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Tijtgat J, Calliauw E, Dirven I, Vounckx M, Kamel R, Vanbinst AM, Everaert H, Seynaeve L, Van Den Berge D, Duerinck J, Neyns B. Low-Dose Bevacizumab for the Treatment of Focal Radiation Necrosis of the Brain (fRNB): A Single-Center Case Series. Cancers (Basel) 2023; 15:cancers15092560. [PMID: 37174026 PMCID: PMC10177060 DOI: 10.3390/cancers15092560] [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: 02/28/2023] [Revised: 04/17/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
Focal radiation necrosis of the brain (fRNB) is a late adverse event that can occur following the treatment of benign or malignant brain lesions with stereotactic radiation therapy (SRT) or stereotactic radiosurgery (SRS). Recent studies have shown that the incidence of fRNB is higher in cancer patients who received immune checkpoint inhibitors. The use of bevacizumab (BEV), a monoclonal antibody that targets the vascular endothelial growth factor (VEGF), is an effective treatment for fRNB when given at a dose of 5-7.5 mg/kg every two weeks. In this single-center retrospective case series, we investigated the effectiveness of a low-dose regimen of BEV (400 mg loading dose followed by 100 mg every 4 weeks) in patients diagnosed with fRNB. A total of 13 patients were included in the study; twelve of them experienced improvement in their existing clinical symptoms, and all patients had a decrease in the volume of edema on MRI scans. No clinically significant treatment-related adverse effects were observed. Our preliminary findings suggest that this fixed low-dose regimen of BEV can be a well-tolerated and cost-effective alternative treatment option for patients diagnosed with fRNB, and it is deserving of further investigation.
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Affiliation(s)
- Jens Tijtgat
- Department of Medical Oncology, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Evan Calliauw
- Department of Medical Oncology, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Iris Dirven
- Department of Medical Oncology, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Manon Vounckx
- Department of Medical Oncology, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Randa Kamel
- Department of Radiotherapy, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Anne Marie Vanbinst
- Department of Medical Imaging, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Hendrik Everaert
- Department of Nuclear Medicine, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Laura Seynaeve
- Department of Neurology, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Dirk Van Den Berge
- Department of Radiotherapy, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Johnny Duerinck
- Department of Neurosurgery, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Bart Neyns
- Department of Medical Oncology, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
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DeVries DA, Tang T, Alqaidy G, Albweady A, Leung A, Laba J, Lagerwaard F, Zindler J, Hajdok G, Ward AD. Dual-center validation of using magnetic resonance imaging radiomics to predict stereotactic radiosurgery outcomes. Neurooncol Adv 2023; 5:vdad064. [PMID: 37358938 PMCID: PMC10289521 DOI: 10.1093/noajnl/vdad064] [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] [Indexed: 06/28/2023] Open
Abstract
Background MRI radiomic features and machine learning have been used to predict brain metastasis (BM) stereotactic radiosurgery (SRS) outcomes. Previous studies used only single-center datasets, representing a significant barrier to clinical translation and further research. This study, therefore, presents the first dual-center validation of these techniques. Methods SRS datasets were acquired from 2 centers (n = 123 BMs and n = 117 BMs). Each dataset contained 8 clinical features, 107 pretreatment T1w contrast-enhanced MRI radiomic features, and post-SRS BM progression endpoints determined from follow-up MRI. Random decision forest models were used with clinical and/or radiomic features to predict progression. 250 bootstrap repetitions were used for single-center experiments. Results Training a model with one center's dataset and testing it with the other center's dataset required using a set of features important for outcome prediction at both centers, and achieved area under the receiver operating characteristic curve (AUC) values up to 0.70. A model training methodology developed using the first center's dataset was locked and externally validated with the second center's dataset, achieving a bootstrap-corrected AUC of 0.80. Lastly, models trained on pooled data from both centers offered balanced accuracy across centers with an overall bootstrap-corrected AUC of 0.78. Conclusions Using the presented validated methodology, radiomic models trained at a single center can be used externally, though they must utilize features important across all centers. These models' accuracies are inferior to those of models trained using each individual center's data. Pooling data across centers shows accurate and balanced performance, though further validation is required.
