Propensity-score matched pair comparison of whole brain with simultaneous in-field boost radiotherapy and stereotactic radiosurgery

Effects of brain radiotherapy strategies on survival in the era of MRI for patients with limited stage small cell lung cancer

BACKGROUND AND PURPOSE

In the context of the widespread availability of magnetic resonance imaging (MRI) and aggressive salvage irradiation techniques, there has been controversy surrounding the use of prophylactic cranial irradiation (PCI) for small-cell lung cancer (SCLC) patients. This study aimed to explore whether regular brain MRI plus salvage brain irradiation (SBI) is not inferior to PCI in patients with limited-stage SCLC (LS-SCLC).

METHODS

This real-world multicenter study, which was conducted between January 2014 and September 2020 at three general hospitals, involved patients with LS-SCLC who had a good response to initial chemoradiotherapy and no brain metastasis confirmed by MRI. Overall survival (OS) was compared between patients who did not receive PCI for various reasons but chose regular MRI surveillance and followed salvage brain irradiation (SBI) when brain metastasis was detected and patients who received PCI.

RESULTS

120 patients met the inclusion criteria. 55 patients received regular brain MRI plus SBI (SBI group) and 65 patients received PCI (PCI group). There was no statistically significant difference in median OS between the two groups (27.14 versus 33.00 months; P = 0.18). In the SBI group, 32 patients underwent whole brain radiotherapy and 23 patients underwent whole brain radiotherapy + simultaneous integrated boost. On multivariate analysis, only extracranial metastasis was independently associated with poor OS in the SBI group.

CONCLUSION

The results of this real-world study showed that MRI surveillance plus SBI is not inferior to PCI in OS for LS-SCLC patients who had a good response to initial chemoradiotherapy.

Choice of radiotherapy modality for the combined treatment of non-small cell lung cancer with brain metastases: whole-brain radiation therapy with simultaneous integrated boost or stereotactic radiosurgery

Purpose

To compare Whole-brain radiation therapy with simultaneous integrated boost (WBRT+SIB) to stereotactic radiosurgery (SRS)for non-small cell lung cancer (NSCLC)with brain metastases (BMs)in terms of overall survival (OS), intracranial progression-free-survival(iPFS), toxicity and objective response rate (ORR).

Methods

A retrospective review was performed in our hospital of 90 patients diagnosed with NSCLC- BM who received either SRS (n = 48) or WBRT+SIB (n = 42) from January 2016 to January 2022. 76 (84.44%) patients received systemic drug therapy after radiotherapy, including chemotherapy(n=53), targeted therapy(n=40), immunotherapy(n=23), and anti-vascular drug therapy(n=45). OS and iPFS were estimated by the Kaplan-Meier method and compared using the log-rank test. Univariate and Multivariate analysis of the prognostic factors was performed using the Cox proportional hazard regression model.

Results

The WBRT+SIB cohort had a longer median iPFS (20.0 versus (VS) 12.0 months, P = 0.0069) and a similar median OS (32.0 vs 28.0 months, P = 0.195) than the SRS cohort. Intracranial objective response rates in WBRT +SIB and SRS cohorts were 76.19% and 70.09%, respectively (P = 0.566). Disease control rates were 88.09% and 83.33%, respectively (P = 0.521). Multivariate analysis showed that WBRT+SIB is the only factor affecting iPFS(hazard ratio (HR):0.597 {95%confidence interval(CI):0.370-0.966}, P=0.035). Sex, Liver metastasis and Lymph node metastasis are risk factors for NSCLC-BM.

Conclusion

In the context of systemic drug therapy, WBRT+SIB may have better intracranial local control than SRS in NSCLC-BM patients.

