1
|
Samanci Y, Ali Tepebasili M, Deniz Ardor G, Haluk Duzkalir A, Orbay Askeroglu M, Peker S. Efficacy of hypofractionated Gamma Knife radiosurgery in treating surgical beds of metastatic brain tumors. J Clin Neurosci 2024; 121:105-113. [PMID: 38387112 DOI: 10.1016/j.jocn.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/01/2024] [Accepted: 02/17/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVE Surgery alone for metastatic brain tumors (METs) often results in local recurrence due to microscopic residual tumor tissue. While stereotactic radiosurgery (SRS) is commonly used post-surgery, hypofractionation may be required for large surgical beds. This study evaluated the efficacy and safety of hypofractionated Gamma Knife radiosurgery (hf-GKRS) for the first time as a post-operative adjuvant therapy. METHODS This retrospective study involved 24 patients (28 surgical beds) who underwent hf-GKRS within four weeks after surgery. The study primarily focused on local control (LC) rate and analyzed distant intracranial failure (DICF), intracranial progression-free survival (PFS), leptomeningeal disease (LMD), overall survival (OS), and radiation necrosis (RN). RESULTS During a median follow-up of 9 months, LC was achieved in 89.3 % of surgical beds. LC estimates at 6, 12, and 24 months were 96.4 %, 82.7 %, and 82.7 %, respectively. DICF was observed in 45.8 % of patients, and LMD was identified in two patients (8.3 %). At the end of the follow-up, 58.3 % of patients were alive, and the median OS was 20 months. RN occurred in only one surgical bed (3.6 %). No grade 5 toxicity was observed. The univariate analysis identified a longer interval to GKRS (HR 11.842, p = 0.042) and a larger treatment volume (HR 1.103, p = 0.037) as significant factors for local failure. CONCLUSIONS hf-GKRS shows potential as an effective and safe adjuvant treatment for surgical beds. It offers an alternative to SRS, SRT, or WBRT, particularly for larger volumes or tumors near critical structures. Further research is needed to confirm these results and optimize treatment approaches.
Collapse
Affiliation(s)
- Yavuz Samanci
- Koc University School of Medicine, Department of Neurosurgery, Istanbul, Turkey
| | | | - Gokce Deniz Ardor
- Koc University Hospital, Department of Neurosurgery, Gamma Knife Center, Istanbul, Turkey
| | - Ali Haluk Duzkalir
- Koc University Hospital, Department of Neurosurgery, Gamma Knife Center, Istanbul, Turkey
| | - M Orbay Askeroglu
- Koc University Hospital, Department of Neurosurgery, Gamma Knife Center, Istanbul, Turkey
| | - Selcuk Peker
- Koc University School of Medicine, Department of Neurosurgery, Istanbul, Turkey.
| |
Collapse
|
2
|
Müller SJ, Khadhraoui E, Ganslandt O, Henkes H, Gihr GA. MRI Treatment Response Assessment Maps (TRAMs) for differentiating recurrent glioblastoma from radiation necrosis. J Neurooncol 2024; 166:513-521. [PMID: 38261142 DOI: 10.1007/s11060-024-04573-x] [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: 10/29/2023] [Accepted: 01/11/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND MRI treatment response assessment maps (TRAMs) were introduced to distinguish recurrent malignant glioma from therapy related changes. TRAMs are calculated with two contrast-enhanced T1-weighted sequences and reflect the "late" wash-out (or contrast clearance) and wash-in of gadolinium. Vital tumor cells are assumed to produce a wash-out because of their high turnover rate and the associated hypervascularization, whereas contrast medium slowly accumulates in scar tissue. To examine the real value of this method, we compared TRAMs with the pathology findings obtained after a second biopsy or surgery when recurrence was suspected. METHODS We retrospectively evaluated TRAMs in adult patients with histologically demonstrated glioblastoma, contrast-enhancing tissue and a pre-operative MRI between January 1, 2017, and December 31, 2022. Only patients with a second biopsy or surgery were evaluated. Volumes of the residual tumor, contrast clearance and contrast accumulation before the second surgery were analyzed. RESULTS Among 339 patients with mGBM who underwent MRI, we identified 29 repeated surgeries/biopsies in 27 patients 59 ± 12 (mean ± standard deviation) years of age. Twenty-eight biopsies were from patients with recurrent glioblastoma histology, and only one was from a patient with radiation necrosis. We volumetrically evaluated the 29 pre-surgery TRAMs. In recurrent glioblastoma, the ratio of wash-out volume to tumor volume was 36 ± 17% (range 1-73%), and the ratio of the wash-out volume to the sum of wash-out and wash-in volumes was 48 ± 21% (range 22-92%). For the one biopsy with radiation necrosis, the ratios were 42% and 54%, respectively. CONCLUSIONS Typical recurrent glioblastoma shows a > 20%ratio of the wash-out volume to the sum of wash-out and wash-in volumes. The one biopsy with radiation necrosis indicated that such necrosis can also produce high wash-out in individual cases. Nevertheless, the additional information provided by TRAMs increases the reliability of diagnosis.
