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Kutuk T, Tolakanahalli R, Chaswal V, Yarlagadda S, Herrera R, Appel H, La Rosa A, Mishra V, Wieczorek DJJ, McDermott MW, Siomin V, Mehta MP, Odia Y, Gutierrez AN, Kotecha R. Surgically targeted radiation therapy (STaRT) for recurrent brain metastases: Initial clinical experience. Brachytherapy 2023; 22:872-881. [PMID: 37722990 DOI: 10.1016/j.brachy.2023.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/23/2023] [Accepted: 08/01/2023] [Indexed: 09/20/2023]
Abstract
PURPOSE This study evaluates the outcomes of recurrent brain metastasis treated with resection and brachytherapy using a novel Cesium-131 carrier, termed surgically targeted radiation therapy (STaRT), and compares them to the first course of external beam radiotherapy (EBRT). METHODS Consecutive patients who underwent STaRT between August 2020 and June 2022 were included. All patients underwent maximal safe resection with pathologic confirmation of viable disease prior to STaRT to 60 Gy to a 5-mm depth from the surface of the resection cavity. Complications were assessed using CTCAE version 5.0. RESULTS Ten patients with 12 recurrent brain metastases after EBRT (median 15.5 months, range: 4.9-44.7) met the inclusion criteria. The median BED10Gy90% and 95% were 132.2 Gy (113.9-265.1 Gy) and 116.0 Gy (96.8-250.6 Gy), respectively. The median maximum point dose BED10Gy for the target was 1076.0 Gy (range: 120.7-1478.3 Gy). The 6-month and 1-year local control rates were 66.7% and 33.3% for the prior EBRT course; these rates were 100% and 100% for STaRT, respectively (p < 0.001). At a median follow-up of 14.5 months, there was one instance of grade two radiation necrosis. Surgery-attributed complications were observed in two patients including pseudomeningocele and minor headache. CONCLUSIONS STaRT with Cs-131 presents an alternative approach for operable recurrent brain metastases and was associated with superior local control than the first course of EBRT in this series. Our initial clinical experience shows that STaRT is associated with a high local control rate, modest surgical complication rate, and low radiation necrosis risk in the reirradiation setting.
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Affiliation(s)
- Tugce Kutuk
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Ranjini Tolakanahalli
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Vibha Chaswal
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Sreenija Yarlagadda
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Roberto Herrera
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Haley Appel
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Alonso La Rosa
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Vivek Mishra
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - D Jay J Wieczorek
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Michael W McDermott
- Department of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL
| | - Vitaly Siomin
- Department of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Yazmin Odia
- Department of Neuro-oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Alonso N Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL.
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Ivren M, Grittner U, Khakhar R, Belotti F, Schneider H, Pöser P, D'Agata F, Spena G, Vajkoczy P, Picht T, Rosenstock T. Comparison of anatomical-based vs. nTMS-based risk stratification model for predicting postoperative motor outcome and extent of resection in brain tumor surgery. Neuroimage Clin 2023; 38:103436. [PMID: 37236052 PMCID: PMC10232884 DOI: 10.1016/j.nicl.2023.103436] [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: 11/04/2022] [Revised: 04/07/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Two statistical models have been established to evaluate characteristics associated with postoperative motor outcome in patients with glioma associated to the motor cortex (M1) or the corticospinal tract (CST). One model is based on a clinicoradiological prognostic sum score (PrS) while the other one relies on navigated transcranial magnetic stimulation (nTMS) and diffusion-tensor-imaging (DTI) tractography. The objective was to compare the models regarding their prognostic value for postoperative motor outcome and extent of resection (EOR) with the aim of developing a combined, improved model. METHODS We retrospectively analyzed a consecutive prospective cohort of patients who underwent resection for motor associated glioma between 2008 and 2020, and received a preoperative nTMS motor mapping with nTMS-based diffusion tensor imaging tractography. The primary outcomes were the EOR and the motor outcome (on the day of discharge and 3 months postoperatively according to the British Medical Research Council (BMRC) grading). For the nTMS model, the infiltration of M1, tumor-tract distance (TTD), resting motor threshold (RMT) and fractional anisotropy (FA) were assesed. For the PrS score (ranging from 1 to 8, lower