = 461) of lesions. Overall prevalence of leukoencephalopathy was 42, 60, 73 and 84 % at 1, 2, 3, and 4 years after SRS. Moderate-severe leukoencephalopathy development was related to an integral dose to skull >3 Joules (p = 0.012) at any radiosurgical treatment and prior WBRT (p<0.042). Leukoencephalopathy incidence was consistently higher in the WBRT + SRS group at each following year of survival from initial SRS. Long-term BM survivors treated with SRS are at progressive risk for developing leukoencephalopathy.Those with a higher BM burden, higher integral SRS dose to the skull, and treatment with WBRT are at increased risk of leukoencephalopathy.
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29
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Severe radiation-induced leukoencephalopathy: Case report and literature review. Adv Radiat Oncol 2016; 1:17-20. [PMID: 28740871 PMCID: PMC5506716 DOI: 10.1016/j.adro.2016.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 01/22/2016] [Accepted: 01/25/2016] [Indexed: 11/22/2022] Open
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