Collapse
Affiliation(s)
| | - Eya Khadhraoui
- Klinik Für Neuroradiologie, Klinikum-Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Germany
| | - Oliver Ganslandt
- Abteilung Für Neurochirurgie, Klinikum-Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Klinik Für Neuroradiologie, Klinikum-Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Germany
| | - Georg Alexander Gihr
- Klinik Für Neuroradiologie, Klinikum-Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Germany
| |
Collapse
|
3
|
Lother D, Robert M, Elwood E, Smith S, Tunariu N, Johnston SRD, Parton M, Bhaludin B, Millard T, Downey K, Sharma B. Imaging in metastatic breast cancer, CT, PET/CT, MRI, WB-DWI, CCA: review and new perspectives. Cancer Imaging 2023; 23:53. [PMID: 37254225 DOI: 10.1186/s40644-023-00557-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 04/17/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Breast cancer is the most frequent cancer in women and remains the second leading cause of death in Western countries. It represents a heterogeneous group of diseases with diverse tumoral behaviour, treatment responsiveness and prognosis. While major progress in diagnosis and treatment has resulted in a decline in breast cancer-related mortality, some patients will relapse and prognosis in this cohort of patients remains poor. Treatment is determined according to tumor subtype; primarily hormone receptor status and HER2 expression. Menopausal status and site of disease relapse are also important considerations in treatment protocols. MAIN BODY Staging and repeated evaluation of patients with metastatic breast cancer are central to the accurate assessment of disease extent at diagnosis and during treatment; guiding ongoing clinical management. Advances have been made in the diagnostic and therapeutic fields, particularly with new targeted therapies. In parallel, oncological imaging has evolved exponentially with the development of functional and anatomical imaging techniques. Consistent, reproducible and validated methods of assessing response to therapy is critical in effectively managing patients with metastatic breast cancer. CONCLUSION Major progress has been made in oncological imaging over the last few decades. Accurate disease assessment at diagnosis and during treatment is important in the management of metastatic breast cancer. CT (and BS if appropriate) is generally widely available, relatively cheap and sufficient in many cases. However, several additional imaging modalities are emerging and can be used as adjuncts, particularly in pregnancy or other diagnostically challenging cases. Nevertheless, no single imaging technique is without limitation. The authors have evaluated the vast array of imaging techniques - individual, combined parametric and multimodal - that are available or that are emerging in the management of metastatic breast cancer. This includes WB DW-MRI, CCA, novel PET breast cancer-epitope specific radiotracers and radiogenomics.
Collapse
Affiliation(s)
| | - Marie Robert
- Institut de Cancérologie de l'Ouest, St Herblain, France
| | | | - Sam Smith
- The Royal Marsden Hospital, London & Sutton, UK
| | - Nina Tunariu
- The Royal Marsden Hospital, London & Sutton, UK
- The Institute of Cancer Research (ICR), London & Sutton, UK
| | - Stephen R D Johnston
- The Royal Marsden Hospital, London & Sutton, UK
- The Institute of Cancer Research (ICR), London & Sutton, UK
| | | | | | | | - Kate Downey
- The Royal Marsden Hospital, London & Sutton, UK
- The Institute of Cancer Research (ICR), London & Sutton, UK
| | - Bhupinder Sharma
- The Royal Marsden Hospital, London & Sutton, UK.
- The Institute of Cancer Research (ICR), London & Sutton, UK.
| |
Collapse
|
4
|
Admojo L, Korte J, Anderson N, Phillips C, Caspersz L, Lasocki A. Investigating the role of delayed contrast magnetic resonance imaging (MRI) to differentiate radiation necrosis from tumour recurrence in brain metastases after stereotactic radiosurgery. J Med Imaging Radiat Oncol 2023; 67:292-298. [PMID: 36650724 DOI: 10.1111/1754-9485.13504] [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] [Received: 09/21/2021] [Accepted: 12/21/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION The incidence of radionecrosis (RN) after stereotactic radiosurgery (SRS) to brain metastases is increasing. An overlap in the conventional MRI appearances of RN and tumour recurrence (TR) is diagnostically challenging. Delayed contrast MRI compares contrast enhancement over two time periods to create treatment response assessment maps (TRAMs). We aim to assess the utility of TRAMs in brain metastases patients. METHODS Delayed contrast MRI scans were performed on ten brain metastases patients, previously treated with SRS, who developed equivocal lesion(s) on routine MRI follow-up. T1-weighted images were obtained five minutes and 60-75 min after contrast injection, followed by Brain Lab software analysis to create TRAMs. TRAMs patterns were then compared with the patient's clinical status, subsequent imaging, and histology results. RESULTS We identified three regions on TRAMs: central, peripheral, and surrounding. Each region could be described either as contrast accumulation (red colour and representing non-tumour tissue) or contrast clearance (blue colour and representing tumour tissue). Our analysis demonstrated similarities in the TRAMs pattern between TR and RN, though to varying degrees. CONCLUSION In conclusion, the TRAMs appearances of RN and TR overlap. Our findings suggest that the previously-described correlation between contrast clearance and TR is at least partially attributable to more solid initial enhancement, rather than convincingly a difference in the underlying tissue properties, and the additional diagnostic value of TRAMs may be limited. Thus, further research on TRAMs is necessary prior to incorporating it into routine clinical management after SRS for brain metastases.
