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Joo B, Kim JH, Ahn SG, Park M, Suh SH, Ahn SJ. De novo versus recurrent metastatic breast cancer affects the extent of brain metastases. J Neurooncol 2024; 169:309-316. [PMID: 38865012 DOI: 10.1007/s11060-024-04735-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 06/01/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE We aimed to identify factors associated with the extent of brain metastases in patients with breast cancer to help distinguish brain oligometastases (1-4 brain metastases) from extensive metastases (5 or more brain metastases). METHODS This retrospective observational study included 100 female patients diagnosed with brain metastases from breast cancer at a single institution between January 2011 and April 2022. Patient demographics and tumor characteristics were compared between the brain oligometastases group and the extensive metastases group. Multivariable logistic regression analysis was performed to determine the independent factors, including age at initial diagnosis, initial stage, breast cancer subtype, detection time of brain metastases, and de novo or recurrent status of the metastatic disease. In a subgroup analysis of patients with brain oligometastases, demographic and tumor characteristics were compared between patients with single and two-four brain metastases. RESULTS Of the 100 patients, 56 had brain oligometastases, while 44 had extensive brain metastases. The multivariable logistic regression analysis revealed that only the de novo/recurrent status of metastatic breast cancer was significantly associated with the extent of brain metastasis (p = 0.023). In the subgroup analysis of 56 patients with brain oligometastases, those diagnosed at an earlier stage were more likely to have a single brain metastasis (p = 0.008). CONCLUSION Patients with de novo metastatic breast cancer are more likely to develop extensive brain metastases than those with recurrent metastatic breast cancer. This insight could influence the development of tailored approaches for monitoring and treating brain metastases, supporting the potential advantages of routine brain screening for patients newly diagnosed with stage IV breast cancer.
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Affiliation(s)
- Bio Joo
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Jee Hung Kim
- Division of Medical Oncology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Gwe Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Mina Park
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Sang Hyun Suh
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Sung Jun Ahn
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea.
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Sarria GR, Fleckenstein J, Eckl M, Stieler F, Ruder A, Bendszus M, Schmeel LC, Koch D, Feisst A, Essig M, Wenz F, Giordano FA. Impact of the Novel MRI Contrast Agent Gadopiclenol on Radiotherapy Decision Making in Patients With Brain Metastases. Invest Radiol 2024:00004424-990000000-00245. [PMID: 39159365 DOI: 10.1097/rli.0000000000001115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/21/2024]
Abstract
PURPOSE The aim of this study was to assess the effect of gadopiclenol versus gadobenate dimeglumine contrast-enhanced magnetic resonance imaging (MRI) on decision-making between whole-brain radiotherapy (WBRT) and stereotactic radiosurgery (SRS) for treatment of brain metastases (BMs). METHODS Patients with BMs underwent 2 separate MRI examinations in a double-blind crossover phase IIb comparative study between the MRI contrast agents gadopiclenol and gadobenate dimeglumine, both administered at 0.1 mmol/kg. The imaging data of a single site using identical MRI scanners and protocols were included in this post hoc analysis. Patients with 1 or more BMs in any of both MRIs were subjected to target volume delineation for treatment planning. Two radiation oncologists contoured all visible lesions and decided upon SRS or WBRT, according to the number of metastases. For each patient, SRS or WBRT treatment plans were calculated for both MRIs, considering the gross target volume (GTV) as the contrast-enhancing aspects of the tumor. Mean GTVs and volume of healthy brain exposed to 12 Gy (V12), as well as Dice similarity coefficient scores, were obtained. The Spearman rank (ρ) correlation was additionally calculated for assessing linear differences. Three different expert radiation oncologists blindly rated the contrast enhancement for contouring purposes. RESULTS Thirteen adult patients were included. Gadopiclenol depicted additional BM as compared with gadobenate dimeglumine in 7 patients (54%). Of a total of 63 identified metastatic lesions in both MRI sets, 3 subgroups could be defined: A, 48 (24 pairs) detected equal GTVs visible in both modalities; B, 13 GTVs only visible in the gadopiclenol set (mean ± SD, 0.16 ± 0.37 cm3); and C, 2 GTVs only visible in the gadobenate dimeglumine set (mean ± SD, 0.01 ± 0.01). Treatment indication was changed for 2 (15%) patients, 1 from no treatment to SRS and for 1 from SRS to WBRT. The mean GTVs and brain V12 were comparable between both agents (P = 0.694, P = 0.974). The mean Dice similarity coefficient was 0.70 ± 0.14 (ρ = 0.82). According to the readers, target volume definition was improved in 63.9% of cases (23 of 36 evaluations) with gadopiclenol and 22.2% with gadobenate dimeglumine (8 of 36), whereas equivalence was obtained in 13.9% (5 of 36). CONCLUSIONS Gadopiclenol-enhanced MRI improved BM detection and characterization, with a direct impact on radiotherapy treatment decision between WBRT and SRS. Additionally, a more exact target delineation and planning could be performed with gadopiclenol. A prospective evaluation in a larger cohort of patients is required to confirm these findings.
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Affiliation(s)
- Gustavo R Sarria
- From the Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany (G.R.S., L.C.S., D.K., A.F.); Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany (J.F., M. Eckl, F.S., A.R., F.A.G.); Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany (M.B.); Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada (M. Essig); and University Medical Center Freiburg, Freiburg University, Freiburg, Germany (F.W.)
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Schulz C, Proescholdt M, Schmidt NO, Steger F, Heudobler D. [Brain metastases]. Pneumologie 2024; 78:578-589. [PMID: 38266745 DOI: 10.1055/a-2238-1840] [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: 01/26/2024]
Abstract
Cerebral metastases in patients with metastatic lung cancer are found in more than 30% of patients at baseline and manifest themselves in two out of three patients during disease evolution. For a long time, the cerebral manifestation of the disease was classified as prognostically unfavorable and hence such patients were regularly excluded from therapy studies. In the context of targeted molecular therapy strategies and established immuno-oncological systemic therapies, the blood-brain barrier no longer represents an insurmountable barrier. However, the treatment of brain metastases requires decision making in a multidisciplinary team within dedicated lung cancer and/or oncology centers. The differentiated treatment decision is based on the number, size and location of the brain metastases, neurology and general condition, comorbidities, potential life expectancy and the patient's wishes, but also tumor biology including molecular targets, extra-cranial tumor burden and availability of a CNS-effective therapy. Systemic therapies as well as neurosurgical and radiotherapeutic concepts are now often combined for optimized and prognosis-improving therapeutic strategies.
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Affiliation(s)
- Christian Schulz
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Martin Proescholdt
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Nils Ole Schmidt
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Felix Steger
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Daniel Heudobler
- Klinik und Poliklinik für Innere Medizin III, Universitätsklinikum Regensburg, Regensburg, Deutschland
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Timakova E, Zavgorodni SF. Effect of modulation factor and low dose threshold level on gamma pass rates of single isocenter multi-target SRT treatment plans. J Appl Clin Med Phys 2024:e14459. [PMID: 39053489 DOI: 10.1002/acm2.14459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 04/16/2024] [Accepted: 06/19/2024] [Indexed: 07/27/2024] Open
Abstract
PURPOSE SRS MapCHECK (SMC) is a commercially available patient-specific quality assurance (PSQA) tool for stereotactic radiosurgery (SRS) applications. This study investigates the effects of degree of modulation, location off-axis, and low dose threshold (LDT) selection on gamma pass rates (GPRs) between SMC and treatment planning system, Analytical Anisotropic Algorithm (AAA), or Vancouver Island Monte Carlo (VMC++ algorithm) system calculated dose distributions. METHODS Volumetric-modulated arc therapy (VMAT) plans with modulation factors (MFs) ranging from 2.7 to 10.2 MU/cGy were delivered to SMC at isocenter and 6 cm off-axis. SMC measured dose distributions were compared against AAA and VMC++ via gamma analysis (3%/1 mm) with LDT of 10% to 80% using SNC Patient software. RESULTS Comparing on-axis SMC dose against AAA and VMC++ with LDT of 10%, all AAA-calculated plans met the acceptance criteria of GPR ≥ 90%, and only one VMC++ calculated plan was marginally outside the acceptance criteria with pass rate of 89.1%. Using LDT of 80% revealed decreasing GPR with increasing MF. For AAA, GPRs reduced from 100% at MF of 2.7 MU/cGy to 57% at MF of 10.2 MU/cGy, and for VMC++ calculated plans, the GPRs reduced from 89% to 60% in the same MF range. Comparison of SMC dose off-axis against AAA and VMC++ showed more pronounced reduction of GPR with increasing MF. For LDT of 10%, AAA GPRs reduced from 100% to 83% in the MF range of 2.7 to 9.8 MU/cGy, and VMC++ GPR reduced from 100% to 91% in the same range. With 80% LDT, GPRs dropped from 100% to 42% for both algorithms. CONCLUSIONS MF, dose calculation algorithm, and LDT selections are vital in VMAT-based SRT PSQA. LDT of 80% enhances sensitivity of gamma analysis for detecting dose differences compared to 10% LDT. To achieve better agreement between calculated and SMC dose, it is recommended to limit the MF to 4.6 MU/cGy on-axis and 3.6 MU/cGy off-axis.
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Affiliation(s)
- Elena Timakova
- University of Victoria, Victoria, British Columbia, Canada
- BC Cancer Agency, Vancouver Island Centre, Victoria, British Columbia, Canada
| | - Sergei F Zavgorodni
- University of Victoria, Victoria, British Columbia, Canada
- BC Cancer Agency, Vancouver Island Centre, Victoria, British Columbia, Canada
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Zheng D, Yoon J, Jung H, Lemus OMD, Gou L, Zhou Y, Usuki KY, Hardy S, Milano MT. How Does the Number of Brain Metastases Correlate With Normal Brain Exposure in Single-Isocenter Multitarget Multifraction Stereotactic Radiosurgery. Adv Radiat Oncol 2024; 9:101499. [PMID: 38681891 PMCID: PMC11047183 DOI: 10.1016/j.adro.2024.101499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 03/11/2024] [Indexed: 05/01/2024] Open
Abstract
Purpose To investigate the relationship between normal brain exposure in LINAC-based single-isocenter multitarget multifraction stereotactic radiosurgery or stereotactic radiation therapy (SRT) and the number or volume of treated brain metastases, especially for high numbers of metastases. Methods and Materials A cohort of 44 SRT patients with 709 brain metastases was studied. Renormalizing to a uniform prescription of 27 Gy in 3 fractions, normal brain dose volume indices, including V23 Gy (volume receiving >23 Gy), V18 Gy (volume receiving >18 Gy), and mean dose, were evaluated on these plans against the number and the total volume of targets for each plan. To compare with exposures from whole-brain radiation therapy (WBRT), the SRT dose distributions were converted to equivalent dose in 3 Gy fractions (EQD3) using an alpha-beta ratio of 2 Gy. Results With increasing number of targets and increasing total target volume, normal brain exposures to dose ≥18 Gy increases, and so does the mean normal brain dose. The factors of the number of targets and the total target volume are both significant, although the number of targets has a larger effect on the mean normal brain dose and the total target volume has a larger effect on V23 Gy and V18 Gy. The EQD3 mean normal brain dose with SRT planning is lower than conventional WBRT. On the other hand, SRT results in higher hot spot (ie, maximum dose outside of tumor) EQD3 dose than WBRT. Conclusions Based on clinical SRT plans, our study provides information on correlations between normal brain exposure and the number and total volume of targets. As SRT becomes more greatly used for patients with increasingly extensive brain metastases, more clinical data on outcomes and toxicities is necessary to better define the normal brain dose constraints for high-exposure cases and to optimize the SRT management for those patients.
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Affiliation(s)
- Dandan Zheng
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Jihyung Yoon
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Hyunuk Jung
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Olga Maria Dona Lemus
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Lang Gou
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Yuwei Zhou
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Kenneth Y. Usuki
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Sara Hardy
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Michael T. Milano
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
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de Boisanger J, Brewer M, Fittall MW, Tran A, Thomas K, Dreibe S, Creak A, Solda F, Konadu J, Taylor H, Saran F, Welsh L, Rosenfelder N. Survival after Stereotactic Radiosurgery in the Era of Targeted Therapy: Number of Metastases No Longer Matters. Curr Oncol 2024; 31:2994-3005. [PMID: 38920712 PMCID: PMC11202506 DOI: 10.3390/curroncol31060228] [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: 04/18/2024] [Revised: 05/22/2024] [Accepted: 05/24/2024] [Indexed: 06/27/2024] Open
Abstract
Randomised control trial data support the use of stereotactic radiosurgery (SRS) in up to 4 brain metastases (BMs), with non-randomised prospective data complementing this for up to 10 BMs. There is debate in the neuro-oncology community as to the appropriateness of SRS in patients with >10 BMs. We present data from a large single-centre cohort, reporting survival in those with >10 BMs and in a >20 BMs subgroup. A total of 1181 patients receiving SRS for BMs were included. Data were collected prospectively from the time of SRS referral. Kaplan-Meier graphs and logrank tests were used to compare survival between groups. Multivariate analysis was performed using the Cox proportional hazards model to account for differences in group characteristics. Median survival with 1 BM (n = 379), 2-4 BMs (n = 438), 5-10 BMs (n = 236), and >10 BMs (n = 128) was 12.49, 10.22, 10.68, and 10.09 months, respectively. Using 2-4 BMs as the reference group, survival was not significantly different in those with >10 BMs in either our univariable (p = 0.6882) or multivariable analysis (p = 0.0564). In our subgroup analyses, median survival for those with >20 BMs was comparable to those with 2-4 BMs (10.09 vs. 10.22 months, p = 0.3558). This study contributes a large dataset to the existing literature on SRS for those with multi-metastases and supports growing evidence that those with >10 BMs should be considered for SRS.
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Affiliation(s)
- James de Boisanger
- The Royal Marsden Hospital, London SW3 6JJ, UK
- The Institute of Cancer Research, London SM2 5NG, UK
| | | | | | - Amina Tran
- The Royal Marsden Hospital, London SW3 6JJ, UK
| | | | | | | | | | | | | | - Frank Saran
- Cancer and Blood Service, Auckland City Hospital, Auckland 1023, New Zealand
| | - Liam Welsh
- The Royal Marsden Hospital, London SW3 6JJ, UK
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Kinj R, Hottinger AF, Böhlen TT, Ozsahin M, Vallet V, Dunet V, Bouchaab H, Peters S, Tuleasca C, Bourhis J, Schiappacasse L. Long-Term Results of Stereotactic Radiotherapy in Patients with at Least 10 Brain Metastases at Diagnosis. Cancers (Basel) 2024; 16:1742. [PMID: 38730695 PMCID: PMC11083879 DOI: 10.3390/cancers16091742] [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: 04/05/2024] [Revised: 04/24/2024] [Accepted: 04/28/2024] [Indexed: 05/13/2024] Open
Abstract
PURPOSE to evaluate an SRT approach in patients with at least 10 lesions at the time of BM initial diagnosis. METHODS This is a monocentric prospective cohort of patients treated by SRT, followed by a brain MRI every two months. Subsequent SRT could be delivered in cases of new BMs during follow-up. The main endpoints were local control rate (LCR), overall survival (OS), and strategy success rate (SSR). Acute and late toxicity were evaluated. RESULTS Seventy patients were included from October 2014 to January 2019, and the most frequent primary diagnosis was non-small-cell lung cancer (N = 36, 51.4%). A total of 1174 BMs were treated at first treatment, corresponding to a median number of 14 BMs per patient. Most of the patients (N = 51, 72.6%) received a single fraction of 20-24 Gy. At 1 year, OS was 62.3%, with a median OS of 19.2 months, and SSR was 77.8%. A cumulative number of 1537 BM were treated over time, corresponding to a median cumulative number of 16 BM per patient. At 1-year, the LCR was 97.3%, with a cumulative incidence of radio-necrosis of 2.1% per lesion. Three patients (4.3%) presented Grade 2 toxicity, and there was no Grade ≥ 3 toxicity. The number of treated BMs and the treatment volume did not influence OS or SSR (p > 0.05). CONCLUSIONS SRT was highly efficient in controlling the BM, with minimal side effects. In this setting, an SRT treatment should be proposed even in patients with ≥10 BMs at diagnosis.