scores indicating a higher risk), we assessed tumor margins, volume, presence of cysts, contrast agent enhancement, MRI index (grading white matter infiltration), preoperative seizures or sensorimotor deficits. RESULTS Two hundred and three patients with a median age of 50 years (range: 20-81 years) were analyzed of whom 145 patients (71.4%) received a GTR. The rate of transient new motor deficits was 24.1% and of permanent new motor deficits 18.8%. The nTMS model demonstrated a good discrimination ability for the short-term motor outcome at day 7 of discharge (AUC = 0.79, 95 %CI: 0.72-0.86) and the long-term motor outcome after 3 months (AUC = 0.79, 95 %CI: 0.71-0.87). The PrS score was not capable to predict the postoperative motor outcome in this cohort but was moderately associated with the EOR (AUC = 0.64; CI 0.55-0.72). An improved, combined model was calculated to predict the EOR more accurately (AUC = 0.74, 95 %CI: 0.65-0.83). CONCLUSION The nTMS model was superior to the clinicoradiological PrS model for potentially predicting the motor outcome. A combined, improved model was calculated to estimate the EOR. Thus, patient counseling and surgical planning in patients with motor-associated tumors should be performed using functional nTMS data combined with tractography.
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Affiliation(s)
- Meltem Ivren
- Department of Neurosurgery, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany; Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
| | - Rutvik Khakhar
- Department of Neurosurgery, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
| | - Francesco Belotti
- Department of Neurosurgery, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany; Neurosurgery Unit, Spedali Civili di Brescia Hospital, 25123 Brescia, Italy
| | - Heike Schneider
- Department of Neurosurgery, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
| | - Paul Pöser
- Department of Neurosurgery, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
| | - Federico D'Agata
- Department of Neuroscience, University of Turin, Via Verdi 8, 10124 Turin, Italy
| | - Giannantonio Spena
- Neurosurgery Unit, Spedali Civili di Brescia Hospital, 25123 Brescia, Italy
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
| | - Thomas Picht
- Department of Neurosurgery, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany; Cluster of Excellence: "Matters of Activity. Image Space Material," Humboldt University, Unter den Linden 6, 10099 Berlin, Germany
| | - Tizian Rosenstock
- Department of Neurosurgery, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Digital Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany.
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Imber BS, Young RJ, Beal K, Reiner AS, Giantini-Larsen AM, Yang JT, Aramburu-Nunez D, Cohen GN, Brennan C, Tabar V, Moss NS. Salvage resection plus cesium-131 brachytherapy durably controls post-SRS recurrent brain metastases. J Neurooncol 2022; 159:609-618. [PMID: 35896906 PMCID: PMC9328626 DOI: 10.1007/s11060-022-04101-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/16/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Salvage of recurrent previously irradiated brain metastases (rBrM) is a significant challenge. Resection without adjuvant re-irradiation is associated with a high local failure rate, while reirradiation only partially reduces failure but is associated with greater radiation necrosis risk. Salvage resection plus Cs131 brachytherapy may offer dosimetric and biologic advantages including improved local control versus observation, with reduced normal brain dose versus re-irradiation, however data are limited. METHODS A prospective registry of consecutive patients with post-stereotactic radiosurgery (SRS) rBrM undergoing resection plus implantation of collagen-matrix embedded Cs131 seeds (GammaTile, GT Medical Technologies) prescribed to 60 Gy at 5 mm from the cavity was analyzed. RESULTS Twenty patients underwent 24 operations with Cs131 implantation in 25 tumor cavities. Median maximum preoperative diameter was 3.0 cm (range 1.1-6.3). Gross- or near-total resection was achieved in 80% of lesions. A median of 16 Cs131 seeds (range 6-30), with a median air-kerma strength of 3.5 U/seed were implanted. There was one postoperative wound dehiscence. With median follow-up of 1.6 years for survivors, two tumors recurred (one in-field, one marginal) resulting in 8.4% 1-year progression incidence (95%CI = 0.0-19.9). Radiographic seed settling was identified in 7/25 cavities (28%) 1.9-11.7 months post-implantation, with 1 case of distant migration (4%), without clinical sequelae. There were 8 cases of radiation necrosis, of which 4 were symptomatic. CONCLUSIONS With > 1.5 years of follow-up, intraoperative brachytherapy with commercially available Cs131 implants was associated with favorable local control and toxicity profiles. Weak correlation between preoperative tumor geometry and implanted tiles highlights a need to optimize planning criteria.