Collapse
Affiliation(s)
- Lorenztino Admojo
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Austin Health, Melbourne, Victoria, Australia
| | - James Korte
- Department of Physical Science, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Biomedical Engineering, University of Melbourne, Melbourne, Victoria, Australia
| | - Nigel Anderson
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,Radiation Therapy Services, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Claire Phillips
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Lauren Caspersz
- Department of Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Arian Lasocki
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,Department of Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| |
Collapse
|
5
|
Teunissen WHT, Govaerts CW, Kramer MCA, Labrecque JA, Smits M, Dirven L, van der Hoorn A. Diagnostic accuracy of MRI techniques for treatment response evaluation in patients with brain metastasis: A systematic review and meta-analysis. Radiother Oncol 2022; 177:121-133. [PMID: 36377093 DOI: 10.1016/j.radonc.2022.10.026] [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: 05/11/2022] [Revised: 10/11/2022] [Accepted: 10/21/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Treatment response assessment in patients with brain metastasis uses contrast enhanced T1-weighted MRI. Advanced MRI techniques have been studied, but the diagnostic accuracy is not well known. Therefore, we performed a metaanalysis to assess the diagnostic accuracy of the currently available MRI techniques for treatment response. METHODS A systematic literature search was done. Study selection and data extraction were done by two authors independently. Meta-analysis was performed using a bivariate random effects model. An independent cohort was used for DSC perfusion external validation of diagnostic accuracy. RESULTS Anatomical MRI (16 studies, 726 lesions) showed a pooled sensitivity of 79% and a specificity of 76%. DCE perfusion (4 studies, 114 lesions) showed a pooled sensitivity of 74% and a specificity of 92%. DSC perfusion (12 studies, 418 lesions) showed a pooled sensitivity was 83% with a specificity of 78%. Diffusion weighted imaging (7 studies, 288 lesions) showed a pooled sensitivity of 67% and a specificity of 79%. MRS (4 studies, 54 lesions) showed a pooled sensitivity of 80% and a specificity of 78%. Combined techniques (6 studies, 375 lesions) showed a pooled sensitivity of 84% and a specificity of 88%. External validation of DSC showed a lower sensitivity and a higher specificity for the reported cut-off values included in this metaanalysis. CONCLUSION A combination of techniques shows the highest diagnostic accuracy differentiating tumor progression from treatment induced abnormalities. External validation of imaging results is important to better define the reliability of imaging results with the different techniques.
Collapse
Affiliation(s)
- Wouter H T Teunissen
- Erasmus MC, department of Radiology and Nuclear Medicine, Rotterdam, the Netherlands; Brain Tumor Centre, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Medical Delta, Delft, The Netherlands
| | - Chris W Govaerts
- University Medical Center Groningen, Medical imaging center, department of Radiology, Groningen, the Netherlands
| | - Miranda C A Kramer
- University Medical Center Groningen, department of Radiotherapy, Groningen, the Netherlands
| | - Jeremy A Labrecque
- Erasmus MC, Netherlands Institute for Health Science (NIHES), Rotterdam, the Netherlands
| | - Marion Smits
- Erasmus MC, department of Radiology and Nuclear Medicine, Rotterdam, the Netherlands; Brain Tumor Centre, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Medical Delta, Delft, The Netherlands
| | - Linda Dirven
- Leiden University Medical Center, department of Neurology, Leiden, the Netherlands; Haaglanden Medical Center, department of Neurology, The Hague, the Netherlands
| | - Anouk van der Hoorn
- University Medical Center Groningen, Medical imaging center, department of Radiology, Groningen, the Netherlands.