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Affiliation(s)
- Rémy Kinj
- Department of Radiation Oncology, Lausanne University Hospital and University of Lausanne, CHUV, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland
- Lundin Family Brain Tumor Centre, Departments of Oncology & Clinical Neurosciences, Hospital and University of Lausanne, CH-1011 Lausanne, Switzerland
| | - Andreas Felix Hottinger
- Lundin Family Brain Tumor Centre, Departments of Oncology & Clinical Neurosciences, Hospital and University of Lausanne, CH-1011 Lausanne, Switzerland
- Departments of Medical Oncology & Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, CH-1011 Lausanne, Switzerland
| | - Till Tobias Böhlen
- Lundin Family Brain Tumor Centre, Departments of Oncology & Clinical Neurosciences, Hospital and University of Lausanne, CH-1011 Lausanne, Switzerland
- Institute of Radiation Physics, Lausanne University Hospital and University of Lausanne, CH-1011 Lausanne, Switzerland
| | - Mahmut Ozsahin
- Department of Radiation Oncology, Lausanne University Hospital and University of Lausanne, CHUV, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland
| | - Véronique Vallet
- Institute of Radiation Physics, Lausanne University Hospital and University of Lausanne, CH-1011 Lausanne, Switzerland
| | - Vincent Dunet
- Lundin Family Brain Tumor Centre, Departments of Oncology & Clinical Neurosciences, Hospital and University of Lausanne, CH-1011 Lausanne, Switzerland
- Departement of Medical Radiology, Lausanne University Hospital and University of Lausanne, CH-1011 Lausanne, Switzerland
| | - Hasna Bouchaab
- Departments of Medical Oncology, Lausanne University Hospital and University of Lausanne, CH-1011 Lausanne, Switzerland
| | - Solange Peters
- Departments of Medical Oncology, Lausanne University Hospital and University of Lausanne, CH-1011 Lausanne, Switzerland
| | - Constantin Tuleasca
- Lundin Family Brain Tumor Centre, Departments of Oncology & Clinical Neurosciences, Hospital and University of Lausanne, CH-1011 Lausanne, Switzerland
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital, University of Lausanne, CH-1011 Lausanne, Switzerland
| | - Jean Bourhis
- Department of Radiation Oncology, Lausanne University Hospital and University of Lausanne, CHUV, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland
- Lundin Family Brain Tumor Centre, Departments of Oncology & Clinical Neurosciences, Hospital and University of Lausanne, CH-1011 Lausanne, Switzerland
| | - Luis Schiappacasse
- Department of Radiation Oncology, Lausanne University Hospital and University of Lausanne, CHUV, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland
- Lundin Family Brain Tumor Centre, Departments of Oncology & Clinical Neurosciences, Hospital and University of Lausanne, CH-1011 Lausanne, Switzerland
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Lu S, Guo X, Yang Z, Sun Y, Niu J, Jing X, Zhu H. Immunotherapy combined with cranial radiotherapy for driver-negative non-small-cell lung cancer brain metastases: a retrospective study. Future Oncol 2024:1-14. [PMID: 38591950 DOI: 10.2217/fon-2023-1061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/07/2024] [Indexed: 04/10/2024] Open
Abstract
Background: This study assesses immune checkpoint inhibitors' efficacy for non-small-cell lung cancer (NSCLC) with brain metastases (BM) and explores the role of cranial radiation therapy (CRT) in the immunotherapy era. Methods: The retrospective analysis screened NSCLC patients with BMs from July 2018 to December 2021. Treatment involved chemotherapy combined with immune checkpoint inhibitors as the first-line, with patients divided into CRT and non-CRT groups. Overall survival (OS), progression-free survival and intracranial progression-free survival were calculated and compared. Results: Among 113 patients, 74 who received CRT had significantly better median OS (not reached vs 15.31 months), particularly among those with one to three BMs. Factors correlating with better OS included CRT, PD-L1 expression and diagnosis-specific graded prognostic assessment scores. Conclusion: Integrating CRT with anti-PD-1 therapy notably enhanced long-term survival in NSCLC patients with BMs.
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Affiliation(s)
- Shuangqing Lu
- Department of Radiation Oncology, Shandong Cancer Hospital & Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong Province, 250117, China
| | - Xiaokang Guo
- Department of Surgical Oncology, Shandong Cancer Hospital & Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong Province, 250117, China
| | - Zhengqiang Yang
- Department of Radiation Oncology, Shandong Cancer Hospital & Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong Province, 250117, China
| | - Yulan Sun
- Department of Medical Oncology, Shandong Cancer Hospital & Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong Province, 250117, China
| | - Jiling Niu
- Department of Radiation Oncology, Shandong Cancer Hospital & Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong Province, 250117, China
| | - Xuquan Jing
- Department of Radiation Oncology, Shandong Cancer Hospital & Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong Province, 250117, China
| | - Hui Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital & Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong Province, 250117, China
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Palmer JD, Perlow HK, Lehrer EJ, Wardak Z, Soliman H. Novel radiotherapeutic strategies in the management of brain metastases: Challenging the dogma. Neuro Oncol 2024; 26:S46-S55. [PMID: 38437668 PMCID: PMC10911796 DOI: 10.1093/neuonc/noad260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
The role of radiation therapy in the management of brain metastasis is evolving. Advancements in machine learning techniques have improved our ability to both detect brain metastasis and our ability to contour substructures of the brain as critical organs at risk. Advanced imaging with PET tracers and magnetic resonance imaging-based artificial intelligence models can now predict tumor control and differentiate tumor progression from radiation necrosis. These advancements will help to optimize dose and fractionation for each patient's lesion based on tumor size, histology, systemic therapy, medical comorbidities/patient genetics, and tumor molecular features. This review will discuss the current state of brain directed radiation for brain metastasis. We will also discuss future directions to improve the precision of stereotactic radiosurgery and optimize whole brain radiation techniques to improve local tumor control and prevent cognitive decline without forming necrosis.
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Affiliation(s)
- Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Haley K Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Eric J Lehrer
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Zabi Wardak
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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10
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Kienzler JC, Becher B. Immunity in malignant brain tumors: Tumor entities, role of immunotherapy, and specific contribution of myeloid cells to the brain tumor microenvironment. Eur J Immunol 2024; 54:e2250257. [PMID: 37940552 DOI: 10.1002/eji.202250257] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 10/30/2023] [Accepted: 11/07/2023] [Indexed: 11/10/2023]
Abstract
Malignant brain tumors lack effective treatment, that can improve their poor overall survival achieved with standard of care. Advancement in different cancer treatments has shifted the focus in brain tumor research and clinical trials toward immunotherapy-based approaches. The investigation of the immune cell landscape revealed a dominance of myeloid cells in the tumor microenvironment. Their exact roles and functions are the subject of ongoing research. Current evidence suggests a complex interplay of tumor cells and myeloid cells with competing functions toward support vs. control of tumor growth. Here, we provide a brief overview of the three most abundant brain tumor entities: meningioma, glioma, and brain metastases. We also describe the field of ongoing immunotherapy trials and their results, including immune checkpoint inhibitors, vaccination studies, oncolytic viral therapy, and CAR-T cells. Finally, we summarize the phenotypes of microglia, monocyte-derived macrophages, border-associated macrophages, neutrophils, and potential novel therapy targets.
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Affiliation(s)
- Jenny C Kienzler
- Institute of Experimental Immunology, Inflammation Research Lab, University of Zurich, Zurich, Switzerland
| | - Burkhard Becher
- Institute of Experimental Immunology, Inflammation Research Lab, University of Zurich, Zurich, Switzerland
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Williams MM, Sohrabi AK, Kittel CA, White JJ, Cramer CK, Lanier CM, Ruiz J, Xing F, Li W, Whitlow CT, Tatter SB, Chan MD, Laxton AW. Delayed Imaging Changes 18 Months or Longer After Stereotactic Radiosurgery for Brain Metastases: Necrosis or Progression. World Neurosurg 2024; 181:e453-e458. [PMID: 37865197 DOI: 10.1016/j.wneu.2023.10.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 10/16/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVE Imaging changes after stereotactic radiosurgery (SRS) can occur for years after treatment, although the available data on the incidence of tumor progression and adverse radiation effects (ARE) are generally limited to the first 2 years after treatment. METHODS A single-institution retrospective review was conducted of patients who had >18 months of imaging follow-up available. Patients who had ≥1 metastatic brain lesions treated with Gamma Knife SRS were assessed for the time to radiographic progression. Those with progression ≥18 months after the initial treatment were included in the present study. The lesions that progressed were characterized as either ARE or tumor progression based on the tissue diagnosis or imaging characteristics over time. RESULTS The cumulative incidence of delayed imaging radiographic progression was 35% at 5 years after the initial SRS. The cumulative incidence curves of the time to radiographic progression for lesions determined to be ARE and lesions determined to be tumor progression were not significantly different statistically. The cumulative incidence of delayed ARE and delayed tumor progression was 17% and 16% at 5 years, respectively. Multivariate analysis indicated that the number of metastatic brain lesions present at the initial SRS was the only factor associated with late radiographic progression. CONCLUSIONS The timing of late radiographic progression does not differ between ARE and tumor progression. The number of metastatic brain lesions at the initial SRS is a risk factor for late radiographic progression.
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Affiliation(s)
- Michelle M Williams
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Arian K Sohrabi
- Department of Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Carol A Kittel
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Jaclyn J White
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Christina K Cramer
- Department of Medicine (Hematology & Oncology), Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Claire M Lanier
- Department of Medicine (Hematology & Oncology), Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Jimmy Ruiz
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Fei Xing
- Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Wencheng Li
- Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Christopher T Whitlow
- Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Michael D Chan
- Department of Medicine (Hematology & Oncology), Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
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12
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Li F, Mail N, Stefania diMayorca M, McCaw TJ, Ozhasoglu C, Lalonde R, Chang J, Huq MS. Single isocenter HyperArc treatment of multiple intracranial metastases: Targeting accuracy. J Appl Clin Med Phys 2024; 25:e14234. [PMID: 38059673 PMCID: PMC10795440 DOI: 10.1002/acm2.14234] [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: 05/01/2023] [Revised: 10/12/2023] [Accepted: 10/25/2023] [Indexed: 12/08/2023] Open
Abstract
PURPOSE/OBJECTIVES (A) To examine the alignment accuracy of CBCT guidance for brain metastases with off centered isocenters, (B) to test dose delivery and targeting accuracy for single isocenter treatments with multiple brain metastases. We report the results of the end-to-end test for Truebeam stereotactic radiosurgery (SRS). MATERIALS/METHODS An anthropomorphic CT head phantom was drilled with five MOSFET inserts and two PTW Pinpoint chamber inserts. The phantom was simulated, planned, and delivered. For the purpose of comparing the accuracy of alignment, CBCTs were acquired with the isocenter centered and offset superiorly 8 cm, inferiorly 8 cm, anteriorly 7 cm, posteriorly 7 cm, and right 5 cm. There were six degrees of freedom corrections applied to the plans, as well as intentional rotational and translational errors for dose comparisons. Dose accuracy checks were performed with MOSFET and PTW Pinpoint chamber, and targeting accuracy was assessed with GafChromic films. RESULT (A) Compared to centered CBCT, off-centered CBCT scan showed some alignment errors, with a maximum difference of 0.6-degree pitch and 0.9 mm translation when the phantom was placed 8 cm inferior off center. (B) For the single isocenter plan, measured doses of the five MOSFET were 95%-100% of the planned dose, whereas the multiple isocenter plans were 96%-100%. With intentional setup errors of 1-degree pitch, doses were 97.1%-100.4% compared to the perfect setup. The same was found for the two pinpoint chamber readings with 1-degree rotation and 1 mm translation. (C) Targeting accuracy for targets at the isocenter is 0.67 mm, within the machine specification of 0.75 mm. Targeting accuracy for isocenters 6-12 cm away from the target is in the range 0.67-1.18 mm. CONCLUSION (A) Single isocenter HyperArc treatments for multiple brain metastases are feasible and targeting accuracy is clinically acceptable. (B) The vertex in a cranial scan is very important for proper alignment.
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Affiliation(s)
- Fang Li
- Radiation OncologyUPMC Hillman Cancer CenterPittsburghPennsylvaniaUSA
| | - Noor Mail
- Radiation OncologyUPMC Hillman Cancer CenterPittsburghPennsylvaniaUSA
| | | | - Travis J. McCaw
- Radiation OncologyUPMC Hillman Cancer CenterPittsburghPennsylvaniaUSA
| | - Cihat Ozhasoglu
- Radiation OncologyUPMC Hillman Cancer CenterPittsburghPennsylvaniaUSA
| | - Ronald Lalonde
- Radiation OncologyUPMC Hillman Cancer CenterPittsburghPennsylvaniaUSA
| | - Jina Chang
- Radiation OncologyUPMC Hillman Cancer CenterPittsburghPennsylvaniaUSA
| | - Mohammed Saiful Huq
- Radiation OncologyUniversity of Pittsburgh School of Medicine and UPMC Hillman Cancer CenterPittsburghPennsylvaniaUSA
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13
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Bansal R, Van Swearingen AED, Anders CK. Triple Negative Breast Cancer and Brain Metastases. Clin Breast Cancer 2023; 23:825-831. [PMID: 37586926 DOI: 10.1016/j.clbc.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/11/2023] [Accepted: 07/30/2023] [Indexed: 08/18/2023]
Abstract
The treatment of metastatic breast cancer (MBC) has improved over the past decade, however prognosis continues to be mitigated by the fact that about 1 in 5 patients with MBC will develop brain metastases (BrM) during their metastatic disease course. 1 This number is even higher for patients with triple-negative breast cancer (TNBC), with studies showing as high as 40% of patients developing BrM. 2, 3 Studies have shown that TNBC portends a worse survival after a diagnosis of BrM compared with non-TNBC subtypes. 4 Given the unique location and biologic properties of BrM, treatment options have historically been limited. Challenges to the treatment of TNBC BrM include a lack of targeted therapies and difficulties in delivery of drug to the brain past the blood-brain barrier (BBB). Herein, we will review the advances in local and systemic therapies to most effectively treat patients with TNBC BrM, including therapies on the horizon currently in clinical trials.
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Affiliation(s)
- Rani Bansal
- Division of Medical Oncology, Duke Cancer Institute, Duke University Medical Center, Durham, NC
| | - Amanda E D Van Swearingen
- Division of Medical Oncology, Duke Cancer Institute, Duke University Medical Center, Durham, NC; Division of Medical Oncology, Duke Center for Brain and Spine Metastasis, Duke University Medical Center, Durham, NC
| | - Carey K Anders
- Division of Medical Oncology, Duke Cancer Institute, Duke University Medical Center, Durham, NC; Division of Medical Oncology, Duke Center for Brain and Spine Metastasis, Duke University Medical Center, Durham, NC.
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14
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Abdulhaleem M, Hunting JC, Wang Y, Smith MR, Agostino RDJ, Lycan T, Farris MK, Ververs J, Lo HW, Watabe K, Topaloglu U, Li W, Whitlow C, Su J, Wang G, Chan MD, Xing F, Ruiz J. Use of comprehensive genomic profiling for biomarker discovery for the management of non-small cell lung cancer brain metastases. Front Oncol 2023; 13:1214126. [PMID: 38023147 PMCID: PMC10661935 DOI: 10.3389/fonc.2023.1214126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
Background Clinical biomarkers for brain metastases remain elusive. Increased availability of genomic profiling has brought discovery of these biomarkers to the forefront of research interests. Method In this single institution retrospective series, 130 patients presenting with brain metastasis secondary to Non-Small Cell Lung Cancer (NSCLC) underwent comprehensive genomic profiling conducted using next generation circulating tumor deoxyribonucleic acid (DNA) (Guardant Health, Redwood City, CA). A total of 77 genetic mutation identified and correlated with nine clinical outcomes using appropriate statistical tests (general linear models, Mantel-Haenzel Chi Square test, and Cox proportional hazard regression models). For each outcome, a genetic signature composite score was created by summing the total genes wherein genes predictive of a clinically unfavorable outcome assigned a positive score, and genes with favorable clinical outcome assigned negative score. Results Seventy-two genes appeared in at least one gene signature including: 14 genes had only unfavorable associations, 36 genes had only favorable associations, and 22 genes had mixed effects. Statistically significant associated signatures were found for the clinical endpoints of brain metastasis velocity, time to distant brain failure, lowest radiosurgery dose, extent of extracranial metastatic disease, concurrent diagnosis of brain metastasis and NSCLC, number of brain metastases at diagnosis as well as distant brain failure. Some genes were solely associated with multiple favorable or unfavorable outcomes. Conclusion Genetic signatures were derived that showed strong associations with different clinical outcomes in NSCLC brain metastases patients. While these data remain to be validated, they may have prognostic and/or therapeutic impact in the future. Statement of translation relevance Using Liquid biopsy in NSCLC brain metastases patients, the genetic signatures identified in this series are associated with multiple clinical outcomes particularly these ones that lead to early or more numerous metastases. These findings can be reverse-translated in laboratory studies to determine if they are part of the genetic pathway leading to brain metastasis formation.