Modern Radiation Therapy for the Management of Brain Metastases From Non-Small Cell Lung Cancer: Current Approaches and Future Directions

Brain metastases (BMs) represent the most frequent event during the course of Non-Small Cell Lung Cancer (NSCLC) disease. Recent advancements in the diagnostic and therapeutic procedures result in increased incidence and earlier diagnosis of BMs, with an emerging need to optimize the prognosis of these patients through the adoption of tailored treatment solutions. Nowadays a personalized and multidisciplinary approach should rely on several clinical and molecular factors like patient’s performance status, extent and location of brain involvement, extracranial disease control and the presence of any “druggable” molecular target. Radiation therapy (RT), in all its focal (radiosurgery and fractionated stereotactic radiotherapy) or extended (whole brain radiotherapy) declinations, is a cornerstone of BMs management, either alone or combined with surgery and systemic therapies. Our review aims to provide an overview of the many modern RT solutions available for the treatment of BMs from NSCLC in the different clinical scenarios (single lesion, oligo and poly-metastasis, leptomeningeal carcinomatosis). This includes a detailed review of the current standard of care in each setting, with a presentation of the literature data and of the possible technical solutions to offer a “state-of-art” treatment to these patients. In addition to the validated treatment options, we will also discuss the future perspectives on emerging RT technical strategies (e.g., hippocampal avoidance whole brain RT, simultaneous integrated boost, radiosurgery for multiple lesions), and present the innovative and promising findings regarding the combination of novel targeted agents such as tyrosine kinase inhibitors and immune checkpoint inhibitors with brain irradiation.

Stereotactic radiotherapy of the tumor bed compared to whole brain radiotherapy after surgery of single brain metastasis: Results from a randomized trial

PURPOSE

To evaluate if neurological/cognitive function outcomes in patients with resected single brain metastasis (BM) after stereotactic radiotherapy of the tumor bed (SRT-TB) are not inferior compared to those achieved with whole-brain radiotherapy (WBRT).

METHODS

Patients with total/subtotal resection of single BM were randomly assigned either to SRT-TB (n=29) or WBRT (n=30). SRT-TB arm consisted of 15Gy/1 fraction, or 5×5Gy. WBRT consisted of 30Gy/10 fractions. Neurological/cognitive failure was defined as a decrease of neurological score by one point or more, or a worsening of the MiniMental test by at least 3 points, or neurological death. Cumulative incidence of neurological/cognitive failure (CINCF), neurological death (CIND), and overall survival (OS) were compared.

RESULTS

Median follow-up was 29months (range: 8-45) for 15 patients still alive. The difference in the probability of CINCF at 6months (primary endpoint) was -8% in favor of WBRT (95% confidence interval: +17% -35%; non-inferiority margin: -20%). In the intention-to-treat analysis, two-year CIND rates were 66% vs. 31%, for SRT-TB and WBRT arm, respectively, p=.015. The corresponding figures for OS were 10% vs. 37%, p=.046.

CONCLUSIONS

Non-inferiority of SRT-TB was not demonstrated in our underpowered study. More data from randomized studies are needed for confirmation of the value of this method.

Whole brain radiotherapy with adjuvant or concomitant boost in brain metastasis: dosimetric comparison between helical and volumetric IMRT technique

BACKGROUND

To compare and evaluate the possible advantages related to the use of VMAT and helical IMRT and two different modalities of boost delivering, adjuvant stereotactic boost (SRS) or simultaneous integrated boost (SIB), in the treatment of brain metastasis (BM) in RPA classes I-II patients.

METHODS

Ten patients were treated with helical IMRT, 5 of them with SRS after whole brain radiotherapy (WBRT) and 5 with SIB. MRI co-registration with planning CT was mandatory and prescribed doses were 30 Gy in 10 fractions (fr) for WBRT and 15Gy/1fr or 45Gy/10fr in SRS or SIB, respectively. For each patient, 4 "treatment plans" (VMAT SRS and SIB, helical IMRT SRS and SIB) were calculated and accepted if PTV boost was included in 95 % isodose and dose constraints of the main organs at risk were respected without major deviations. Homogeneity Index (HI), Conformal Index (CI) and Conformal Number (CN) were considered to compare the different plans. Moreover, time of treatment delivery was calculated and considered in the analysis.