| |
Collapse
|
6
|
Bodensohn R, Forbrig R, Quach S, Reis J, Boulesteix AL, Mansmann U, Hadi I, Fleischmann D, Mücke J, Holzgreve A, Albert N, Ruf V, Dorostkar M, Corradini S, Herms J, Belka C, Thon N, Niyazi M. MRI-based contrast clearance analysis shows high differentiation accuracy between radiation-induced reactions and progressive disease after cranial radiotherapy. ESMO Open 2022; 7:100424. [PMID: 35248822 PMCID: PMC9058918 DOI: 10.1016/j.esmoop.2022.100424] [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: 12/02/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 11/26/2022] Open
Abstract
Background Pseudoprogression (PsP) or radiation necrosis (RN) may frequently occur after cranial radiotherapy and show a similar imaging pattern compared with progressive disease (PD). We aimed to evaluate the diagnostic accuracy of magnetic resonance imaging-based contrast clearance analysis (CCA) in this clinical setting. Patients and methods Patients with equivocal imaging findings after cranial radiotherapy were consecutively included into this monocentric prospective study. CCA was carried out by software-based automated subtraction of imaging features in late versus early T1-weighted sequences after contrast agent application. Two experienced neuroradiologists evaluated CCA with respect to PsP/RN and PD being blinded for histological findings. The radiological assessment was compared with the histopathological results, and its accuracy was calculated statistically. Results A total of 33 patients were included; 16 (48.5%) were treated because of a primary brain tumor (BT), and 17 (51.1%) because of a secondary BT. In one patient, CCA was technically infeasible. The accuracy of CCA in predicting the histological result was 0.84 [95% confidence interval (CI) 0.67-0.95; one-sided P = 0.051; n = 32]. Sensitivity and specificity of CCA were 0.93 (95% CI 0.66-1.00) and 0.78 (95% CI 0.52-0.94), respectively. The accuracy in patients with secondary BTs was 0.94 (95% CI 0.71-1.00) and nonsignificantly higher compared with patients with primary BT with an accuracy of 0.73 (95% CI 0.45-0.92), P = 0.16. Conclusions In this study, CCA was a highly accurate, easy, and helpful method for distinguishing PsP or RN from PD after cranial radiotherapy, especially in patients with secondary tumors after radiosurgical treatment. CCA is accurate in distinguishing treatment reactions from true PD. CCA was more accurate for irradiated metastases than primary BTs. CCA is not feasible for lesions with no contrast media uptake.
Collapse
|
7
|
Samanci Y, Karakose F, Senyurek S, Peker S. Single-fraction versus hypofractionated gamma knife radiosurgery for small metastatic brain tumors. Clin Exp Metastasis 2021; 38:305-320. [PMID: 33733707 DOI: 10.1007/s10585-021-10086-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/08/2021] [Indexed: 12/31/2022]
Abstract
Stereotactic radiosurgery (SRS) has become a standard of care for the treatment of metastatic brain tumors (METs). Although a better balance of tumor control and toxicity of hypofractionated SRS (hfSRS) compared with single-fraction SRS (sfSRS) was demonstrated in large METs, there is no data comparing two approaches for small METs (< 4 cm3). It was aimed to compare clinical outcomes between sfSRS versus hfSRS Gamma Knife radiosurgery (GKRS) in a series of patients with unresected, small METs. Patients (n = 208) treated with sfGKRS or hfGKRS between June 2017 and May 2020 were retrospectively examined in a single center. The co-primary endpoints of local control (LC) and toxicity were estimated by applying the Kaplan-Meier method. Multivariate analysis using Cox proportional hazards (HR) modeling was used to assess the effect of independent variables on the outcomes. The actuarial LC rate was 99.7% at six months and 98.8% at 18 months in the sfGKRS group, and 99.4% and 94.3% in the hfGKRS group (p = 0.089), respectively. In multivariate analysis, MET volume (p = 0.023, HR 2.064) and biologically effective dose (BED10) (p < 0.0001, HR 0.753) was associated with LC. In total, treatment-related toxicity was observed in 13 (8.7%) patients during a median period of 10 weeks (range 1-31). Radiation necrosis was observed in four patients (1.9%), and all patients were in the sfGKRS group (p = 0.042). Only the maximum dose was associated with toxicity (p = 0.032, HR 1.047). Our current results suggest that hfGKRS is advantageous and beneficial also in patients with unresected, small METs.
Collapse
Affiliation(s)
- Yavuz Samanci
- Department of Neurosurgery, Koç University Hospital, Istanbul, Turkey
| | - Fatih Karakose
- Department of Radiation Oncology, Koç University Hospital, Istanbul, Turkey
| | - Sukran Senyurek
- Department of Radiation Oncology, Koç University Hospital, Istanbul, Turkey
| | - Selcuk Peker
- Department of Neurosurgery, School of Medicine, Koç University, Istanbul, Turkey.
| |
Collapse
|