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Affiliation(s)
- Mohammed Abdulhaleem
- Department of Internal Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - John C. Hunting
- Department of Internal Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Yuezhu Wang
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Margaret R. Smith
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Ralph D’ jr. Agostino
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Thomas Lycan
- Department of Internal Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Michael K. Farris
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - James Ververs
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Hui-Wen Lo
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Umit Topaloglu
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Wencheng Li
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Christopher Whitlow
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Jing Su
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ge Wang
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY, United States
| | - Michael D. Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Fei Xing
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Jimmy Ruiz
- Department of Internal Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC, United States
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15
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Yoon J, Jung H, Tanny SM, Lemus OMD, Milano MT, Hardy SJ, Usuki KY, Zheng D. A comprehensive evaluation of advanced dose calculation algorithms for brain stereotactic radiosurgery. J Appl Clin Med Phys 2023; 24:e14169. [PMID: 37775989 PMCID: PMC10647955 DOI: 10.1002/acm2.14169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 09/01/2023] [Accepted: 09/18/2023] [Indexed: 10/01/2023] Open
Abstract
PURPOSE Accurate dose calculation is important in both target and low dose normal tissue regions for brain stereotactic radiosurgery (SRS). In this study, we aim to evaluate the dosimetric accuracy of the two advanced dose calculation algorithms for brain SRS. METHODS Retrospective clinical case study and phantom study were performed. For the clinical study, 138 SRS patient plans (443 targets) were generated using BrainLab Elements Voxel Monte Carlo (VMC). To evaluate the dose calculation accuracy, the plans were exported into Eclipse and recalculated with Acuros XB (AXB) algorithm with identical beam parameters. The calculated dose at the target center (Dref), dose to 95% target volume (D95), and the average dose to target (Dmean) were compared. Also, the distance from the skull was analyzed. For the phantom study, a cylindrical phantom and a head phantom were used, and the delivered dose was measured by an ion chamber and EBT3 film, respectively, at various locations. The measurement was compared with the calculated doses from VMC and AXB. RESULTS In clinical cases, VMC dose calculations tended to be higher than AXB. It was found that the difference in Dref showed > 5% in some cases for smaller volumes < 0.3 cm3 . Dmean and D95 differences were also higher for small targets. No obvious trend was found between the dose difference and the distance from the skull. In phantom studies, VMC dose was also higher than AXB for smaller targets, and VMC showed better agreement with the measurements than AXB for both point dose and high dose spread. CONCLUSION The two advanced calculation algorithms were extensively compared. For brain SRS, AXB sometimes calculates a noticeable lower target dose for small targets than VMC, and VMC tends to have a slightly closer agreement with measurements than AXB.
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Affiliation(s)
- Jihyung Yoon
- Department of Radiation OncologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Hyunuk Jung
- Department of Radiation OncologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Sean M. Tanny
- Department of Radiation OncologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Olga Maria Dona Lemus
- Department of Radiation OncologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Michael T. Milano
- Department of Radiation OncologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Sara J. Hardy
- Department of Radiation OncologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Kenneth Y. Usuki
- Department of Radiation OncologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Dandan Zheng
- Department of Radiation OncologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
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16
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Bodensohn R, Kaempfel AL, Boulesteix AL, Orzelek AM, Corradini S, Fleischmann DF, Forbrig R, Garny S, Hadi I, Hofmaier J, Minniti G, Mansmann U, Pazos Escudero M, Thon N, Belka C, Niyazi M. Stereotactic radiosurgery versus whole-brain radiotherapy in patients with 4-10 brain metastases: A nonrandomized controlled trial. Radiother Oncol 2023; 186:109744. [PMID: 37330054 DOI: 10.1016/j.radonc.2023.109744] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 05/09/2023] [Accepted: 06/07/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND AND PURPOSE There is no randomized evidence comparing whole-brain radiotherapy (WBRT) and stereotactic radiosurgery (SRS) in the treatment of multiple brain metastases. This prospective nonrandomized controlled single arm trial attempts to reduce the gap until prospective randomized controlled trial results are available. MATERIAL AND METHODS We included patients with 4-10 brain metastases and ECOG performance status ≤ 2 from all histologies except small-cell lung cancer, germ cell tumors, and lymphoma. The retrospective WBRT-cohort was selected 2:1 from consecutive patients treated within 2012-2017. Propensity-score matching was performed to adjust for confounding factors such as sex, age, primary tumor histology, dsGPA score, and systemic therapy. SRS was performed using a LINAC-based single-isocenter technique employing prescription doses from 15-20Gyx1 at the 80% isodose line. The historical control consisted of equivalent WBRT dose regimens of either 3Gyx10 or 2.5Gyx14. RESULTS Patients were recruited from 2017-2020, end of follow-up was July 1st, 2021. 40 patients were recruited to the SRS-cohort and 70 patients were eligible as controls in the WBRT-cohort. Median OS, and iPFS were 10.4 months (95%-CI 9.3-NA) and 7.1 months (95%-CI 3.9-14.2) for the SRS-cohort, and 6.5 months (95%-CI 4.9-10.4), and 5.9 months (95%-CI 4.1-8.8) for the WBRT-cohort, respectively. Differences were non-significant for OS (HR: 0.65; 95%-CI 0.40-1.05; P =.074) and iPFS (P =.28). No grade III toxicities were observed in the SRS-cohort. CONCLUSION This trial did not meet its primary endpoint as the OS-improvement of SRS compared to WBRT was non-significant and thus superiority could not be proven. Prospective randomized trials in the era of immunotherapy and targeted therapies are warranted.
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Affiliation(s)
- Raphael Bodensohn
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany; Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Anna-Lena Kaempfel
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Anne-Laure Boulesteix
- Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Anna Maria Orzelek
- Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Daniel Felix Fleischmann
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany; German Cancer Consortium (DKTK), Munich, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Robert Forbrig
- Institute of Neuroradiology, University Hospital, LMU Munich, Munich, Germany
| | - Sylvia Garny
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Indrawati Hadi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Jan Hofmaier
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Giuseppe Minniti
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy; IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy
| | - Ulrich Mansmann
- Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | | | - Niklas Thon
- Department of Neurosurgery, University Hospital, LMU Munich, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany; German Cancer Consortium (DKTK), Munich, Germany; Department of Neurosurgery, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany; Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany; German Cancer Consortium (DKTK), Munich, Germany; Bavarian Cancer Research Center (BZKF), Munich, Germany.
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17
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Sun L, Kienzler JC, Reynoso JG, Lee A, Shiuan E, Li S, Kim J, Ding L, Monteleone AJ, Owens GC, Phillips JJ, Everson RG, Nathanson D, Cloughesy TF, Li G, Liau LM, Hugo W, Kim W, Prins RM. Immune checkpoint blockade induces distinct alterations in the microenvironments of primary and metastatic brain tumors. J Clin Invest 2023; 133:e169314. [PMID: 37655659 PMCID: PMC10471177 DOI: 10.1172/jci169314] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 07/12/2023] [Indexed: 09/02/2023] Open
Abstract
In comparison with responses in recurrent glioblastoma (rGBM), the intracranial response of brain metastases (BrM) to immune checkpoint blockade (ICB) is less well studied. Here, we present an integrated single-cell RNA-Seq (scRNA-Seq) study of 19 ICB-naive and 9 ICB-treated BrM samples from our own and published data sets. We compared them with our previously published scRNA-Seq data from rGBM and found that ICB led to more prominent T cell infiltration into BrM than rGBM. These BrM-infiltrating T cells exhibited a tumor-specific phenotype and displayed greater activated/exhausted features. We also used multiplex immunofluorescence and spatial transcriptomics to reveal that ICB reduced a distinct CD206+ macrophage population in the perivascular space, which may modulate T cell entry into BrM. Furthermore, we identified a subset of progenitor exhausted T cells that correlated with longer overall survival in BrM patients. Our study provides a comprehensive immune cellular landscape of ICB's effect on metastatic brain tumors and offers insights into potential strategies for improving ICB efficacy for brain tumor patients.
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Affiliation(s)
- Lu Sun
- Department of Neurosurgery, UCLA, Los Angeles, California, USA
| | - Jenny C. Kienzler
- Department of Neurosurgery, UCLA, Los Angeles, California, USA
- Inflammation Research Group, Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland
| | | | - Alexander Lee
- Department of Neurosurgery, UCLA, Los Angeles, California, USA
- Department of Molecular and Medical Pharmacology
| | | | | | | | - Lizhong Ding
- UCLA Jonsson Comprehensive Cancer Center (JCCC), and
- Department of Medicine/Dermatology, UCLA, Los Angeles, California, USA
- Parker Institute for Cancer Immunotherapy, San Francisco, California, USA
| | | | | | - Joanna J. Phillips
- Helen Diller Family Comprehensive Cancer Center and
- Department of Neurological Surgery, UCSF, San Francisco, California, USA
| | - Richard G. Everson
- Department of Neurosurgery, UCLA, Los Angeles, California, USA
- UCLA Jonsson Comprehensive Cancer Center (JCCC), and
| | - David Nathanson
- Department of Molecular and Medical Pharmacology
- UCLA Jonsson Comprehensive Cancer Center (JCCC), and
| | - Timothy F. Cloughesy
- Department of Neurosurgery, UCLA, Los Angeles, California, USA
- Department of Molecular and Medical Pharmacology
- UCLA Jonsson Comprehensive Cancer Center (JCCC), and
- Department of Neurology/Neuro-Oncology, UCLA, Los Angeles, California, USA
| | | | - Linda M. Liau
- Department of Neurosurgery, UCLA, Los Angeles, California, USA
- Department of Molecular and Medical Pharmacology
- UCLA Jonsson Comprehensive Cancer Center (JCCC), and
| | - Willy Hugo
- UCLA Jonsson Comprehensive Cancer Center (JCCC), and
- Department of Medicine/Dermatology, UCLA, Los Angeles, California, USA
- Parker Institute for Cancer Immunotherapy, San Francisco, California, USA
| | - Won Kim
- Department of Neurosurgery, UCLA, Los Angeles, California, USA
- UCLA Jonsson Comprehensive Cancer Center (JCCC), and
| | - Robert M. Prins
- Department of Neurosurgery, UCLA, Los Angeles, California, USA
- Department of Molecular and Medical Pharmacology
- UCLA Jonsson Comprehensive Cancer Center (JCCC), and
- Parker Institute for Cancer Immunotherapy, San Francisco, California, USA
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18
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Chen VE, Kim M, Nelson N, Kim IK, Shi W. Cost-effectiveness analysis of 3 radiation treatment strategies for patients with multiple brain metastases. Neurooncol Pract 2023; 10:344-351. [PMID: 37457226 PMCID: PMC10346394 DOI: 10.1093/nop/npac093] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023] Open
Abstract
Background Patients diagnosed with multiple brain metastases often survive for less than 2 years, and clinicians must carefully evaluate the impact of interventions on quality of life. Three types of radiation treatment are widely accepted for patients with multiple brain metastases: Whole brain radiation therapy (WBRT), hippocampal avoidance whole-brain radiation therapy (HA-WBRT), and stereotactic radiosurgery (SRS). WBRT, the standard option, is less costly than its newer alternatives but causes more severe adverse effects such as memory loss. To determine whether the cost-effectiveness ratio of HA-WBRT and SRS are superior to WBRT, we used published data to simulate cases of multiple brain metastases. Methods We designed a Markov model using data from previously published studies to simulate the disease course of patients with 5 to 15 brain metastases and determine the cost-effectiveness of HA-WBRT and SRS relative to WBRT. Incremental cost-effectiveness ratios (ICERs) were calculated and compared against a willingness-to-pay threshold of $100 000 per quality-adjusted life year. Results SRS met the threshold for cost-effectiveness, with ICERs ranging $41 198-$54 852 for patients with 5 to 15 brain metastases; however, HA-WBRT was not cost-effective, with an ICER of $163 915 for all simulated patients. Model results were robust to sensitivity analyses. Conclusions We propose that SRS, but not HA-WBRT, should be offered to patients with multiple brain metastases as a treatment alternative to standard WBRT. Incorporating these findings into clinical practice will help promote patient-centered care and decrease national healthcare expenditures, thereby addressing issues around health equity and access to care.
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Affiliation(s)
- Victor Eric Chen
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Minchul Kim
- Center for Outcomes Research, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - Nicolas Nelson
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Inkyu Kevin Kim
- College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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19
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Cuccia F, D'Alessandro S, Carruba G, Figlia V, Spera A, Cespuglio D, Mortellaro G, Iacoviello G, Lo Casto A, Tringali G, Craparo G, Blasi L, Ferrera G. Fractionated Stereotactic Radiotherapy with Helical Tomotherapy for Brain Metastases: A Mono-Institutional Experience. J Pers Med 2023; 13:1099. [PMID: 37511711 PMCID: PMC10381210 DOI: 10.3390/jpm13071099] [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: 05/26/2023] [Revised: 06/19/2023] [Accepted: 07/03/2023] [Indexed: 07/30/2023] Open
Abstract
Background: The present study reports on the outcomes of our mono-institutional experience of Helical Tomotherapy (HT)-based SRT for brain metastases. The use of this linac is less frequently reported for this kind of treatment. Methods: This retrospective study displays a series of patients treated with HT-SRT. The eligibility of using SRT for brain metastases was defined by a Karnofsky performance status of >70, a life expectancy of >6 months, and controlled extra-cranial disease; no SRT was allowed in the case of a number of brain metastases larger than 10. All the cases were discussed by a multidisciplinary board. Toxicity assessments were performed based on CTCAE v5.0. Survival endpoints were assessed using the Kaplan-Meier method, and univariate and multivariate analyses were carried out to identify any potential predictive factor for an improved outcome. Results: Sixty-four lesions in 37 patients were treated using HT-SRT with a median total dose of 30 Gy in five fractions. The median follow-up was 7 months, and the 1- and 2-year LC rates were both 92.5%. The IPFS rates were and 56.75% and 51.35%. The OS rates were 54% and 40%. The UA showed better IPFS rates significantly related to male sex (p = 0.049), a BED12 of ≥42 Gy (p = 0.006), and controlled extracranial disease (p = 0.03); in the MA, a favorable trend towards LC (p = 0.11) and higher BED (p = 0.11) schedules maintained a correlation with improved IPFS rates, although statistical significance was not reached. Conclusions: HT-based SRT for brain metastases showed safety and efficacy in our monoinstiutional experience. Higher RT doses showed statistical significance for improved outcomes of LC and OS.
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Affiliation(s)
| | | | - Giuseppe Carruba
- Division of Internationalization and Health Research (SIRS), ARNAS Civico Hospital, 90100 Palermo, Italy
| | - Vanessa Figlia
- Radiation Oncology, ARNAS Civico Hospital, 90100 Palermo, Italy
| | - Antonio Spera
- Radiation Oncology, ARNAS Civico Hospital, 90100 Palermo, Italy
| | | | | | | | - Antonio Lo Casto
- Radiation Oncology School, University of Palermo, 90133 Palermo, Italy
| | | | - Giuseppe Craparo
- Neuroradiology Unit, ARNAS Civico Hospital, 90100 Palermo, Italy
| | - Livio Blasi
- Medical Oncology, ARNAS Civico Hospital, 90100 Palermo, Italy
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20
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Shi W, Li Y, Sun H, Zhang L, Meng J, Wang X, Chen X, Zhang X, Mei X, Ma J, Mo M, Zhou C, Liang F, Shao Z, Zhang Z, Guo X, Yu X, Yang Z. Favorable prognosis of breast cancer brain metastases patients with limited intracranial and extracranial metastatic lesions. Radiat Oncol 2023; 18:107. [PMID: 37393259 DOI: 10.1186/s13014-023-02293-6] [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: 10/05/2022] [Accepted: 05/30/2023] [Indexed: 07/03/2023] Open
Abstract
BACKGROUND Breast cancer brain metastases (BCBM) are highly heterogenous with widely differing survival. The prognosis of the oligometastatic breast cancer (BC) patients with brain metastases (BM) has not been well studied. We aimed to investigate the prognosis of BCBM patients with limited intracranial and extracranial metastatic lesions. METHODS Four hundred and forty-five BCBM patients treated between 1st January 2008 and 31st December 2018 at our institute were included. Clinical characteristics and treatment information were obtained from patient's medical records. The updated breast Graded Prognostic Assessment (Breast GPA) was calculated. RESULTS The median OS after diagnosis of BM were 15.9 months. Median OS for patients with GPA 0-1.0, 1.5-2, 2.5-3 and 3.5-4 were 6.9, 14.2, 21.8, 42.6 months respectively. The total number of intracranial and extracranial metastatic lesions, in addition to the Breast GPA, salvage local therapy and systemic therapy (anti-HER2 therapy, chemotherapy and endocrine therapy) were demonstrated to be associated with prognosis. One hundred and thirteen patients (25.4%) had 1-5 total metastatic lesions at BM diagnosis. Patients with 1-5 total metastatic lesions had a significantly longer median OS of 24.3 months compared to those with greater than 5 total metastatic lesions with a median OS of 12.2 months (P < 0.001; multivariate HR 0.55, 95% CI, 0.43-0.72). Among the patients with 1-5 metastatic lesions, median OS for GPA 0-1.0 was 9.8 months, compared to 22.8, 28.8 and 71.0 for GPA 1.5-2.0, 2.5-3.0 and 3.5-4.0 respectively, which is much longer than the corresponding patients with greater than 5 total metastatic lesions, with medium OS of 6.8, 11.6, 18.6 and 42.6 months respectively for GPA 0-1.0, 1.5-2.0, 2.5-3.0 and 3.5-4.0. CONCLUSIONS The patients with 1-5 total metastatic lesions demonstrated better OS. The prognostic value of the Breast GPA and the survival benefit of salvage local therapy and continuation of systemic therapy after BM were confirmed.