RESULTS

Volume of brain metastasis ranged between 1.43 and 51.01 cc (mean 12.89 ± 6.37 ml) and 3 patients had double lesions. V95% resulted over 95 % in the average for each kind of technique, but the "target coverage" was inadequate for VMAT planning with two sites. The HI resulted close to the ideal value of zero in all cases; VMAT-SIB, VMAT-SRS, Helical IMRT-SIB and Helical IMRT-SRS showed mean CI of 2.15, 2.10, 2.44 and 1.66, respectively (optimal range: 1.5-2.0). Helical IMRT-SRS was related to the best and reliable finding of CN (0.66). The mean of treatment time was 210 s, 467 s, 440 s, 1598 s, respectively, for VMAT-SIB, VMAT-SRS, Helical IMRT-SIB and Helical IMRT-SRS.

CONCLUSIONS

This dosimetric comparison show that helical IMRT obtain better target coverage and respect of CI and CN; VMAT could be acceptable in solitary metastasis. SIB modality can be considered as a good choice for clinical and logistic compliance; literature's preliminary data are confirming also a radiobiological benefit for SIB. Helical IMRT-SRS seems less effective for the long time of treatment compared to other techniques.

Supine Versus Standing Radiographs for Detecting Ischiofemoral Impingement: A Propensity Score-Matched Analysis

OBJECTIVE

The purpose of this study was to assess parameters of ischiofemoral impingement on supine and standing anteroposterior hip radiographs and to suggest optimal cutoff points for detection of ischiofemoral impingement.

MATERIALS AND METHODS

A retrospective study included patients with a clinical history of hip pain. All hip joints with evidence of quadratus femoris muscle edema on MR images were included in the ischiofemoral impingement patient group. An age- and sex-matched control group was derived from the same cohort by propensity score matching. On radiographs, two readers independently measured the following parameters: ischiofemoral space, quadratus femoris space, hamstring tendon area, ischiofemoral distance on supine radiograph, ischiofemoral distance on standing radiograph, and femoral neck-shaft angle. Group differences in parameters were assessed by Mann-Whitney U test. The intraclass correlation coefficient and the ROC AUC were obtained. Correlations between radiographic and MRI measures were assessed with Pearson correlation and Bland-Altman plot analyses. The Youden J index was used to select optimum cutoff points for each parameter.

RESULTS

There were 30 patients (44 hip joints; mean age, 54.8 ± 11 years) in the ischiofemoral impingement group and 88 patients (88 hip joints; mean age, 51.8 ± 13.4 years) in the control group. There were significant group differences in ischiofemoral space, quadratus femoris space, ischiofemoral distance on supine radiograph, ischiofemoral distance on standing radiograph, and neck-shaft angle (p < 0.05). Ischiofemoral distance on supine and standing radiographs exhibited good discriminative ability (AUC > 0.80). The optimal cutoff points for ischiofemoral distances on supine and standing radiographs were 19.9 and 19.1 mm for reader 1 and 21.1 and 17.0 mm for reader 2. Ischiofemoral space, quadratus femoris space, ischiofemoral distance on supine radiograph, and ischiofemoral distance on standing radiograph exhibited nearly perfect interobserver agreement (r > 0.8).

CONCLUSION

Ischiofemoral distances on supine and standing hip radiographs had good diagnostic performance and can be used as a screening tool, with optimal cutoff points.

Comparison of symptomatic anastomotic leakage following laparoscopic and open low anterior resection for rectal cancer: a propensity score matching analysis of 1014 consecutive patients

BACKGROUND

This observational study was conducted to compare the rate of symptomatic anastomotic leakage (AL), as defined by precise criteria, between laparoscopic and open surgery in patients with mid-to-low rectal cancer using a relatively novel statistical technique.

METHODS

A total of 1014 consecutive low anterior resection (LAR) patients were registered, of whom 936 were included in this prospective, multicenter, and cohort study (UMIN-CTR, Number 000004017). Patients with rectal cancer within 10 cm from the anal verge underwent either open or laparoscopic LAR at one of the 40 institutions in Japan from June 2010 to February 2013. The primary endpoint of this study was to compare the rate of symptomatic AL between the two groups before and after propensity score matching (PSM). The secondary endpoint was to analyze the risk factors for symptomatic AL in open and laparoscopic surgery.

