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Gecici NN, Gurses ME, Kaye B, Jimenez NLF, Berke C, Gökalp E, Lu VM, Ivan ME, Komotar RJ, Shah AH. Comparative analysis of bevacizumab and LITT for treating radiation necrosis in previously radiated CNS neoplasms: a systematic review and meta-analysis. J Neurooncol 2024; 168:1-11. [PMID: 38619777 PMCID: PMC11093788 DOI: 10.1007/s11060-024-04650-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 03/15/2024] [Indexed: 04/16/2024]
Abstract
PURPOSE Radiation necrosis (RN) is a local inflammatory reaction that arises in response to radiation injury and may cause significant morbidity. This study aims to evaluate and compare the efficacy of bevacizumab and laser interstitial thermal therapy (LITT) in treating RN in patients with previously radiated central nervous system (CNS) neoplasms. METHODS PubMed, Cochrane, Scopus, and EMBASE databases were screened. Studies of patients with radiation necrosis from primary or secondary brain tumors were included. Indirect meta-analysis with random-effect modeling was performed to compare clinical and radiological outcomes. RESULTS Twenty-four studies were included with 210 patients in the bevacizumab group and 337 patients in the LITT group. Bevacizumab demonstrated symptomatic improvement/stability in 87.7% of cases, radiological improvement/stability in 86.2%, and steroid wean-off in 45%. LITT exhibited symptomatic improvement/stability in 71.2%, radiological improvement/stability in 64.7%, and steroid wean-off in 62.4%. Comparative analysis revealed statistically significant differences favoring bevacizumab in symptomatic improvement/stability (p = 0.02), while no significant differences were observed in radiological improvement/stability (p = 0.27) or steroid wean-off (p = 0.90). The rates of adverse reactions were 11.2% for bevacizumab and 14.9% for LITT (p = 0.66), with the majority being grade 2 or lower (72.2% for bevacizumab and 62.5% for LITT). CONCLUSION Both bevacizumab and LITT exhibited favorable clinical and radiological outcomes in managing RN. Bevacizumab was found to be associated with better symptomatic control compared to LITT. Patient-, diagnosis- and lesion-related factors should be considered when choosing the ideal treatment modality for RN to enhance overall patient outcomes.
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Affiliation(s)
- Neslihan Nisa Gecici
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, 33136, US
| | - Muhammet Enes Gurses
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, 33136, US.
| | - Brandon Kaye
- Dr. Kiran C. Patel College of Allopathic Medicine, Davie, FL, 33326, US
| | | | - Chandler Berke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, 33136, US
| | - Elif Gökalp
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, 33136, US
| | - Victor M Lu
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, 33136, US
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, 33136, US
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, 33136, US
| | - Ashish H Shah
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, 33136, US
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Vellayappan B, Lim-Fat MJ, Kotecha R, De Salles A, Fariselli L, Levivier M, Ma L, Paddick I, Pollock BE, Regis J, Sheehan JP, Suh JH, Yomo S, Sahgal A. A Systematic Review Informing the Management of Symptomatic Brain Radiation Necrosis After Stereotactic Radiosurgery and International Stereotactic Radiosurgery Society Recommendations. Int J Radiat Oncol Biol Phys 2024; 118:14-28. [PMID: 37482137 DOI: 10.1016/j.ijrobp.2023.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 07/02/2023] [Accepted: 07/14/2023] [Indexed: 07/25/2023]
Abstract
Radiation necrosis (RN) secondary to stereotactic radiosurgery is a significant cause of morbidity. The optimal management of corticosteroid-refractory brain RN remains unclear. Our objective was to summarize the literature specific to efficacy and toxicity of treatment paradigms for patients with symptomatic corticosteroid-refractory RN and to provide consensus guidelines for grading and management of RN on behalf of the International Stereotactic Radiosurgery Society. A systematic review of articles pertaining to treatment of RN with bevacizumab, laser interstitial thermal therapy (LITT), surgical resection, or hyperbaric oxygen therapy was performed. The primary composite outcome was clinical and/or radiologic stability/improvement (ie, proportion of patients achieving improvement or stability with the given intervention). Proportions of patients achieving the primary outcome were pooled using random weighted-effects analysis but not directly compared between interventions. Twenty-one articles were included, of which only 2 were prospective studies. Thirteen reports were relevant for bevacizumab, 5 for LITT, 5 for surgical resection and 1 for hyperbaric oxygen therapy. Weighted effects analysis revealed that bevacizumab had a pooled symptom improvement/stability rate of 86% (95% CI 77%-92%), pooled T2 imaging improvement/stability rate of 93% (95% CI 87%-98%), and pooled T1 postcontrast improvement/stability rate of 94% (95% CI 87%-98%). Subgroup analysis showed a statistically significant improvement favoring treatment with low-dose (below median, ≤7.5 mg/kg every 3 weeks) versus high-dose bevacizumab with regards to symptom improvement/stability rate (P = .02) but not for radiologic T1 or T2 changes. The pooled T1 postcontrast improvement/stability rate for LITT was 88% (95% CI 82%-93%), and pooled symptom improvement/stability rate for surgery was 89% (95% CI 81%-96%). Toxicity was inconsistently reported but was generally low for all treatment paradigms. Corticosteroid-refractory RN that does not require urgent surgical intervention, with sufficient noninvasive diagnostic testing that favors RN, can be treated medically with bevacizumab in carefully selected patients as a strong recommendation. The role of LITT is evolving as a less invasive image guided surgical modality; however, the overall evidence for each modality is of low quality. Prospective head-to-head comparisons are needed to evaluate the relative efficacy and toxicity profile among treatment approaches.
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Affiliation(s)
- Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore.
| | - Mary Jane Lim-Fat
- Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Antonio De Salles
- Department of Neurosurgery, University of California, Los Angeles, California; HCor Neuroscience, São Paulo, Brazil
| | - Laura Fariselli
- Department of Neurosurgery, Unit of Radiotherapy, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Marc Levivier
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of Southern California, Los Angeles, California
| | - Ian Paddick
- Division Physics, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jean Regis
- Department of Functional Neurosurgery, Aix Marseille University, Timone University Hospital, Marseille, France
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Vaios EJ, Winter SF, Shih HA, Dietrich J, Peters KB, Floyd SR, Kirkpatrick JP, Reitman ZJ. Novel Mechanisms and Future Opportunities for the Management of Radiation Necrosis in Patients Treated for Brain Metastases in the Era of Immunotherapy. Cancers (Basel) 2023; 15:2432. [PMID: 37173897 PMCID: PMC10177360 DOI: 10.3390/cancers15092432] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/12/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023] Open
Abstract
Radiation necrosis, also known as treatment-induced necrosis, has emerged as an important adverse effect following stereotactic radiotherapy (SRS) for brain metastases. The improved survival of patients with brain metastases and increased use of combined systemic therapy and SRS have contributed to a growing incidence of necrosis. The cyclic GMP-AMP (cGAMP) synthase (cGAS) and stimulator of interferon genes (STING) pathway (cGAS-STING) represents a key biological mechanism linking radiation-induced DNA damage to pro-inflammatory effects and innate immunity. By recognizing cytosolic double-stranded DNA, cGAS induces a signaling cascade that results in the upregulation of type 1 interferons and dendritic cell activation. This pathway could play a key role in the pathogenesis of necrosis and provides attractive targets for therapeutic development. Immunotherapy and other novel systemic agents may potentiate activation of cGAS-STING signaling following radiotherapy and increase necrosis risk. Advancements in dosimetric strategies, novel imaging modalities, artificial intelligence, and circulating biomarkers could improve the management of necrosis. This review provides new insights into the pathophysiology of necrosis and synthesizes our current understanding regarding the diagnosis, risk factors, and management options of necrosis while highlighting novel avenues for discovery.