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Affiliation(s)
- Wei Shi
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Yang Li
- Affiliated Hospital of Jining Medical University, Jining, 272029, Shandong, China
| | - Hua Sun
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Li Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Jin Meng
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Xiaofang Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Xingxing Chen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Xiaomeng Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Xin Mei
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Jinli Ma
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Miao Mo
- Department of Cancer Prevention and Clinical Statistics Center, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
| | - Changming Zhou
- Department of Cancer Prevention and Clinical Statistics Center, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
| | - Fei Liang
- Department of Biostatistics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhimin Shao
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Xiaomao Guo
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Xiaoli Yu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China.
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China.
| | - Zhaozhi Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China.
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
- Shanghai Clinical Research Center for Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China.
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Nagai N, Koide Y, Shindo Y, Hashimoto S, Tachibana H, Kodaira T, Ishihara S, Naganawa S. Retrospective non-inferiority study of stereotactic radiosurgery for more than ten brain metastases. J Neurooncol 2023; 163:385-395. [PMID: 37286638 DOI: 10.1007/s11060-023-04358-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/29/2023] [Indexed: 06/09/2023]
Abstract
AIM This study aimed to investigate the clinical benefits of stereotactic radiosurgery (SRS) in patients with > 10 brain metastases (BM) compared to patients with 2-10 BM. METHODS The study included multiple BM patients who underwent SRS between 2014 and 2022, excluding patients who underwent whole brain radiotherapy, had a Karnofsky Performance Status score < 60, suspected leptomeningeal disease, or a single BM lesion. Patients were divided into two groups (2-10 and > 10 BM groups) and matched 2:1 based on propensity scores. The primary endpoint was overall survival (OS) in the matched dataset, with intracranial progression-free survival (PFS) as the secondary endpoint. Non-inferiority was established if the upper limit of the 95% confidence interval (CI) of the adjusted hazard ratio was below 1.3. RESULTS Of the 1042 patients identified, 434 met eligibility criteria. After propensity score matching, 240 patients were analyzed (160 in the BM 2-10 group and 80 in the > 10 BM group). The median OS was 18.2 months in the 2-10 BM group and 19.4 months in the > 10 BM group (P = 0.60). The adjusted hazard ratio was 0.86 (95% CI: 0.59-1.24), indicating non-inferiority. PFS was not significantly different between the groups (4.8 months vs. 4.8 months, P = 0.94). The number of BM did not significantly impact OS or PFS. CONCLUSIONS SRS for selected patients with > 10 BM was non-inferior in terms of OS compared to those with 2-10 BM in a propensity score-matched dataset.
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Affiliation(s)
- Naoya Nagai
- Department of Radiation Oncology, Aichi Cancer Center, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Postal Code: 464-0824, Japan
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yutaro Koide
- Department of Radiation Oncology, Aichi Cancer Center, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Postal Code: 464-0824, Japan.
| | - Yurika Shindo
- Department of Radiation Oncology, Aichi Cancer Center, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Postal Code: 464-0824, Japan
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shingo Hashimoto
- Department of Radiation Oncology, Aichi Cancer Center, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Postal Code: 464-0824, Japan
| | - Hiroyuki Tachibana
- Department of Radiation Oncology, Aichi Cancer Center, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Postal Code: 464-0824, Japan
| | - Takeshi Kodaira
- Department of Radiation Oncology, Aichi Cancer Center, Kanokoden 1-1, Chikusa-Ku, Nagoya, Aichi, Postal Code: 464-0824, Japan
| | - Shunichi Ishihara
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shinji Naganawa
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Farris JC, Hughes RT, Razavian NB, Pearce JB, Snavely AC, Chan MD, Steber CR, Leyrer CM, Bunch PM, Willey JS, Farris MK. Brain Metastasis Incidence and Patterns of Presentation After Definitive Treatment of Locally Advanced Non-Small Cell Lung Cancer: A Potential Argument for Brain Magnetic Resonance Imaging Surveillance. Adv Radiat Oncol 2023; 8:101058. [PMID: 37273925 PMCID: PMC10238260 DOI: 10.1016/j.adro.2022.101058] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/11/2022] [Indexed: 06/06/2023] Open
Abstract
Purpose Brain metastases (BMs) are a common source of morbidity and mortality. Guidelines do not advise brain surveillance for locally advanced non-small cell lung cancer (LA-NSCLC). We describe the incidence, time to development, presentation, and management of BMs after definitive chemoradiotherapy (CRT). Methods and Materials We reviewed records of patients with LA-NSCLC treated with CRT within the period from 2013 to 2020. Descriptive statistics were used to characterize the population and the Kaplan-Meier method was used to estimate time to BM. Fisher exact tests and Wilcoxon rank-sum tests were used to compare outcomes between symptomatic and asymptomatic patients. Results A total of 219 patients were reviewed including 96 with squamous cell carcinoma, 88 with adenocarcinoma, and 35 with large cell/not otherwise specified (LC/NOS). Thirty-nine patients (17.8%) developed BMs: 35 (90%) symptomatic and 4 (10%) asymptomatic. The rate of BM was highest in LC/NOS (34.3%) and adenocarcinoma (23.9%). Ninety percent of BMs occurred within 2 years. All asymptomatic patients underwent stereotactic radiosurgery alone, compared with 40% of symptomatic patients (P = .04). Symptomatic patients were more likely to require hospitalization (65.7% vs 0%, P = .02), craniotomy (25.7% vs 0%, not significant), and steroids (91.4% vs 0%, P < .001). Cumulative BM volume was higher for symptomatic patients (4 vs 0.24 cm3, P < .001) as was median greatest axial dimension (2.18 vs 0.52 cm, P < .001). Conclusions We identified a high rate of BMs, particularly in LC/NOS and adenocarcinoma histology NSCLC. The majority were symptomatic. These results provide rationale for post-CRT magnetic resonance imaging brain surveillance for patients at high risk of BM.
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Affiliation(s)
- Joshua C. Farris
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Ryan T. Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Niema B. Razavian
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Jane B. Pearce
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Anna C. Snavely
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Michael D. Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Cole R. Steber
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - C. Marc Leyrer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Paul M. Bunch
- Department of Radiology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Jeffrey S. Willey
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Michael K. Farris
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
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23
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Matsui JK, Perlow HK, Upadhyay R, McCalla A, Raval RR, Thomas EM, Blakaj DM, Beyer SJ, Palmer JD. Advances in Radiotherapy for Brain Metastases. Surg Oncol Clin N Am 2023; 32:569-586. [PMID: 37182993 DOI: 10.1016/j.soc.2023.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Radiotherapy remains a cornerstone treatment of brain metastases. With new treatment advances, patients with brain metastases are living longer, and finding solutions for mitigating treatment-related neurotoxicity and improving quality of life is important. Historically, whole-brain radiation therapy (WBRT) was widely used but treatment options such as hippocampal sparing WBRT and stereotactic radiosurgery (SRS) have emerged as promising alternatives. Herein, we discuss the recent advances in radiotherapy for brain metastases including the sparing of critical structures that may improve long-term neurocognitive outcomes (eg, hippocampus, fornix) that may improve long-term neurocognitive outcome, evidence supporting preoperative and fractionated-SRS, and treatment strategies for managing radiation necrosis.
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24
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Becker SJ, Lipson EJ, Jozsef G, Molitoris JK, Silverman JS, Presser J, Kondziolka D. How many brain metastases can be treated with stereotactic radiosurgery before the radiation dose delivered to normal brain tissue rivals that associated with standard whole brain radiotherapy? J Appl Clin Med Phys 2023; 24:e13856. [PMID: 36628586 PMCID: PMC10018670 DOI: 10.1002/acm2.13856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/03/2022] [Accepted: 11/14/2022] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Clinical trial data comparing outcomes after administration of stereotactic radiosurgery (SRS) or whole-brain radiotherapy (WBRT) to patients with brain metastases (BM) suggest that SRS better preserves cognitive function and quality of life without negatively impacting overall survival. Here, we estimate the maximum number of BM that can be treated using single and multi-session SRS while limiting the dose of radiation delivered to normal brain tissue to that associated with WBRT. METHODS Multiple-tumor SRS was simulated using a Monte Carlo - type approach and a pre-calculated dose kernel method. Tumors with diameters ≤36 mm were randomly placed throughout the contoured brain parenchyma until the brain mean dose reached 3 Gy, equivalent to the radiation dose delivered during a single fraction of a standard course of WBRT (a total dose of 30 Gy in 10 daily fractions of 3 Gy). Distribution of tumor sizes, dose coverage, selectivity, normalization, and maximum dose data used in the simulations were based on institutional clinical metastases data. RESULTS The mean number of tumors treated, mean volume of healthy brain tissue receiving > 12 Gy (V12) per tumor, and total tumor volume treated using mixed tumor size distributions were 12.7 ± 4.2, 2.2 cc, and 12.9 cc, respectively. Thus, we estimate that treating 12-13 tumors per day over 10 days would deliver the dose of radiation to healthy brain tissue typically associated with a standard course of WBRT. CONCLUSION Although in clinical practice, treatment with SRS is often limited to patients with ≤15 BM, our findings suggest that many more lesions could be targeted while still minimizing the negative impacts on quality of life and neurocognition often associated with WBRT. Results from this in silico analysis require clinical validation.
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Affiliation(s)
- Stewart J Becker
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Evan J Lipson
- Bloomberg∼Kimmel Institute for Cancer Immunotherapy and Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland, USA
| | - Gabor Jozsef
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York, USA
| | - Jason K Molitoris
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joshua S Silverman
- Department of Radiation Oncology, New York University Langone Medical Center, New York, New York, USA
| | - Joseph Presser
- Department of Radiation Oncology, Mount Sinai South Nassau, Oceanside, New York, USA
| | - Douglas Kondziolka
- Department of Radiation Oncology, New York University Langone Medical Center, New York, New York, USA.,Department of Neurosurgery, New York University Langone Medical Center, New York, New York, USA
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25
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Zhang C, Zhou W, Zhang D, Ma S, Wang X, Jia W, Guan X, Qian K. Treatments for brain metastases from EGFR/ALK-negative/unselected NSCLC: A network meta-analysis. Open Med (Wars) 2023; 18:20220574. [PMID: 36820064 PMCID: PMC9938645 DOI: 10.1515/med-2022-0574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 08/26/2022] [Accepted: 08/30/2022] [Indexed: 02/16/2023] Open
Abstract
More clinical evidence is needed regarding the relative priority of treatments for brain metastases (BMs) from EGFR/ALK-negative/unselected non-small cell lung cancer (NSCLC). PubMed, EMBASE, Web of Science, Cochrane Library, and ClinicalTrials.gov databases were searched. Overall survival (OS), central nervous system progression-free survival (CNS-PFS), and objective response rate (ORR) were selected for Bayesian network meta-analyses. We included 25 eligible randomized control trials (RCTs) involving 3,054 patients, investigating nine kinds of treatments for newly diagnosed BMs and seven kinds of treatments for previously treated BMs. For newly diagnosed BMs, adding chemotherapy, EGFR-TKIs, and other innovative systemic agents (temozolomide, nitroglycerin, endostar, enzastaurin, and veliparib) to radiotherapy did not significantly prolong OS than radiotherapy alone; whereas radiotherapy + nitroglycerin showed significantly better CNS-PFS and ORR. Surgery could significantly prolong OS (hazard ratios [HR]: 0.52, 95% credible intervals: 0.41-0.67) and CNS-PFS (HR: 0.32, 95% confidence interval: 0.18-0.59) compared with radiotherapy alone. For previously treated BMs, pembrolizumab + chemotherapy, nivolumab + ipilimumab, and cemiplimab significantly prolonged OS than chemotherapy alone. Pembrolizumab + chemotherapy also showed better CNS-PFS and ORR than chemotherapy. In summary, immune checkpoint inhibitor (ICI)-based therapies, especially ICI-combined therapies, showed promising efficacies for previously treated BMs from EGFR/ALK-negative/unselected NSCLC. The value of surgery should also be emphasized. The result should be further confirmed by RCTs.
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Affiliation(s)
- Chengkai Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing100071, China
| | - Wenjianlong Zhou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing100071, China
| | - Dainan Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing100071, China
| | - Shunchang Ma
- Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing100071, China
| | - Xi Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing100071, China
| | - Wang Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing100071, China,Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing100071, China
| | - Xiudong Guan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 West Road, Beijing100071, China
| | - Ke Qian
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 West Road, Beijing100071, China
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26
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Dosimetric Impact of Lesion Number, Size, and Volume on Mean Brain Dose with Stereotactic Radiosurgery for Multiple Brain Metastases. Cancers (Basel) 2023; 15:cancers15030780. [PMID: 36765738 PMCID: PMC9913147 DOI: 10.3390/cancers15030780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
We evaluated the effect of lesion number and volume for brain metastasis treated with SRS using GammaKnife® ICON™ (GK) and CyberKnife® M6™ (CK). Four sets of lesion sizes (<5 mm, 5-10 mm, >10-15 mm, and >15 mm) were contoured and prescribed a dose of 20 Gy/1 fraction. The number of lesions was increased until a threshold mean brain dose of 8 Gy was reached; then individually optimized to achieve maximum conformity. Across GK plans, mean brain dose was linearly proportional to the number of lesions and total GTV for all sizes. The numbers of lesions needed to reach this threshold for GK were 177, 57, 29, and 10 for each size group, respectively; corresponding total GTVs were 3.62 cc, 20.37 cc, 30.25 cc, and 57.96 cc, respectively. For CK, the threshold numbers of lesions were 135, 35, 18, and 8, with corresponding total GTVs of 2.32 cc, 12.09 cc, 18.24 cc, and 41.52 cc respectively. Mean brain dose increased linearly with number of lesions and total GTV while V8 Gy, V10 Gy, and V12 Gy showed quadratic correlations to the number of lesions and total GTV. Modern dedicated intracranial SRS systems allow for treatment of numerous brain metastases especially for ≤10 mm; clinical evidence to support this practice is critical to expansion in the clinic.
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27
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Geometric and dosimetric consequences of intra-fractional movement in single isocenter non-coplanar stereotactic radiosurgery. Radiat Oncol 2023; 18:9. [PMID: 36631832 PMCID: PMC9835346 DOI: 10.1186/s13014-022-02195-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 12/29/2022] [Indexed: 01/13/2023] Open
Abstract
PURPOSE To investigate the geometric and dosimetric impacts of intra-fractional movement for patients with single or multiple brain metastasis treated using Varian Hyperarc™ mono-isocentric radiosurgery. METHODS A total of 50 single or hypo-fractionated Hyperarc™ treatment courses (118 lesions) were included in the analysis. Intra-fractional translational and rotational movements were quantified according to the post-treatment cone-beam CT (CBCT). Geometric displacements of all targets were calculated individually based on the assessed head movement in each treatment fraction and their relationships with treatment time and target-to-isocenter distances were studied. For dosimetric analysis, only single-fraction treatments (56 lesions) were included. Re-planning was performed with 0, 1, and 2 mm planning target volume (PTV) margins. Doses were then re-calculated on rotated CT images with isocenter shifted which emulate the change in patient treatment position. Target coverage, target and normal brain doses before and after intra-fractional movement were compared. RESULTS The mean 3D target displacements was 0.6 ± 0.3 (SD) mm. Target shifts for patients treated within 10 min were significantly smaller than those treated in longer sessions. No correlation was found between target shift and target-to-isocenter distance as the origin of head rotation was not located at the isocenter. Loss of target coverage and minimum Gross Tumor Volume (GTV) dose due to intra-fractional movement were apparent only when no margin was used, leading to an extra 23% of the targets violating the dose acceptance criteria, in contrast, the effects on normal brain V12Gy were negligible regardless of the margin used. The use of 1 mm PTV margin can compensate clinically significant geographical miss caused by intra-fractional movements while limiting V12Gy to within dose criteria for 88% of the cases. The plan acceptance rate (fulfillment of both target and normal brain dose criteria) after intra-fractional movement was also the highest with the 1 mm margin. CONCLUSION Although intra-fractional movements during Hyperarc™ treatments were small, there were substantial dosimetric effects due to the sharp dose fall-off near target boundaries. These effects could be mitigated by using a 1 mm PTV margin and maintaining the effective treatment time to within 10 min.