RESULTS

After PSM, the incidence of symptomatic AL in open and laparoscopic surgery was 12.4 and 15.3 %, respectively (p = 0.48). AL requiring relaparotomy occurred after 3.8 % of open surgeries and 6.2 % of laparoscopic surgeries (p = 0.37). Multivariate analysis identified male gender as an independent risk factor for symptomatic AL following laparoscopic surgery (p = 0.001; odds ratio 5.2; 95 % CI 2.0-13.8), and male gender (p = 0.004; odds ratio 2.6; 95 % CI 1.3-5.6), tumor size (p = 0.002; odds ratio 1.2; 95 % CI 0.7-0.9), and number of stapler firing (p = 0.04; odds ratio 4.1; 95 % CI 1.0-15.0) following open surgery.

CONCLUSION

The rate of symptomatic AL was comparable following laparoscopic and open LAR in this large, multicenter, cohort study after PSM. Male gender was associated with an increased risk of symptomatic AL after laparoscopic LAR.

The challenge of durable brain control in patients with brain-only metastases from breast cancer

The vast majority of patients with brain metastases from breast cancer have extracranial metastases, e.g., in the liver, lungs or bones, with serious impact on prognosis. Limited research has been performed on patients with brain-only disease. We analyzed patterns of treatment, brain control and survival in uni- and multivariate analyses. All 25 patients with brain-only disease were treated with radiotherapy (whole-brain radiotherapy (WBRT) with or without stereotactic radiotherapy/radiosurgery (SRS) or surgical resection) and most patients with systemic treatment later during the disease trajectory. Only a minority of patients remained free from brain progression at 1 year after their initial therapy, regardless of initial treatment approach (median brain progression-free survival 6.2 months). However, overall survival was significantly better after initial surgical resection/SRS as compared to upfront WBRT (median 24.1 and 5.2 months, respectively). For all patients combined, median survival was 11.7 months (2-year survival rate 28 %). Several prognostic factors for shorter survival were identified in multivariate regression analysis: lower KPS, triple-negative tumor, coordination deficit, older age, lack of upfront surgical resection or SRS, and lack of endocrine or HER2-directed therapy after brain metastases treatment. Although durable brain control and long-term survival beyond 5 years could be achieved in a subset of patients (largely after successful salvage), progression of brain metastases during the first year after diagnosis was common. Prognosis was influenced by patient-, disease- and treatment-related factors.

The treatment of patients with 1-3 brain metastases: is there a place for whole brain radiotherapy alone, yet? A retrospective analysis

AIM

To evaluate the efficacy of whole brain radiotherapy (WBRT) with or without other treatments in patients (pts) with 1-3 brain metastases (BM).

MATERIALS AND METHODS

Toxicities and survival of 134 pts treated between 2009 and 2013 with WBRT alone (58 pts), WBRT plus surgery (SUR-WBRT: 42 pts) or WBRT followed by stereotactic or integrated boost radiotherapy (SRT-WBRT: 34 pts) were analyzed. Differences in toxicity (acute and late) incidence and in overall (OS), disease-free (DFS) and disease-specific survival (DSS) were evaluated (χ(2)-test, uni- and multivariate analysis).

RESULTS

Pts given intensified treatments (SUR- and SBRT-WBRT) had better 3-month local response compared to WBRT alone group (p < 0.045). Better 1-year local control was evident only in SRT-WBRT pts (p < 0.035). Univariate OS analysis confirmed, as favorable prognostic factors, RPA class I (p < 0.001), GPA class III and IV (p < 0.001), single metastasis (p = 0.045), stable primary disease (p = 0.03), intensified treatment (p = 0.000), systemic therapy after radiotherapy (p = 0.04) and response of metastatic lesions (p = 0.002). At multivariate analysis, OS was better in RPA class I pts (p = 0.002), who had more aggressive radiotherapy treatments (p = 0.001), chemotherapy after radiotherapy (p < 0.001) and response to RT (p = 0.003). Response to radiotherapy (p = 0.002) and BM number (p < 0.001) resulted independently prognostic for DFS. About 60 % of patients had mild acute toxicity (G1), especially headache (51 %) and fatigue (34 %); only 2 patients (2 %) had severe (G3) headache and 5 patients (4 %) severe fatigue (G3) reversible with oral steroids. No differences were evident between the different treatment groups. Among 80 pts followed up with MRI, 12 (15 %) had leukoencephalopathy (equally distributed across subgroups) and 5 (6 %) radionecroses, 4/5 asymptomatic, 5/5 in pts given intensified treatments.