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Affiliation(s)
- Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert J Young
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Radiology, Neuroradiology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anne S Reiner
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | - Jonathan T Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Aramburu-Nunez
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gil'ad N Cohen
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cameron Brennan
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Viviane Tabar
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nelson S Moss
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA. .,Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Rosenstock T, Pöser P, Wasilewski D, Bauknecht HC, Grittner U, Picht T, Misch M, Onken JS, Vajkoczy P. MRI-Based Risk Assessment for Incomplete Resection of Brain Metastases. Front Oncol 2022; 12:873175. [PMID: 35651793 PMCID: PMC9149256 DOI: 10.3389/fonc.2022.873175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/07/2022] [Indexed: 11/13/2022] Open
Abstract
Object Recent studies demonstrated that gross total resection of brain metastases cannot always be achieved. Subtotal resection (STR) can result in an early recurrence and might affect patient survival. We initiated a prospective observational study to establish a MRI-based risk assessment for incomplete resection of brain metastases. Methods All patients in whom ≥1 brain metastasis was resected were prospectively included in this study (DRKS ID: DRKS00021224; Nov 2020 - Nov 2021). An interdisciplinary board of neurosurgeons and neuroradiologists evaluated the pre- and postoperative MRI (≤48h after surgery) for residual tumor. Extensive neuroradiological analyses were performed to identify risk factors for an unintended STR which were integrated into a regression tree analysis to determine the patients' individual risk for a STR. Results We included 150 patients (74 female; mean age: 61 years), in whom 165 brain metastases were resected. A STR was detected in 32 cases (19.4%) (median residual tumor volume: 1.36ml, median EORrel: 93.6%), of which 6 (3.6%) were intended STR (median residual tumor volume: 3.27ml, median EORrel: 67.3%) - mainly due to motor-eloquent location - and 26 (15.8%) were unintended STR (uSTR) (median residual tumor volume: 0.64ml, median EORrel: 94.7%). The following risk factors for an uSTR could be identified: subcortical metastasis ≥5mm distant from cortex, diffuse contrast agent enhancement, proximity to the ventricles, contact to falx/tentorium and non-transcortical approaches. Regression tree analysis revealed that the individual risk for an uSTR was mainly associated to the distance from the cortex (distance ≥5mm vs. <5mm: OR 8.0; 95%CI: 2.7 - 24.4) and the contrast agent patterns (diffuse vs. non-diffuse in those with distance ≥5mm: OR: 4.2; 95%CI: 1.3 - 13.7). The preoperative tumor volume was not substantially associated with the extent of resection. Conclusions Subcortical metastases ≥5mm distant from cortex with diffuse contrast agent enhancement showed the highest incidence of uSTR. The proposed MRI-based assessment allows estimation of the individual risk for uSTR and can help indicating intraoperative imaging.
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Affiliation(s)
- Tizian Rosenstock
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Digital Clinician Scientist Program, Berlin, Germany
| | - Paul Pöser
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - David Wasilewski
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Hans-Christian Bauknecht
- Institute of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Thomas Picht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Cluster of Excellence: "Matters of Activity. Image Space Material," Humboldt University, Berlin, Germany
| | - Martin Misch
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Julia Sophie Onken
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Does pigmentation, hemosiderin and blood affect visible 5-ALA fluorescence in cerebral melanoma metastasis? Photodiagnosis Photodyn Ther 2022; 39:102864. [DOI: 10.1016/j.pdpdt.2022.102864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/10/2022] [Accepted: 04/12/2022] [Indexed: 11/23/2022]
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