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Affiliation(s)
- Eugene J. Vaios
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
| | - Sebastian F. Winter
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Helen A. Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jorg Dietrich
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Katherine B. Peters
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Scott R. Floyd
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
| | - John P. Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Zachary J. Reitman
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
- Department of Pathology, Duke University Medical Center, Durham, NC 27710, USA
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DEGRO practical guideline for central nervous system radiation necrosis part 2: treatment. Strahlenther Onkol 2022; 198:971-980. [PMID: 36038670 PMCID: PMC9581806 DOI: 10.1007/s00066-022-01973-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 06/15/2022] [Indexed: 11/08/2022]
Abstract
Purpose The Working Group for Neurooncology of the German Society for Radiation Oncology (DEGRO; AG NRO) in cooperation with members of the Neurooncological Working Group of the German Cancer Society (DKG-NOA) aimed to define a practical guideline for the diagnosis and treatment of radiation-induced necrosis (RN) of the central nervous system (CNS). Methods Panel members of the DEGRO working group invited experts, participated in a series of conferences, supplemented their clinical experience, performed a literature review, and formulated recommendations for medical treatment of RN, including bevacizumab, in clinical routine. Conclusion Diagnosis and treatment of RN requires multidisciplinary structures of care and defined processes. Diagnosis has to be made on an interdisciplinary level with the joint knowledge of a neuroradiologist, radiation oncologist, neurosurgeon, neuropathologist, and neurooncologist. If the diagnosis of blood–brain barrier disruptions (BBD) or RN is likely, treatment should be initiated depending on the symptoms, location, and dynamic of the lesion. Multiple treatment options are available (such as observation, surgery, steroids, and bevacizumab) and the optimal approach should be discussed in an interdisciplinary setting. In this practice guideline, we offer detailed treatment strategies for various scenarios.
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Effect of Family Participatory Nursing Model Based on WeChat Platform on Psychological Elasticity and Quality of Life of Patients with Lung Cancer. BIOMED RESEARCH INTERNATIONAL 2022; 2022:4704107. [PMID: 35578722 PMCID: PMC9107353 DOI: 10.1155/2022/4704107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/22/2022] [Accepted: 03/28/2022] [Indexed: 11/24/2022]
Abstract
Objective To explore the effect of family participatory nursing model based on WeChat platform on psychological elasticity and life quality of patients with lung cancer. Methods One hundred patients with lung cancer treated in our hospital from February 2019 to April 2021 were enrolled. The patients were randomly assigned into control group and study group. The control group received routine nursing and the study group received family participatory nursing model based on WeChat platform. The scores of nursing satisfaction, self-feeling burden, symptom group assessment scale, family care index, and compliance and life quality were compared. Results First of all, we compared the nursing satisfaction: the study group was very satisfied in 25 cases, satisfactory in 20 cases, general in 5 cases, the satisfaction rate was 100.00%; the control group was very satisfied in 14 cases, satisfactory in 17 cases, general in 13 cases, dissatisfied in 6 cases, and the satisfaction rate was 88.00%. Compared between the two groups, the nursing satisfaction in the study group was higher compared to the control group (P < 0.05). Secondly, we compared the self-perceived burden, the emotional burden, physical burden, and economic burden and total scores of the study group were lower compared to the control group (P < 0.05). Comparing the scores of symptom group evaluation scale, the scores of respiratory symptoms, fatigue symptoms, psychological and emotional symptoms, digestive tract symptoms, and nervous system symptoms in the study group were lower compared to the control group (P < 0.05). In terms of the family care index of the two groups, the scores of fitness, cooperation, length, emotion, and intimacy in the study group were higher compared to the control group (P < 0.05). Comparison of compliance, the study group was very compliant in 42 cases, compliant in 7 cases, noncompliant in 1 case, the compliance rate was 98.00%; the control group was very compliant in 24 cases, compliant in 20 cases, noncompliant in 6 cases, the compliance rate was 88.00%. The compliance rate in the study group was higher compared to the control group (P < 0.05). Finally, we compared the scores of qualities of life. Before nursing, there exhibited no significant difference (P > 0.05). The scores of physiological function, psychological function, social function, and health self-cognition in the study group were lower compared to the control group (P < 0.05). Conclusion The family participatory nursing model based on WeChat platform helps to facilitate the psychological elasticity and quality of life of patients with lung cancer and further promote patients' self-care ability and compliance with lung cancer. It can also effectively enhance family care and nursing satisfaction; the nursing model is worth popularizing and applying in clinic.
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