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Rossi S, Marinello A, Pagliaro A, Franceschini D, Navarria P, Finocchiaro G, Toschi L, Scorsetti M, Santoro A. Current treatment approaches for brain metastases in ALK/ ROS1/ NTRK-positive non-small-cell lung cancer. Expert Rev Anticancer Ther 2023; 23:29-41. [PMID: 36548111 DOI: 10.1080/14737140.2023.2162044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Oncogene-addicted non-small cell lung cancer (NSCLC) patients present a high incidence of CNS metastases either at diagnosis or during the course of the disease. In this case, patients present with worse prognosis and are often excluded from clinical trials unless brain metastases are pre-treated or clinically stable. AREAS COVERED As a result of the discovery of several oncogenic drivers in ALK/ROS1/NTRK-positive NSCLC, targeted agents have been tested in several trials. We evaluate and compare the intracranial efficacy of available targeted agents in ALK/ROS1/NTRK-positive NSCLC based on subgroup analysis from pivotal trials. EXPERT OPINION Last-generation ALK inhibitors have shown slightly superior intracranial activity but pivotal trials do not consider the same endpoints for intracranial efficacy, therefore data are not comparable. Local treatments for BM including surgical resection, stereotactic radiosurgery (SRS) and WBRT, should be integrated with systemic therapies basing on specific criteria like presence of oligoprogression or symptomatic progression.
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Affiliation(s)
- Sabrina Rossi
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Arianna Marinello
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Arianna Pagliaro
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Davide Franceschini
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Pierina Navarria
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Giovanna Finocchiaro
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Luca Toschi
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Marta Scorsetti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Armando Santoro
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Hirata M, Yasui K, Oota N, Ogawa H, Onoe T, Maki S, Ito Y, Hayashi K, Asakura H, Murayama S, Mitsuya K, Deguchi S, Nakamura K, Hayashi N, Nishimura T, Harada H. Feasibility of linac-based fractionated stereotactic radiotherapy and stereotactic radiosurgery for patients with up to ten brain metastases. Radiat Oncol 2022; 17:213. [PMID: 36578021 PMCID: PMC9795627 DOI: 10.1186/s13014-022-02185-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Linac-based fractionated stereotactic radiotherapy (fSRT) and stereotactic radiosurgery (SRS) are increasingly being used to manage patients with multiple metastases. This retrospective cohort study aimed to compare the outcomes after linac-based fSRT and SRS between three patient groups classified based on the number of brain metastases (BMs): 1 BM, 2-4 BM, 5-10 BM. METHODS The data of consecutive patients with 1-10 BMs treated with fSRT or SRS between July 2016 and June 2018 at a single institution were collected. Patients with previous whole-brain radiotherapy (WBRT), concurrent use of WBRT, or surgical resection were excluded from the analysis. A total of 176 patients were classified into three groups according to the number of BMs: 78, 67, and 31 patients in 1 BM, 2-4 BM, and 5-10 BM, respectively. The Kaplan-Meier method was used to estimate overall survival (OS) curves, and the cumulative incidence with competing risks was used to estimate local control (LC), distant intracranial failure (DIF), and radiation necrosis (RN). RESULTS Median OS was 19.8 months (95% confidence interval [CI] 10.2-27.5), 7.3 months (4.9-11.1), and 5.1 months (4.0-9.0) in 1 BM, 2-4 BM, and 5-10 BM, respectively. Compared to 2-4 BM, 1 BM had significantly better OS (hazard ratio [HR] 0.59, 95% CI 0.40-0.87; p = 0.0075); however, 5-10 BM had comparable OS (HR 1.36, 95% CI 0.85-2.19; p = 0.199). There was no significant difference in LC, DIF, and RN between tumor number groups, but DIF was lower in 1 BM. RN of grade 2 or higher occurred in 21 patients (13.5%); grade 4 and 5 RN were not observed. CONCLUSIONS The linac-based fSRT and SRS for patients with 5-10 BMs is comparable to that for patients with 2-4 BMs in OS, LC, DIF, and RN. It seems reasonable to use linac-based fSRT and SRS in patients with 5-10 BMs.
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Affiliation(s)
- Masanori Hirata
- grid.415797.90000 0004 1774 9501Radiation and Proton Therapy Center, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777 Japan ,grid.471533.70000 0004 1773 3964Department of Radiation Oncology, Hamamatsu University Hospital, Shizuoka, Japan
| | - Kazuaki Yasui
- grid.415797.90000 0004 1774 9501Radiation and Proton Therapy Center, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777 Japan
| | - Naofumi Oota
- grid.415797.90000 0004 1774 9501Radiation and Proton Therapy Center, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777 Japan
| | - Hirofumi Ogawa
- grid.415797.90000 0004 1774 9501Radiation and Proton Therapy Center, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777 Japan
| | - Tsuyoshi Onoe
- grid.415797.90000 0004 1774 9501Radiation and Proton Therapy Center, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777 Japan
| | - Sayo Maki
- grid.415797.90000 0004 1774 9501Radiation and Proton Therapy Center, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777 Japan
| | - Yusuke Ito
- grid.415797.90000 0004 1774 9501Radiation and Proton Therapy Center, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777 Japan
| | - Kenji Hayashi
- grid.415797.90000 0004 1774 9501Radiation and Proton Therapy Center, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777 Japan
| | - Hirofumi Asakura
- grid.415797.90000 0004 1774 9501Radiation and Proton Therapy Center, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777 Japan
| | - Shigeyuki Murayama
- grid.415797.90000 0004 1774 9501Radiation and Proton Therapy Center, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777 Japan
| | - Koichi Mitsuya
- grid.415797.90000 0004 1774 9501Division of Neurosurgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Shoichi Deguchi
- grid.415797.90000 0004 1774 9501Division of Neurosurgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsumasa Nakamura
- grid.471533.70000 0004 1773 3964Department of Radiation Oncology, Hamamatsu University Hospital, Shizuoka, Japan
| | - Nakamasa Hayashi
- grid.415797.90000 0004 1774 9501Division of Neurosurgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Tetsuo Nishimura
- grid.415797.90000 0004 1774 9501Radiation and Proton Therapy Center, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777 Japan
| | - Hideyuki Harada
- Radiation and Proton Therapy Center, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777, Japan.
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Dial C, Sarkar V, Nelson G, Paxton A, Salter B. Technical note: A method for generating lesion-specific nonuniform rotational margins for targets remote from isocenter. Med Phys 2022; 49:7438-7446. [PMID: 36201254 DOI: 10.1002/mp.16013] [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: 11/30/2021] [Revised: 08/27/2022] [Accepted: 09/04/2022] [Indexed: 12/27/2022] Open
Abstract
PURPOSE To present a novel method for generating nonuniform lesion-specific rotational margins for targets remote from isocenter, as encountered in single isocenter multiple metastasis radiotherapy. METHODS Target contours are rotated using a large series of 3D rotations, corresponding to a given range of rotational uncertainty, and combined to create a rotational envelope that encompasses potential motion. A set of artificial spherical targets ranging from 0.5 to 2.0 cm in diameter, and residing a distance of 1 - 15 cm from isocenter, is used to generate rotational envelopes assuming uncertainties of 0.5-3.0°. Computing time and number of samples are reported for simulated scenarios. Hausdorff distances (HD) between rotational envelopes and original target structures are calculated to represent the magnitude of uniform expansion required to encompass potential rotation. Volume differences between uniform expansions (based on HD) and rotational envelopes are reported to articulate potential advantages. RESULTS Median time to generate rotational envelopes was 60 s (31-974 s). Median required samples was 86 (61-851). Maximum HD for all targets located 10 cm from isocenter was 1.5 mm, 3.0 mm, 5.8 mm, and 8.6 mm assuming 0.5°, 1.0°, 2.0°, and 3.0° of rotational uncertainty, respectively. At 5 cm from isocenter and assuming 0.5° of rotational uncertainty, volumes were decreased by 0.07 cc (60%), 0.24 cc (39%), and 1.08 cc (19%) for 5 mm, 10 mm, and 20 mm targets respectively. At 10 cm from isocenter and 1.0° of uncertainty, volumes decreased by 0.42 cc (58%), 2.0 cc (40%), and 2.5 cc (27%). On average target volumes decreased 45% (SD = 17%) when compared with uniform expansions based on HD. CONCLUSION Rotational margins may be generated by sampling a set of 3D rotations. Resulting margins explicitly account for target shape, distance from isocenter, and magnitude of rotational uncertainty, while reducing treated volumes when compared with uniform expansions.
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Affiliation(s)
- Christian Dial
- Department of Radiation Oncology, University of Utah, 1950 Circle of Hope Dr., Salt Lake City, Utah, USA
| | - Vikren Sarkar
- Department of Radiation Oncology, University of Utah, 1950 Circle of Hope Dr., Salt Lake City, Utah, USA
| | - Geoff Nelson
- Department of Radiation Oncology, University of Utah, 1950 Circle of Hope Dr., Salt Lake City, Utah, USA
| | - Adam Paxton
- Department of Radiation Oncology, University of Utah, 1950 Circle of Hope Dr., Salt Lake City, Utah, USA
| | - Bill Salter
- Department of Radiation Oncology, University of Utah, 1950 Circle of Hope Dr., Salt Lake City, Utah, USA
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Hou C, Yin H, Gong G, Wang L, Su Y, Lu J, Yin Y. A novel approach for dose painting radiotherapy of brain metastases guided by mr perfusion images. Front Oncol 2022; 12:828312. [DOI: 10.3389/fonc.2022.828312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 11/15/2022] [Indexed: 12/05/2022] Open
Abstract
PurposeTo investigate the feasibility and dosimetric index features of dose painting guided by perfusion heterogeneity for brain metastasis (BMs) patients.MethodsA total of 50 patients with single BMs were selected for this study. CT and MR simulation images were obtained, including contrast-enhanced T1-weighted images (T1WI+C) and cerebral blood flow (CBF) maps from 3D-arterial spin labeling (ASL). The gross tumor volume (GTV) was determined by fusion of CT and T1WI+C images. Hypoperfused subvolumes (GTVH) with less than 25% of the maximum CBF value were defined as the dose escalation region. The planning target volume (PTV) and PTVH were calculated from GTV and GTVH respectively. The PTVN was obtained by subtracting PTVH from PTV, and conventional dose was given. Three kinds of radiotherapy plans were designed based on the CBF values. Plan 1 was defined as the conventional plan with an arbitrary prescription dose of 60 Gy for PTV. For dose painting, Plan 2 and Plan 3 escalated the prescription dose for PTVH to 72 Gy based on Plan 1, but Plan 3 removed the maximum dose constraint. Dosimetric indices were compared among the three plans.ResultsThe mean GTV volume was 34.5 (8.4-118.0) cm3, and mean GTVH volume was 17.0 (4.5-58.3) cm3, accounting for 49.3% of GTV. Both conventional plan and dose painting plans achieved 98% target coverage. The conformity index of PTVH were 0.44 (Plan1), 0.64 and 0.72 (Plan 2 and Plan 3, P<0.05). Compared to Plan 1, the D2%, D98% and Dmean values of the PTVH escalated by 20.50%, 19.32%, and 19.60% in Plan 2 and by 24.88%, 17.22% and 19.22% in Plan 3 respectively (P<0.05). In the three plans, the index of achievement value for PTVH was between 1.01 and 1.03 (P<0.05). The dose increment rates of Plan 2 and Plan 3 for each organs at risk (OARs) was controlled at 2.19% - 5.61% compared with Plan 1. The doses received by OARs did not significantly differ among the three plans (P >0.05).ConclusionsBMs are associated with significant heterogeneity, and effective escalation of the dose delivered to target subvolumes can be achieved with dose painting guided by 3D-ASL without extra doses to OARs.
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Lanier CM, Pearce J, Isom S, Xing F, Lo HW, Whitlow CT, Ruiz J, White JJ, Laxton AW, Tatter SB, Cramer CK, Chan MD. Long term survivors of stereotactic radiosurgery for brain metastases: do distant brain failures reach a plateau and what factors are associated with a brain metastasis velocity of zero? J Neurooncol 2022; 160:643-648. [DOI: 10.1007/s11060-022-04183-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/22/2022] [Indexed: 11/09/2022]
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Hayashi N, Kurata S, Saito Y, Ogawa S, Yasui K. Simple quality assurance based on filtered back projection for geometrical/irradiation accuracy in single-isocenter multiple-target stereotactic radiotherapy. Radiol Phys Technol 2022; 15:409-416. [PMID: 36261754 DOI: 10.1007/s12194-022-00683-1] [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: 06/25/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 10/24/2022]
Abstract
In single-isocenter multiple-target stereotactic radiotherapy (SIMT-SRT), it is difficult to evaluate both the geometrical accuracy and absorbed dose measurement when irradiating off-isocenter targets. This study aimed to develop a simple quality assurance (QA) method to evaluate off-isocenter irradiation position accuracy in SIMT-SRT and compare its feasibility with that of a commercial device. First, we created two types of inserts and metallic balls with a diameter of 5 mm to be inserted into a commercially available phantom (SIMT phantom). Second, we developed a dedicated analysis software using Python for the Winston-Lutz test (WLT). Third, an image processing software, including the filtered back-projection algorithm, was developed to analyze the images obtained using an electronic portal imaging device (EPID). Fourth, the feasibility of our method was evaluated by comparing it with the results of WLT using two commercially available phantoms: WL-QA and MultiMet-WL cubes. Notably, 92% of the results in one-dimensional deviations were within 0.26 mm (EPID pixel width). The correlation coefficients were 0.52, 0.92, and 0.96 in the left-right, superior-inferior, and anterior-posterior directions, respectively. In the WLT, a maximum two-dimensional deviation of 0.70 mm was detected in our method, while the deviation in the other method was within 0.5 mm. The advantage of our method is that it can evaluate the geometrical accuracy at any gantry angle during dynamic rotation irradiation using a filtered back-projection algorithm, even if the target is located off the isocenter. Our method can perform WLT at arbitrary positions and is suitable for the QA of dynamic rotation irradiation using an EPID.
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Affiliation(s)
- Naoki Hayashi
- School of Medical Sciences, Fujita Health University, Toyoake, Aichi, Japan.
| | - Shun Kurata
- School of Medical Sciences, Fujita Health University, Toyoake, Aichi, Japan.,Department of Radiology, Kindai University Hospital, Osakasayama, Osaka, Japan
| | - Yasunori Saito
- School of Medical Sciences, Fujita Health University, Toyoake, Aichi, Japan.,Department of Radiology, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Shuta Ogawa
- Department of Radiology, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Keisuke Yasui
- School of Medical Sciences, Fujita Health University, Toyoake, Aichi, Japan
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Asso RN, Mancini A, Palhares DMF, Junior WFPPN, Marta GN, da Silva JLF, Ramos BFG, Gadia R, Hanna SA. Radiosurgery for multiple brain metastases using volumetric modulated arc therapy: a single institutional series. Rep Pract Oncol Radiother 2022; 27:593-601. [PMID: 36196425 PMCID: PMC9521688 DOI: 10.5603/rpor.a2022.0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 05/04/2022] [Indexed: 11/25/2022] Open
Abstract
Background Patients with brain metastases (BM) live longer due to improved diagnosis and oncologic treatments. The association of volumetric modulated arc therapy (VMAT) and image-guided radiation therapy (IGRT) with brain radiosurgery (SRS) allows complex dose distributions and faster treatment delivery to multiple lesions. Materials and methods This study is a retrospective analysis of SRS for brain metastasis using VMAT. The primary endpoints were local disease-free survival (LDFS) and overall survival (OS). The secondary outcomes were intracranial disease-free survival (IDFS) and meningeal disease-free survival (MDFS). Results The average number of treated lesions was 5.79 (range: 2-20) per treatment in a total of 113 patients. The mean prescribed dose was 18 Gy (range: 12-24 Gy). The median LDFS was 46 months. The LDFS in 6, 12, and 24 months was for 86%, 79%, and 63%, respectively. Moreover, brain progression occurred in 50 patients. The median overall survival was 47 months. The OS in 75%, 69%, and 61% patients was 6, 12, and 24 months, respectively. IDFS was 6 and 24 months in 35% and 14% patients, respectively. The mean MDFS was 62 months; it was 6 and 24 months for 87% and 83% of patients. Acute severe toxicity was relatively rare. During follow-up, the rates of radionecrosis and neurocognitive impairment were low (10%). Conclusion The use of VMAT-SRS for multiple BM was feasible, effective, and associated with low treatment-related toxicity rates. Thus, treatment with VMAT is a safe technique to plan to achieve local control without toxicity.