CONCLUSIONS

This analysis confirms the known prognostic factors for BM, emphasizing the importance of intensified treatments in a population with favorable features.

Brachytherapy improves biochemical failure-free survival in low- and intermediate-risk prostate cancer compared with conventionally fractionated external beam radiation therapy: a propensity score matched analysis

PURPOSE

To compare, in a retrospective study, biochemical failure-free survival (bFFS) and overall survival (OS) in low-risk and intermediate-risk prostate cancer patients who received brachytherapy (BT) (either low-dose-rate brachytherapy [LDR-BT] or high-dose-rate brachytherapy with external beam radiation therapy [HDR-BT+EBRT]) versus external beam radiation therapy (EBRT) alone.

METHODS AND MATERIALS

Patient data were obtained from the ProCaRS database, which contains 7974 prostate cancer patients treated with primary radiation therapy at four Canadian cancer institutions from 1994 to 2010. Propensity score matching was used to obtain the following 3 matched cohorts with balanced baseline prognostic factors: (1) low-risk LDR-BT versus EBRT; (2) intermediate-risk LDR-BT versus EBRT; and (3) intermediate-risk HDR-BT+EBRT versus EBRT. Kaplan-Meier survival analysis was performed to compare differences in bFFS (primary endpoint) and OS in the 3 matched groups.

RESULTS

Propensity score matching created acceptable balance in the baseline prognostic factors in all matches. Final matches included 2 1:1 matches in the intermediate-risk cohorts, LDR-BT versus EBRT (total n=254) and HDR-BT+EBRT versus EBRT (total n=388), and one 4:1 match in the low-risk cohort (LDR-BT:EBRT, total n=400). Median follow-up ranged from 2.7 to 7.3 years for the 3 matched cohorts. Kaplan-Meier survival analysis showed that all BT treatment options were associated with statistically significant improvements in bFFS when compared with EBRT in all cohorts (intermediate-risk EBRT vs LDR-BT hazard ratio [HR] 4.58, P=.001; intermediate-risk EBRT vs HDR-BT+EBRT HR 2.08, P=.007; low-risk EBRT vs LDR-BT HR 2.90, P=.004). No significant difference in OS was found in all comparisons (intermediate-risk EBRT vs LDR-BT HR 1.27, P=.687; intermediate-risk EBRT vs HDR-BT+EBRT HR 1.55, P=.470; low-risk LDR-BT vs EBRT HR 1.41, P=.500).

CONCLUSIONS

Propensity score matched analysis showed that BT options led to statistically significant improvements in bFFS in low- and intermediate-risk prostate cancer patient populations.

Population-based outcomes of boost versus salvage radiosurgery for brain metastases after whole brain radiotherapy

PURPOSE

We conducted a retrospective population-based study to examine the survival outcomes in patients with brain metastases treated with salvage stereotactic radiosurgery (SRS), compared to boost SRS, after previous whole brain radiotherapy (WBRT).

METHODS AND MATERIALS

From January 2000 to June 2011, 191 patients treated with WBRT and SRS for brain metastases in British Columbia were studied. Patients were divided into a boost cohort and a salvage cohort. The criteria used to determine eligibility for SRS were: 1-3 metastases, ≤4cm size, Karnofsky performance status ≥ 70, and control of extracranial disease.

RESULTS

Diagnosis by primary site was 84 lung, 47 breast, 15 melanoma, 12 renal, 9 colorectal, and 24 other. There were 113 patients (59%) in the boost cohort and 78 patients (41%) in the salvage cohort. The median overall survival from WBRT for the whole population was 17.7months: 12.1 months for the boost cohort and 22.7 months for the salvage cohort. There was no difference in median survival after SRS for the boost and salvage cohorts (11.2 vs. 11.2 months, p=0.78).

CONCLUSIONS

In selected patients with brain metastases treated with WBRT, survival following salvage SRS is as good as survival after WBRT + boost SRS.