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Affiliation(s)
- Rie Nadia Asso
- McGill University Health Centre Glen Site (MUHC), Montreal, Canada
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Sita TL, Gopalakrishnan M, Rooney MK, Ho A, Savoor R, Sonabend AM, Tate MC, Chandler JP, Lesniak MS, Kruser TJ, Kalapurakal JA, Sachdev S. Mean Brain Dose Remains Uninfluenced by the Lesion Number for Gamma Knife Stereotactic Radiosurgery for 10+ Metastases. World Neurosurg 2022; 165:e380-e385. [PMID: 35724885 DOI: 10.1016/j.wneu.2022.06.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/10/2022] [Accepted: 06/11/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Gamma Knife (GK) stereotactic radiosurgery (SRS) is increasingly used as an initial treatment for patients with 10 or more brain metastases. However, the clinical and dosimetric consequences of this practice are not well established. METHODS We performed a single-institution, retrospective analysis of 30 patients who received Gamma Knife SRS for 10 or more brain metastases in 1 session. We utilized MIM Software to contour the whole brain and accumulated the doses from all treated lesions to determine the mean dose delivered to the whole brain. Patient outcomes were determined from chart review. RESULTS Our cohort had a median number of 13 treated lesions (range 10-26 lesions) for a total of 427 treated lesions. The mean dose to the whole brain was determined to be 1.8 ± 0.91 Gy (range 0.70-3.8 Gy). The mean dose to the whole brain did not correlate with the number of treated lesions (Pearson r = 0.23, P = 0.21), but was closely associated with tumor volume (Pearson r = 0.95, P < 0.0001). There were no significant correlations between overall survival and number of lesions or aggregate tumor volume. Fourteen patients (47%) underwent additional SRS sessions and 6 patients (20%) underwent whole-brain radiotherapy with a median of 6.6 months (range 3.0-50 months) after SRS. Two patients (6.6%) developed grade 2 radionecrosis following SRS beyond earlier whole-brain radiotherapy. CONCLUSION The mean dose to the whole brain in patients treated with Gamma Knife SRS for 10 or more brain metastases remained low with an acceptable rate of radionecrosis. This strategy allowed the majority of patients to avoid subsequent whole-brain radiotherapy.
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Affiliation(s)
- Timothy L Sita
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mahesh Gopalakrishnan
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael K Rooney
- Department of Radiation Oncology, M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Alexander Ho
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rohan Savoor
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Adam M Sonabend
- Department of Neurological Surgery, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew C Tate
- Department of Neurological Surgery, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - James P Chandler
- Department of Neurological Surgery, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Maciej S Lesniak
- Department of Neurological Surgery, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tim J Kruser
- Turville Bay Radiation Oncology Center, SSM Health, Madison, Wisconsin, USA
| | - John A Kalapurakal
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sean Sachdev
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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Benjamin CG, Gurewitz J, Kavi A, Bernstein K, Silverman J, Mureb M, Donahue B, Kondziolka D. Survival and outcomes in patients with ≥ 25 cumulative brain metastases treated with stereotactic radiosurgery. J Neurosurg 2022; 137:571-581. [PMID: 34952524 DOI: 10.3171/2021.9.jns21882] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 09/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In the era in which more patients with greater numbers of brain metastases (BMs) are being treated with stereotactic radiosurgery (SRS) alone, it is critical to understand how patient, tumor, and treatment factors affect functional status and overall survival (OS). The authors examined the survival outcomes and dosimetry to critical structures in patients treated with Gamma Knife radiosurgery (GKRS) for ≥ 25 metastases in a single session or cumulatively over the course of their disease. METHODS A retrospective analysis was conducted at a single institution. The institution's prospective Gamma Knife (GK) SRS registry was queried to identify patients treated with GKRS for ≥ 25 cumulative BMs between June 2013 and April 2020. Ninety-five patients were identified, and their data were used for analysis. Treatment plans for dosimetric analysis were available for 89 patients. Patient, tumor, and treatment characteristics were identified, and outcomes and OS were evaluated. RESULTS The authors identified 1132 patients with BMs in their institutional registry. Ninety-five patients were treated for ≥ 25 cumulative metastases, resulting in a total of 3596 tumors treated during 373 separate treatment sessions. The median number of SRS sessions per patient was 3 (range 1-12 SRS sessions), with nearly all patients (n = 93, 98%) having > 1 session. On univariate analysis, factors affecting OS in a statistically significant manner included histology, tumor volume, tumor number, diagnosis-specific graded prognostic assessment (DS-GPA), brain metastasis velocity (BMV), and need for subsequent whole-brain radiation therapy (WBRT). The median of the mean WB dose was 4.07 Gy (range 1.39-10.15 Gy). In the top quartile for both the highest cumulative number and highest cumulative volume of treated metastases, the median of the mean WB dose was 6.14 Gy (range 4.02-10.15 Gy). Seventy-nine patients (83%) had all treated tumors controlled at last follow-up, reflecting the high and durable control rate. Corticosteroids for tumor- or treatment-related effects were prescribed in just over one-quarter of the patients. Of the patients with radiographically proven adverse radiation effects (AREs; 15%), 4 were symptomatic. Four patients required subsequent craniotomy for hemorrhage, progression, or AREs. CONCLUSIONS In selected patients with a large number of cumulative BMs, multiple courses of SRS are feasible and safe. Together with new systemic therapies, the study results demonstrate that the achieved survival rates compare favorably to those of larger contemporary cohorts, while avoiding WBRT in the majority of patients. Therefore, along with the findings of other series, this study supports SRS as a standard practice in selected patients with larger numbers of BMs.
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Affiliation(s)
| | - Jason Gurewitz
- 2Department of Radiation Oncology, NYU Langone Medical Center, New York
| | - Ami Kavi
- 2Department of Radiation Oncology, NYU Langone Medical Center, New York
| | - Kenneth Bernstein
- 2Department of Radiation Oncology, NYU Langone Medical Center, New York
| | - Joshua Silverman
- 2Department of Radiation Oncology, NYU Langone Medical Center, New York
| | - Monica Mureb
- 3Department of Neurosurgery, Westchester Medical Center, Valhalla
| | - Bernadine Donahue
- 2Department of Radiation Oncology, NYU Langone Medical Center, New York
- 5Department of Radiation Oncology, Maimonides Medical Center, Brooklyn, New York
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Gondi V, Bauman G, Bradfield L, Burri SH, Cabrera AR, Cunningham DA, Eaton BR, Hattangadi-Gluth JA, Kim MM, Kotecha R, Kraemer L, Li J, Nagpal S, Rusthoven CG, Suh JH, Tomé WA, Wang TJC, Zimmer AS, Ziu M, Brown PD. Radiation Therapy for Brain Metastases: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2022; 12:265-282. [PMID: 35534352 DOI: 10.1016/j.prro.2022.02.003] [Citation(s) in RCA: 102] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/07/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE This guideline provides updated evidence-based recommendations addressing recent developments in the management of patients with brain metastases, including advanced radiation therapy techniques such as stereotactic radiosurgery (SRS) and hippocampal avoidance whole brain radiation therapy and the emergence of systemic therapies with central nervous system activity. METHODS The American Society for Radiation Oncology convened a task force to address 4 key questions focused on the radiotherapeutic management of intact and resected brain metastases from nonhematologic solid tumors. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS Strong recommendations are made for SRS for patients with limited brain metastases and Eastern Cooperative Oncology Group performance status 0 to 2. Multidisciplinary discussion with neurosurgery is conditionally recommended to consider surgical resection for all tumors causing mass effect and/or that are greater than 4 cm. For patients with symptomatic brain metastases, upfront local therapy is strongly recommended. For patients with asymptomatic brain metastases eligible for central nervous system-active systemic therapy, multidisciplinary and patient-centered decision-making to determine whether local therapy may be safely deferred is conditionally recommended. For patients with resected brain metastases, SRS is strongly recommended to improve local control. For patients with favorable prognosis and brain metastases receiving whole brain radiation therapy, hippocampal avoidance and memantine are strongly recommended. For patients with poor prognosis, early introduction of palliative care for symptom management and caregiver support are strongly recommended. CONCLUSIONS The task force has proposed recommendations to inform best clinical practices on the use of radiation therapy for brain metastases with strong emphasis on multidisciplinary care.
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Affiliation(s)
- Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center and Proton Center, Warrenville, Illinois.
| | - Glenn Bauman
- Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre & Western University, London, Ontario, Canada
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Stuart H Burri
- Department of Radiation Oncology, Atrium Health, Charlotte, North Carolina
| | - Alvin R Cabrera
- Department of Radiation Oncology, Kaiser Permanente, Seattle, Washington
| | | | - Bree R Eaton
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | | | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | | | - Jing Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Seema Nagpal
- Division of Neuro-oncology, Department of Neurology, Stanford University, Stanford, California
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - John H Suh
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Wolfgang A Tomé
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Tony J C Wang
- Department of Radiation Oncology, Columbia University, New York, New York
| | - Alexandra S Zimmer
- Women's Malignancies Branch, National Institutes of Health/National Cancer Institute, Bethesda, Maryland
| | - Mateo Ziu
- Department of Neurosciences, INOVA Neuroscience and INOVA Schar Cancer Institute, Falls Church, Virginia
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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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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Wang Y, Lang J, Zuo JZ, Dong Y, Hu Z, Xu X, Zhang Y, Wang Q, Yang L, Wong STC, Wang H, Li H. The radiomic-clinical model using the SHAP method for assessing the treatment response of whole-brain radiotherapy: a multicentric study. Eur Radiol 2022; 32:8737-8747. [PMID: 35678859 DOI: 10.1007/s00330-022-08887-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/11/2022] [Accepted: 05/16/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To develop and validate a pretreatment magnetic resonance imaging (MRI)-based radiomic-clinical model to assess the treatment response of whole-brain radiotherapy (WBRT) by using SHapley Additive exPlanations (SHAP), which is derived from game theory, and can explain the output of different machine learning models. METHODS We retrospectively enrolled 228 patients with brain metastases from two medical centers (184 in the training cohort and 44 in the validation cohort). Treatment responses of patients were categorized as a non-responding group vs. a responding group according to the Response Assessment in Neuro-Oncology Brain Metastases (RANO-BM) criteria. For each tumor, 960 features were extracted from the MRI sequence. The least absolute shrinkage and selection operator (LASSO) was used for feature selection. A support vector machine (SVM) model incorporating clinical factors and radiomic features wase used to construct the radiomic-clinical model. SHAP method explained the SVM model by prioritizing the importance of features, in terms of assessment contribution. RESULTS Three radiomic features and three clinical factors were identified to build the model. Radiomic-clinical model yielded AUCs of 0.928 (95%CI 0.901-0.949) and 0.851 (95%CI 0.816-0.886) for assessing the treatment response in the training cohort and validation cohort, respectively. SHAP summary plot illustrated the feature's value affected the feature's impact attributed to model, and SHAP force plot showed the integration of features' impact attributed to individual response. CONCLUSION The radiomic-clinical model with the SHAP method can be useful for assessing the treatment response of WBRT and may assist clinicians in directing personalized WBRT strategies in an understandable manner. KEY POINTS • Radiomic-clinical model can be useful for assessing the treatment response of WBRT. • SHAP could explain and visualize radiomic-clinical machine learning model in a clinician-friendly way.
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Affiliation(s)
- Yixin Wang
- Anhui Province Key Laboratory of Medical Physics and Technology, Institute of Health and Medical Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, 230031, People's Republic of China.,University of Science and Technology of China, Hefei, 230026, People's Republic of China.,Department of Oncology, Hefei Cancer Hospital, Chinese Academy of Sciences, Hefei, 230031, People's Republic of China
| | - Jinwei Lang
- Anhui Province Key Laboratory of Medical Physics and Technology, Institute of Health and Medical Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, 230031, People's Republic of China.,University of Science and Technology of China, Hefei, 230026, People's Republic of China
| | - Joey Zhaoyu Zuo
- Anhui Province Key Laboratory of Medical Physics and Technology, Institute of Health and Medical Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, 230031, People's Republic of China.,University of Science and Technology of China, Hefei, 230026, People's Republic of China
| | - Yaqin Dong
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, People's Republic of China
| | - Zongtao Hu
- Anhui Province Key Laboratory of Medical Physics and Technology, Institute of Health and Medical Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, 230031, People's Republic of China.,Department of Oncology, Hefei Cancer Hospital, Chinese Academy of Sciences, Hefei, 230031, People's Republic of China
| | - Xiuli Xu
- Department of Oncology, Hefei Cancer Hospital, Chinese Academy of Sciences, Hefei, 230031, People's Republic of China
| | - Yongkang Zhang
- Department of Oncology, Hefei Cancer Hospital, Chinese Academy of Sciences, Hefei, 230031, People's Republic of China
| | - Qinjie Wang
- Anhui Province Key Laboratory of Medical Physics and Technology, Institute of Health and Medical Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, 230031, People's Republic of China.,University of Science and Technology of China, Hefei, 230026, People's Republic of China
| | - Lizhuang Yang
- Anhui Province Key Laboratory of Medical Physics and Technology, Institute of Health and Medical Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, 230031, People's Republic of China.,University of Science and Technology of China, Hefei, 230026, People's Republic of China.,Department of Oncology, Hefei Cancer Hospital, Chinese Academy of Sciences, Hefei, 230031, People's Republic of China
| | - Stephen T C Wong
- Department of Systems Medicine and Bioengineering, Houston Methodist Cancer Center, Weill Cornell Medical College, Houston, TX, 77030, USA
| | - Hongzhi Wang
- Anhui Province Key Laboratory of Medical Physics and Technology, Institute of Health and Medical Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, 230031, People's Republic of China. .,University of Science and Technology of China, Hefei, 230026, People's Republic of China. .,Department of Oncology, Hefei Cancer Hospital, Chinese Academy of Sciences, Hefei, 230031, People's Republic of China.
| | - Hai Li
- Anhui Province Key Laboratory of Medical Physics and Technology, Institute of Health and Medical Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, 230031, People's Republic of China. .,University of Science and Technology of China, Hefei, 230026, People's Republic of China. .,Department of Oncology, Hefei Cancer Hospital, Chinese Academy of Sciences, Hefei, 230031, People's Republic of China.
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Franklin C, Mohr P, Bluhm L, Grimmelmann I, Gutzmer R, Meier F, Garzarolli M, Weichenthal M, Pfoehler C, Herbst R, Terheyden P, Utikal J, Ulrich J, Debus D, Haferkamp S, Kaatz M, Forschner A, Leiter U, Nashan D, Kreuter A, Sachse M, Welzel J, Heinzerling L, Meiss F, Weishaupt C, Gambichler T, Weyandt G, Dippel E, Schatton K, Celik E, Trommer M, Helfrich I, Roesch A, Zimmer L, Livingstone E, Schadendorf D, Horn S, Ugurel S. Impact of radiotherapy and sequencing of systemic therapy on survival outcomes in melanoma patients with previously untreated brain metastasis: a multicenter DeCOG study on 450 patients from the prospective skin cancer registry ADOREG. J Immunother Cancer 2022; 10:jitc-2022-004509. [PMID: 35688555 PMCID: PMC9189852 DOI: 10.1136/jitc-2022-004509] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Despite of various therapeutic strategies, treatment of patients with melanoma brain metastasis (MBM) still is a major challenge. This study aimed at investigating the impact of type and sequence of immune checkpoint blockade (ICB) and targeted therapy (TT), radiotherapy, and surgery on the survival outcome of patients with MBM. METHOD We assessed data of 450 patients collected within the prospective multicenter real-world skin cancer registry ADOREG who were diagnosed with MBM before start of the first non-adjuvant systemic therapy. Study endpoints were progression-free survival (PFS) and overall survival (OS). RESULTS Of 450 MBM patients, 175 (38.9%) received CTLA-4+PD-1 ICB, 161 (35.8%) PD-1 ICB, and 114 (25.3%) BRAF+MEK TT as first-line treatment. Additional to systemic therapy, 67.3% of the patients received radiotherapy (stereotactic radiosurgery (SRS); conventional radiotherapy (CRT)) and 24.4% had surgery of MBM. 199 patients (42.2%) received a second-line systemic therapy. Multivariate Cox regression analysis revealed the application of radiotherapy (HR for SRS: 0.213, 95% CI 0.094 to 0.485, p<0.001; HR for CRT: 0.424, 95% CI 0.210 to 0.855, p=0.016), maximal size of brain metastases (HR for MBM >1 cm: 1.977, 95% CI 1.117 to 3.500, p=0.019), age (HR for age >65 years: 1.802, 95% CI 1.016 to 3.197, p=0.044), and ECOG performance status (HR for ECOG ≥2: HR: 2.615, 95% CI 1.024 to 6.676, p=0.044) as independent prognostic factors of OS on first-line therapy. The type of first-line therapy (ICB vs TT) was not independently prognostic. As second-line therapy BRAF+MEK showed the best survival outcome compared with ICB and other therapies (HR for CTLA-4+PD-1 compared with BRAF+MEK: 13.964, 95% CI 3.6 to 54.4, p<0.001; for PD-1 vs BRAF+MEK: 4.587 95% CI 1.3 to 16.8, p=0.022 for OS). Regarding therapy sequencing, patients treated with ICB as first-line therapy and BRAF+MEK as second-line therapy showed an improved OS (HR for CTLA-4+PD-1 followed by BRAF+MEK: 0.370, 95% CI 0.157 to 0.934, p=0.035; HR for PD-1 followed by BRAF+MEK: 0.290, 95% CI 0.092 to 0.918, p=0.035) compared with patients starting with BRAF+MEK in first-line therapy. There was no significant survival difference when comparing first-line therapy with CTLA-4+PD-1 ICB with PD-1 ICB. CONCLUSIONS In patients with MBM, the addition of radiotherapy resulted in a favorable OS on systemic therapy. In BRAF-mutated MBM patients, ICB as first-line therapy and BRAF+MEK as second-line therapy were associated with a significantly prolonged OS.
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Affiliation(s)
- Cindy Franklin
- Department of Dermatology and Venereology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Peter Mohr
- Department of Dermatology, Elbe Kliniken Buxtehude, Buxtehude, Germany
| | - Leonie Bluhm
- Department of Dermatology, Elbe Kliniken Buxtehude, Buxtehude, Germany
| | - Imke Grimmelmann
- Department of Dermatology, Hannover Medical School, Hannover, Germany
| | - Ralf Gutzmer
- Department of Dermatology, Muehlenkreiskliniken Minden and Ruhr University Bochum, Minden, Germany
| | - Friedegund Meier
- Skin Cancer Center at the University Cancer Centre Dresden and National Center for Tumor Diseases, Dresden, Germany; Department of Dermatology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Marlene Garzarolli
- Skin Cancer Center at the University Cancer Centre Dresden and National Center for Tumor Diseases, Dresden, Germany; Department of Dermatology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Michael Weichenthal
- Department of Dermatology, Skin Cancer Center, Schleswig-Holstein University Hospital, Campus Kiel, Kiel, Germany
| | - Claudia Pfoehler
- Department of Dermatology, Saarland University Medical School, Homburg/Saar, Germany
| | - Rudolf Herbst
- Department of Dermatology, HELIOS Klinikum Erfurt, Erfurt, Germany
| | | | - Jochen Utikal
- Skin Cancer Unit, German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Dermatology, Venereology and Allergology, University Medical Center Mannheim, Ruprecht-Karl University of Heidelberg, Heidelberg, Germany
| | - Jens Ulrich
- Department of Dermatology and Skin Cancer Center, Harzklinikum Dorothea Christiane Erxleben, Quedlinburg, Germany
| | - Dirk Debus
- Department of Dermatology, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Sebastian Haferkamp
- Department of Dermatology, University Hospital Regensburg, Regensburg, Germany
| | - Martin Kaatz
- Department of Dermatology, SRH Wald-Klinikum Gera, Gera, Germany
| | - Andrea Forschner
- Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
| | - Ulrike Leiter
- Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
| | - Dorothee Nashan
- Department of Dermatology, Hospital of Dortmund, Dortmund, Germany
| | - Alexander Kreuter
- Department of Dermatology, Venereology and Allergology, HELIOS St. Elisabeth Klinik Oberhausen, University Witten-Herdecke, Herdecke, Germany
| | - Michael Sachse
- Department of Dermatology, Klinikum Bremerhaven Reinkenheide, Bremerhaven, Germany
| | - Julia Welzel
- Department of Dermatology and Allergology, University Hospital Augsburg, Augsburg, Germany
| | - Lucie Heinzerling
- Department of Dermatology and Allergology, Ludwig-Maximilian University, München, Germany
| | - Frank Meiss
- Department of Dermatology and Venereology, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Carsten Weishaupt
- Department of Dermatology, University Hospital of Münster, Münster, Germany
| | - Thilo Gambichler
- Department of Dermatology, Ruhr University Bochum, Bochum, Germany
| | - Gerhard Weyandt
- Department of Dermatology and Allergology, Hospital Bayreuth, Bayreuth, Germany
| | - Edgar Dippel
- Department of Dermatology, Ludwigshafen Medical Center, Ludwigshafen, Germany
| | - Kerstin Schatton
- Department of Dermatology, Heinrich Heine University, Düsseldorf, Germany
| | - Eren Celik
- Department of Radiation Oncology and Cyberknife Center, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Maike Trommer
- Department of Radiation Oncology and Cyberknife Center, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Iris Helfrich
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, Essen, Germany and German Cancer Consortium (DKTK) partner site Essen/Düsseldorf, Essen, Germany
| | - Alexander Roesch
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, Essen, Germany and German Cancer Consortium (DKTK) partner site Essen/Düsseldorf, Essen, Germany
| | - Lisa Zimmer
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, Essen, Germany and German Cancer Consortium (DKTK) partner site Essen/Düsseldorf, Essen, Germany
| | - Elisabeth Livingstone
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, Essen, Germany and German Cancer Consortium (DKTK) partner site Essen/Düsseldorf, Essen, Germany
| | - Dirk Schadendorf
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, Essen, Germany and German Cancer Consortium (DKTK) partner site Essen/Düsseldorf, Essen, Germany
| | - Susanne Horn
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, Essen, Germany and German Cancer Consortium (DKTK) partner site Essen/Düsseldorf, Essen, Germany.,Rudolf-Schönheimer-Institute of Biochemistry, Medical Faculty of the University Leipzig, Leipzig, Germany
| | - Selma Ugurel
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, Essen, Germany and German Cancer Consortium (DKTK) partner site Essen/Düsseldorf, Essen, Germany
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Ene CI, Ferguson SD. Surgical Management of Brain Metastasis: Challenges and Nuances. Front Oncol 2022; 12:847110. [PMID: 35359380 PMCID: PMC8963990 DOI: 10.3389/fonc.2022.847110] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 02/07/2022] [Indexed: 12/15/2022] Open
Abstract
Brain metastasis is the most common type of intracranial tumor. The contemporary management of brain metastasis is a challenging issue and traditionally has carried a poor prognosis as these lesions typically occur in the setting of advanced cancer. However, improvement in systemic therapy, advances in radiation techniques and multimodal therapy tailored to the individual patient, has given hope to this patient population. Surgical resection has a well-established role in the management of brain metastasis. Here we discuss the evolving role of surgery in the treatment of this diverse patient population.
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Affiliation(s)
- Chibawanye I Ene
- Department of Neurosurgery, University of Texas, MD Anderson Cancer Center, Houston, TX, United States
| | - Sherise D Ferguson
- Department of Neurosurgery, University of Texas, MD Anderson Cancer Center, Houston, TX, United States
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Pappas EP, Seimenis I, Kouris P, Theocharis S, Lampropoulos KI, Kollias G, Karaiskos P. Target localization accuracy in frame‐based stereotactic radiosurgery: Comparison between MR‐only and MR/CT co‐registration approaches. J Appl Clin Med Phys 2022; 23:e13580. [PMID: 35285583 PMCID: PMC9121047 DOI: 10.1002/acm2.13580] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 02/17/2022] [Accepted: 02/21/2022] [Indexed: 11/28/2022] Open
Abstract
Purpose In frame‐based Gamma Knife (GK) stereotactic radiosurgery two treatment planning workflows are commonly employed; one based solely on magnetic resonance (MR) images and the other based on magnetic resonance/computed tomography (MR/CT) co‐registered images. In both workflows, target localization accuracy (TLA) can be deteriorated due to MR‐related geometric distortions and/or MR/CT co‐registration uncertainties. In this study, the overall TLA following both clinical workflows is evaluated for cases of multiple brain metastases. Methods A polymer gel‐filled head phantom, having the Leksell stereotactic headframe attached, was CT‐imaged and irradiated by a GK Perfexion unit. A total of 26 4‐mm shots were delivered at 26 locations directly defined in the Leksell stereotactic space (LSS), inducing adequate contrast in corresponding T2‐weighted (T2w) MR images. Prescribed shot coordinates served as reference locations. An additional MR scan was acquired to implement the “mean image” distortion correction technique. The TLA for each workflow was assessed by comparing the radiation‐induced target locations, identified in MR images, with corresponding reference locations. Using T1w MR and CT images of 15 patients (totaling 81 lesions), TLA in clinical cases was similarly assessed, considering MR‐corrected data as reference. For the MR/CT workflow, both global and region of interest (ROI)‐based MR/CT registration approaches were studied. Results In phantom measurements, the MR‐corrected workflow demonstrated unsurpassed TLA (median offset of 0.2 mm) which deteriorated for MR‐only and MR/CT workflows (median offsets of 0.8 and 0.6 mm, respectively). In real‐patient cases, the MR‐only workflow resulted in offsets that exhibit a significant positive correlation with the distance from the MR isocenter, reaching 1.1 mm (median 0.6 mm). Comparable results were obtained for the MR/CT‐global workflow, although a maximum offset of 1.4 mm was detected. TLA was improved with the MR/CT‐ROI workflow resulting in median/maximum offsets of 0.4 mm/1.1 mm. Conclusions Subpixel TLA is achievable in all workflows. For the MR/CT workflow, a ROI‐based MR/CT co‐registration approach could considerably increase TLA and should be preferred instead of a global registration.
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Affiliation(s)
- Eleftherios P. Pappas
- Medical Physics Laboratory Medical School National and Kapodistrian University of Athens Athens Greece
| | - Ioannis Seimenis
- Medical Physics Laboratory Medical School National and Kapodistrian University of Athens Athens Greece
| | - Panagiotis Kouris
- Medical Physics Laboratory Medical School National and Kapodistrian University of Athens Athens Greece
| | - Stefanos Theocharis
- Medical Physics Laboratory Medical School National and Kapodistrian University of Athens Athens Greece
| | | | - Georgios Kollias
- Medical Physics and Gamma Knife Department Hygeia Hospital Marousi Greece
| | - Pantelis Karaiskos
- Medical Physics Laboratory Medical School National and Kapodistrian University of Athens Athens Greece
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Evolving management of HER2+ breast cancer brain metastases and leptomeningeal disease. J Neurooncol 2022; 157:249-269. [PMID: 35244835 DOI: 10.1007/s11060-022-03977-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/23/2022] [Indexed: 12/14/2022]
Abstract
Patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer are at a particularly high risk of breast cancer brain metastasis (BCBM) and leptomeningeal disease (LMD). Improvements in systemic therapy have translated to improved survival for patients with HER2-positive BCBM and LMD. However, the optimal management of these cases is rapidly evolving and requires a multidisciplinary approach. Herein, a team of radiation oncologists, medical oncologists, neuro-oncologists, and breast surgeon created a review of the evolving management of HER2-positive BCBM and LMD. We assess the epidemiology, diagnosis, and evolving treatment options for patients with HER2-positive BCBM and LMD, as well as the ongoing prospective clinical trials enrolling these patients. The management of HER2-positive BCBM and LMD represents an increasingly common challenge that involves the coordination of local and systemic therapy. Advances in systemic therapy have resulted in an improved prognosis, and promising targeted therapies currently under prospective investigation have the potential to further benefit these patients.
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Yan M, Ouyang Q, Sun T, Niu L, Yang J, Li L, Song Y, Hao C, Chen Z, Orlandi A, Ishii N, Takabe K, Franceschini G, Ricci F, Verschraegen C, Liu Z, Zhang M, Lv H, Liu L, Yang X, Xiao H, Gao Z, Li X, Dong F, Chen X, Qiao J, Zhang G. Pyrotinib plus capecitabine for patients with human epidermal growth factor receptor 2-positive breast cancer and brain metastases (PERMEATE): a multicentre, single-arm, two-cohort, phase 2 trial. Lancet Oncol 2022; 23:353-361. [PMID: 35085506 DOI: 10.1016/s1470-2045(21)00716-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/09/2021] [Accepted: 12/10/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Patients with HER2-positive metastatic breast cancer have a high risk of developing brain metastases. Efficacious treatment options are scarce. We investigated the activity and safety of pyrotinib plus capecitabine in patients with HER2-positive metastatic breast cancer and brain metastases. METHODS We did a multicentre, single-arm, two-cohort, phase 2 trial in eight tertiary hospitals in China. Patients aged 18 years or older who had radiotherapy-naive HER2-positive brain metastases (cohort A) or progressive disease after radiotherapy (cohort B), with an Eastern Cooperative Oncology Group performance status of 0-2, received pyrotinib 400 mg orally once daily, and capecitabine 1000 mg/m2 orally twice daily for 14 days, followed by 7 days off every 3 weeks until disease progression or unacceptable toxicity. The primary endpoint was confirmed intracranial objective response rate by investigator assessment according to the Response Evaluation Criteria In Solid Tumours (version 1.1). Activity and safety were analysed in patients with at least one dose of study drug. The study is ongoing, but recruitment is complete. The study is registered with ClinicalTrials.gov, NCT03691051. FINDINGS Between Jan 29, 2019, and July 10, 2020, we enrolled 78 women: 51 (86%) of 59 patients in cohort A and 18 (95%) of 19 patients in cohort B had previous exposure to trastuzumab. Median follow-up duration was 15·7 months (IQR 9·7-19·0). The intracranial objective response rate was 74·6% (95% CI 61·6-85·0; 44 of 59 patients) in cohort A and 42·1% (20·3-66·5; eight of 19 patients) in cohort B. The most common grade 3 or worse treatment-emergent adverse event was diarrhoea (14 [24%] in cohort A and four [21%] in cohort B). Two (3%) patients in cohort A and three (16%) in cohort B had treatment-related serious adverse events. No treatment-related deaths occurred. INTERPRETATION To our knowledge, this is the first prospective study showing the activity and safety of pyrotinib plus capecitabine in patients with HER2-positive breast cancer and brain metastases, especially in radiotherapy-naive population. This combination deserves further validation in a randomised, controlled trial. FUNDING National Cancer Centre Climbing Foundation Key Project of China, Jiangsu Hengrui Pharmaceuticals. TRANSLATION For the Chinese translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Min Yan
- Henan Breast Cancer Centre, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China.
| | - Quchang Ouyang
- Department of Breast Medicine, Hunan Cancer Hospital, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Tao Sun
- Breast Medicine, Cancer Hospital of China Medical University, Liaoning Cancer Hospital, Shenyang, China
| | - Limin Niu
- Henan Breast Cancer Centre, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Jin Yang
- Department of Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Li Li
- Department of Oncology, Qilu Hospital of Shandong University, Jinan, China
| | - Yuhua Song
- Breast Cancer Centre, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chunfang Hao
- Department of Breast Oncology, Tianjin Medical University Cancer Institute & Hospital, Tianjin, China
| | - Zhanhong Chen
- Department of Breast Cancer Internal Medicine, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, China
| | - Armando Orlandi
- Unit of Medical Oncology, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma, Italy
| | - Naohiro Ishii
- Department of Plastic and Reconstructive Surgery, International University of Health and Welfare Hospital, Tochigi, Japan
| | - Kazuaki Takabe
- Division of Breast Surgery, Roswell Park Comprehensive Cancer Centre, Buffalo, NY, USA
| | - Gianluca Franceschini
- Multidisciplinary Breast Centre, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma, Italy
| | | | | | - Zhenzhen Liu
- Henan Breast Cancer Centre, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Mengwei Zhang
- Henan Breast Cancer Centre, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Huimin Lv
- Henan Breast Cancer Centre, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Liping Liu
- Department of Breast Medicine, Hunan Cancer Hospital, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Xiaohong Yang
- Department of Breast Medicine, Hunan Cancer Hospital, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Huawu Xiao
- Department of Breast Medicine, Hunan Cancer Hospital, the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Zhichao Gao
- Breast Medicine, Cancer Hospital of China Medical University, Liaoning Cancer Hospital, Shenyang, China
| | - Xiaorui Li
- Breast Medicine, Cancer Hospital of China Medical University, Liaoning Cancer Hospital, Shenyang, China
| | - Fangyuan Dong
- Breast Medicine, Cancer Hospital of China Medical University, Liaoning Cancer Hospital, Shenyang, China
| | - Xiuchun Chen
- Henan Breast Cancer Centre, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Jianghua Qiao
- Henan Breast Cancer Centre, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Guifang Zhang
- Department of Medical Oncology, Xinxiang Central Hospital, Xinxiang, China
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Trommer M, Adams A, Celik E, Fan J, Funken D, Herter JM, Linde P, Morgenthaler J, Wegen S, Mauch C, Franklin C, Galldiks N, Werner JM, Kocher M, Rueß D, Ruge M, Meißner AK, Baues C, Marnitz S. Oncologic Outcome and Immune Responses of Radiotherapy with Anti-PD-1 Treatment for Brain Metastases Regarding Timing and Benefiting Subgroups. Cancers (Basel) 2022; 14:cancers14051240. [PMID: 35267546 PMCID: PMC8909717 DOI: 10.3390/cancers14051240] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 02/21/2022] [Accepted: 02/24/2022] [Indexed: 02/07/2023] Open
Abstract
While immune checkpoint inhibitors (ICIs) in combination with radiotherapy (RT) are widely used for patients with brain metastasis (BM), markers that predict treatment response for combined RT and ICI (RT-ICI) and their optimal dosing and sequence for the best immunogenic effects are still under investigation. The aim of this study was to evaluate prognostic factors for therapeutic outcome and to compare effects of concurrent and non-concurrent RT-ICI. We retrospectively analyzed data of 93 patients with 319 BMs of different cancer types who received PD-1 inhibitors and RT at the University Hospital Cologne between September/2014 and November/2020. Primary study endpoints were overall survival (OS), progression-free survival (PFS), and local control (LC). We included 66.7% melanoma, 22.8% lung, and 5.5% other cancer types with a mean follow-up time of 23.8 months. Median OS time was 12.19 months. LC at 6 months was 95.3% (concurrent) vs. 69.2% (non-concurrent; p = 0.008). Univariate Cox regression analysis detected following prognostic factors for OS: neutrophil-to-lymphocyte ratio NLR favoring <3 (low; HR 2.037 (1.184−3.506), p = 0.010), lactate dehydrogenase (LDH) favoring ≤ULN (HR 1.853 (1.059−3.241), p = 0.031), absence of neurological symptoms (HR 2.114 (1.285−3.478), p = 0.003), RT concept favoring SRS (HR 1.985 (1.112−3.543), p = 0.019), RT dose favoring ≥60 Gy (HR 0.519 (0.309−0.871), p = 0.013), and prior anti-CTLA4 treatment (HR 0.498 (0.271−0.914), p = 0.024). Independent prognostic factors for OS were concurrent RT-ICI application (HR 0.539 (0.299−0.971), p = 0.024) with a median OS of 17.61 vs. 6.83 months (non-concurrent), ECOG performance status favoring 0 (HR 7.756 (1.253−6.061), p = 0.012), cancer type favoring melanoma (HR 0.516 (0.288−0.926), p = 0.026), BM volume (PTV) favoring ≤3 cm3 (HR 1.947 (1.007−3.763), p = 0.048). Subgroups with the following factors showed significantly longer OS when being treated concurrently: RT dose <60 Gy (p = 0.014), PTV > 3 cm3 (p = 0.007), other cancer types than melanoma (p = 0.006), anti-CTLA4-naïve patients (p < 0.001), low NLR (p = 0.039), steroid intake ≤4 mg (p = 0.042). Specific immune responses, such as abscopal effects (AbEs), pseudoprogression (PsP), or immune-related adverse events (IrAEs), occurred more frequently with concurrent RT-ICI and resulted in better OS. Other toxicities, including radionecrosis, were not statistically different in both groups. The concurrent application of RT and ICI, the ECOG-PS, cancer type, and PTV had an independently prognostic impact on OS. In concurrently treated patients, treatment response (LC) was delayed and specific immune responses (AbE, PsP, IrAE) occurred more frequently with longer OS rates. Our results suggest that concurrent RT-ICI application is more beneficial than sequential treatment in patients with low pretreatment inflammatory status, more and larger BMs, and with other cancer types than melanoma.
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Affiliation(s)
- Maike Trommer
- Department of Radiation Oncology, Cyberknife Center, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (E.C.); (J.F.); (D.F.); (J.M.H.); (P.L.); (J.M.); (S.W.); (C.B.); (S.M.)
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, 50937 Cologne, Germany; (C.M.); (C.F.); (N.G.); (J.-M.W.); (M.K.); (D.R.); (M.R.); (A.-K.M.)
- Center for Molecular Medicine Cologne, University of Cologne, 50937 Cologne, Germany
- Correspondence:
| | - Anne Adams
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany;
| | - Eren Celik
- Department of Radiation Oncology, Cyberknife Center, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (E.C.); (J.F.); (D.F.); (J.M.H.); (P.L.); (J.M.); (S.W.); (C.B.); (S.M.)
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, 50937 Cologne, Germany; (C.M.); (C.F.); (N.G.); (J.-M.W.); (M.K.); (D.R.); (M.R.); (A.-K.M.)
| | - Jiaqi Fan
- Department of Radiation Oncology, Cyberknife Center, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (E.C.); (J.F.); (D.F.); (J.M.H.); (P.L.); (J.M.); (S.W.); (C.B.); (S.M.)
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, 50937 Cologne, Germany; (C.M.); (C.F.); (N.G.); (J.-M.W.); (M.K.); (D.R.); (M.R.); (A.-K.M.)
| | - Dominik Funken
- Department of Radiation Oncology, Cyberknife Center, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (E.C.); (J.F.); (D.F.); (J.M.H.); (P.L.); (J.M.); (S.W.); (C.B.); (S.M.)
| | - Jan M. Herter
- Department of Radiation Oncology, Cyberknife Center, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (E.C.); (J.F.); (D.F.); (J.M.H.); (P.L.); (J.M.); (S.W.); (C.B.); (S.M.)
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, 50937 Cologne, Germany; (C.M.); (C.F.); (N.G.); (J.-M.W.); (M.K.); (D.R.); (M.R.); (A.-K.M.)
- Center for Molecular Medicine Cologne, University of Cologne, 50937 Cologne, Germany
| | - Philipp Linde
- Department of Radiation Oncology, Cyberknife Center, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (E.C.); (J.F.); (D.F.); (J.M.H.); (P.L.); (J.M.); (S.W.); (C.B.); (S.M.)
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, 50937 Cologne, Germany; (C.M.); (C.F.); (N.G.); (J.-M.W.); (M.K.); (D.R.); (M.R.); (A.-K.M.)
| | - Janis Morgenthaler
- Department of Radiation Oncology, Cyberknife Center, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (E.C.); (J.F.); (D.F.); (J.M.H.); (P.L.); (J.M.); (S.W.); (C.B.); (S.M.)
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, 50937 Cologne, Germany; (C.M.); (C.F.); (N.G.); (J.-M.W.); (M.K.); (D.R.); (M.R.); (A.-K.M.)
| | - Simone Wegen
- Department of Radiation Oncology, Cyberknife Center, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (E.C.); (J.F.); (D.F.); (J.M.H.); (P.L.); (J.M.); (S.W.); (C.B.); (S.M.)
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, 50937 Cologne, Germany; (C.M.); (C.F.); (N.G.); (J.-M.W.); (M.K.); (D.R.); (M.R.); (A.-K.M.)
| | - Cornelia Mauch
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, 50937 Cologne, Germany; (C.M.); (C.F.); (N.G.); (J.-M.W.); (M.K.); (D.R.); (M.R.); (A.-K.M.)
- Department of Dermatology, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Cindy Franklin
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, 50937 Cologne, Germany; (C.M.); (C.F.); (N.G.); (J.-M.W.); (M.K.); (D.R.); (M.R.); (A.-K.M.)
- Department of Dermatology, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Norbert Galldiks
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, 50937 Cologne, Germany; (C.M.); (C.F.); (N.G.); (J.-M.W.); (M.K.); (D.R.); (M.R.); (A.-K.M.)
- Department of Neurology, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
- Department of Neuroscience and Medicine (INM-3), Research Center Juelich, 52428 Juelich, Germany
| | - Jan-Michael Werner
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, 50937 Cologne, Germany; (C.M.); (C.F.); (N.G.); (J.-M.W.); (M.K.); (D.R.); (M.R.); (A.-K.M.)
- Department of Neurology, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Martin Kocher
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, 50937 Cologne, Germany; (C.M.); (C.F.); (N.G.); (J.-M.W.); (M.K.); (D.R.); (M.R.); (A.-K.M.)
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Daniel Rueß
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, 50937 Cologne, Germany; (C.M.); (C.F.); (N.G.); (J.-M.W.); (M.K.); (D.R.); (M.R.); (A.-K.M.)
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Maximilian Ruge
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, 50937 Cologne, Germany; (C.M.); (C.F.); (N.G.); (J.-M.W.); (M.K.); (D.R.); (M.R.); (A.-K.M.)
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Anna-Katharina Meißner
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, 50937 Cologne, Germany; (C.M.); (C.F.); (N.G.); (J.-M.W.); (M.K.); (D.R.); (M.R.); (A.-K.M.)
- Department for General Neurosurgery, Centre of Neurosurgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Christian Baues
- Department of Radiation Oncology, Cyberknife Center, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (E.C.); (J.F.); (D.F.); (J.M.H.); (P.L.); (J.M.); (S.W.); (C.B.); (S.M.)
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, 50937 Cologne, Germany; (C.M.); (C.F.); (N.G.); (J.-M.W.); (M.K.); (D.R.); (M.R.); (A.-K.M.)
- Center for Molecular Medicine Cologne, University of Cologne, 50937 Cologne, Germany
| | - Simone Marnitz
- Department of Radiation Oncology, Cyberknife Center, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (E.C.); (J.F.); (D.F.); (J.M.H.); (P.L.); (J.M.); (S.W.); (C.B.); (S.M.)
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, 50937 Cologne, Germany; (C.M.); (C.F.); (N.G.); (J.-M.W.); (M.K.); (D.R.); (M.R.); (A.-K.M.)
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Kinj R, Muggeo E, Schiappacasse L, Bourhis J, Herrera FG. Stereotactic Body Radiation Therapy in Patients with Oligometastatic Disease: Clinical State of the Art and Perspectives. Cancers (Basel) 2022; 14:1152. [PMID: 35267460 PMCID: PMC8909365 DOI: 10.3390/cancers14051152] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/16/2022] [Accepted: 02/22/2022] [Indexed: 02/06/2023] Open
Abstract
Stereotactic body radiation therapy (SBRT) is a form of radiation therapy (RT) in which a small number of high doses of radiation are delivered to a target volume using highly sophisticated equipment. Stereotactic body radiation therapy is crucial in two cancer stages: early primary cancer and oligometastatic disease, with the goal of inducing complete cancer remission in both. This treatment method is commonly used to treat a variety of disease types. Over the years, a growing body of clinical evidence on the use of SBRT for the treatment of primary and metastatic tumors has accumulated, with efficacy and safety demonstrated in randomized clinical trials. This article will review the technical and clinical aspects of SBRT according to disease type and clinical indication.
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Affiliation(s)
- Rémy Kinj
- Service of Radiation Oncology, Department of Oncology, Lausanne University Hospital, 1010 Lausanne, Switzerland; (E.M.); (L.S.); (J.B.)
| | - Emilien Muggeo
- Service of Radiation Oncology, Department of Oncology, Lausanne University Hospital, 1010 Lausanne, Switzerland; (E.M.); (L.S.); (J.B.)
| | - Luis Schiappacasse
- Service of Radiation Oncology, Department of Oncology, Lausanne University Hospital, 1010 Lausanne, Switzerland; (E.M.); (L.S.); (J.B.)
| | - Jean Bourhis
- Service of Radiation Oncology, Department of Oncology, Lausanne University Hospital, 1010 Lausanne, Switzerland; (E.M.); (L.S.); (J.B.)
| | - Fernanda G. Herrera
- Service of Radiation Oncology, Department of Oncology, Lausanne University Hospital, 1010 Lausanne, Switzerland; (E.M.); (L.S.); (J.B.)
- Service of Immuno-Oncology, Department of Oncology, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
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Tsui DCC, Camidge DR, Rusthoven CG. Managing Central Nervous System Spread of Lung Cancer: The State of the Art. J Clin Oncol 2022; 40:642-660. [PMID: 34985937 DOI: 10.1200/jco.21.01715] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Brain metastases (BrM) are common in both non-small-cell lung cancer and small-cell lung cancer. Substantial progress in BrM management has occurred in the past decade related to advances in both radiation and medical oncology. Recent and ongoing radiation trials have focused on increasing the candidacy for focal therapy of BrM with stereotactic radiosurgery; reducing the toxicity and improving patient selection for whole brain radiotherapy; and, in small-cell lung cancer, evaluating brain magnetic resonance imaging surveillance without prophylactic cranial irradiation, hippocampal avoidance in prophylactic cranial irradiation and whole brain radiotherapy, and the role of upfront stereotactic radiosurgery for BrM. In medical oncology, the development of multiple tyrosine kinase inhibitors with encouraging CNS activity and emerging data on the CNS activity of immune checkpoint inhibitors in some patients have opened the door to novel systemic and multidisciplinary treatment strategies for the management of BrM. Future research will focus on more robust characterizations of the CNS activity of targeted therapy and immunotherapies, as well as optimal integration and patient selection for multidisciplinary strategies involving CNS-active drugs, radiation therapy, and CNS surveillance.
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Affiliation(s)
- David Chun Cheong Tsui
- Division of Medical Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
| | - D Ross Camidge
- Division of Medical Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
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Abdulhaleem M, Johnston H, D'Agostino R, Lanier C, LeCompte M, Cramer CK, Ruiz J, Lycan T, Lo HW, Watabe K, O'Neill S, Whitlow C, White JJ, Tatter SB, Laxton AW, Su J, Chan MD. Local control outcomes for combination of stereotactic radiosurgery and immunotherapy for non-small cell lung cancer brain metastases. J Neurooncol 2022; 157:101-107. [PMID: 35166988 DOI: 10.1007/s11060-022-03951-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 01/20/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous series have demonstrated CNS activity for immune checkpoint inhibitors, yet no prior data exists regarding whether this activity can improve outcomes of stereotactic radiosurgery. METHODS In this single institution retrospective series, the clinical outcomes of 80 consecutive lung cancer patients treated with concurrent immune checkpoint inhibitors and stereotactic radiosurgery were compared to 235 in the historical control cohort in which patients were treated prior to immune checkpoint inhibition being standard upfront therapy. Overall survival was estimated using the Kaplan Meier method. Cumulative incidence of local progression was estimated using a competing risk model. RESULTS Median overall survival time was improved in patients receiving upfront immunotherapy compared to the historical control group (40 months vs 8 months, p < 0.001). Factors affected overall survival include concurrent immunotherapy (HR 0.23, p < 0.0001) and KPS (HR 0.97, p = 0.0001). Cumulative incidence of local failure in the historical control group was 10% at 1 year, compared to 1.1% at 1 year in the concurrent immunotherapy group (p = 0.025). Factors affected local control included use of concurrent immunotherapy (HR 0.09, p = 0.012), and lowest margin dose delivered to a metastasis (HR 0.8, p = 0.0018). CONCLUSION Local control and overall survival were both improved in patients receiving concurrent immune checkpoint inhibitors with radiosurgery compared to historical controls. While these data remain to be validated, they suggest that brain metastasis patients may benefit from concurrent use of immunotherapy with SRS.
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Affiliation(s)
- Mohammed Abdulhaleem
- Department of Medicine, Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA. .,Department of Medicine, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
| | - Hannah Johnston
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Ralph D'Agostino
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Claire Lanier
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael LeCompte
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Christina K Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jimmy Ruiz
- Department of Medicine, Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Thomas Lycan
- Department of Medicine, Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Hui-Wen Lo
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kuonosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Stacey O'Neill
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Christopher Whitlow
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jaclyn J White
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jing Su
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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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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