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Affiliation(s)
- David A DeVries
- Department of Medical Biophysics, Western University, London, ON, Canada
- Gerald C. Baines Centre, London Health Sciences Centre, London, ON, Canada
| | - Terence Tang
- Department of Radiation Oncology, London Regional Cancer Program, London, ON, Canada
| | - Ghada Alqaidy
- Radiodiagnostic and Medical Imaging Department, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Ali Albweady
- Department of Radiology, Unaizah College of Medicine and Medical Sciences, Qassim University, Unaizah, Saudi Arabia
| | - Andrew Leung
- Department of Medical Imaging, Western University, London, ON, Canada
| | - Joanna Laba
- Department of Radiation Oncology, London Regional Cancer Program, London, ON, Canada
- Department of Oncology, Western University, London, ON, Canada
| | - Frank Lagerwaard
- Department of Radiation Oncology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Jaap Zindler
- Department of Radiation Oncology, Haaglanden Medical Centre, Den Haag, The Netherlands
- Holland Proton Therapy Centre, Delft, The Netherlands
| | - George Hajdok
- Department of Medical Biophysics, Western University, London, ON, Canada
| | - Aaron D Ward
- Department of Medical Biophysics, Western University, London, ON, Canada
- Gerald C. Baines Centre, London Health Sciences Centre, London, ON, Canada
- Department of Oncology, Western University, London, ON, Canada
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Wu Q, Chen M, Peng F, Zhang Q, Kong Y, Bao Y, Xu Y, Hu X, Chen M. A study of the prognosis of patients with limited-stage small cell lung cancer who did or did not receive prophylactic cranial irradiation after effective chemoradiotherapy. Front Oncol 2023; 13:1118371. [PMID: 37035198 PMCID: PMC10076622 DOI: 10.3389/fonc.2023.1118371] [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: 12/07/2022] [Accepted: 03/09/2023] [Indexed: 04/11/2023] Open
Abstract
Objective To investigate the prognosis of patients with LS-SCLC who responded to chest chemoradiotherapy but did not receive PCI. Methods A retrospective analysis was conducted on LS-SCLC patients who had achieved complete remission (CR) or partial remission (PR) after definitive chemoradiotherapy but did not receive PCI. The survival rates were calculated using Kaplan-Meier method. The prognosis was analyzed using Cox proportional hazard regression model. The main endpoint was OS. Results Of the 500 patients with LS-SCLC admitted between June 2002 and January 2018, 327 achieved CR or PR after definitive chest chemoradiotherapy, 103 did not receive PCI, and 63 of them developed brain metastases (BM). The 1-year and 3-year OS rates in PCI group were 87.5% and 42.3% respectively, versus 70.4% and 20.9% for non-PCI group(P=0.002). The median survival time after BM was 8.7 months (range: 0.3-48.7), and 3-year OS rate was 15.0%, the median survival time of patients without BM was 20.1 months (range: 2.9-79.4), and 3-year OS was 33.4% (P=0.014). Patients with BM were subsequently treated with palliative therapy. Multivariate analysis showed that compared with no treatment, brain radiotherapy alone (HR: 0.131, 95%CI: 0.035-0.491, P=0.003) and radiotherapy combined with chemotherapy (HR: 0.039, 95%CI: 0.008-0.194, P<0.001) significantly reduced the risk of death. Multiple BM (HR: 2.391, 95%CI: 1.082-5.285, P=0.031) was an independent adverse prognostic factor for OS. Conclusion LS-SCLC patients who achieved good response after chest chemoradiotherapy without receiving PCI were prone to develop BM and have a poor prognosis. Multiple BM was an independent adverse prognostic factor. PCI remains the standard of care for LS-SCLC patients.
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Affiliation(s)
- Qing Wu
- The Second Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
- Department of Thoracic Radiotherapy, Zhejiang Cancer Hospital, Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, Zhejiang, China
| | - Mengyuan Chen
- Department of Thoracic Radiotherapy, Zhejiang Cancer Hospital, Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, Zhejiang, China
| | - Fang Peng
- Department of Radiotherapy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Qun Zhang
- Department of Radiotherapy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yue Kong
- Department of Thoracic Radiotherapy, Zhejiang Cancer Hospital, Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, Zhejiang, China
| | - Yong Bao
- Department of Radiotherapy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yujin Xu
- Department of Thoracic Radiotherapy, Zhejiang Cancer Hospital, Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, Zhejiang, China
| | - Xiao Hu
- Department of Thoracic Radiotherapy, Zhejiang Cancer Hospital, Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, Zhejiang, China
- *Correspondence: Xiao Hu, ; Ming Chen,
| | - Ming Chen
- Department of Radiotherapy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
- *Correspondence: Xiao Hu, ; Ming Chen,
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Vetlova ER, Banov SM, Golanov AV, Pronin IN, Antipina NA, Galkin MV. [Results of hypofractionated stereotactic radiotherapy for resected and intact large brain metastases]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:67-75. [PMID: 38054229 DOI: 10.17116/neiro20238706167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
Post-resection or isolated hypofractionated stereotactic radiotherapy (HF-SRT) is a therapeutic option for large brain metastases (>2 cm, LBMs). OBJECTIVE To compare the results of post-resection or isolated HF-SRT in patients with LBMs. MATERIAL AND METHODS A prospective study included 115 patients with 129 intact LBMs and 133 patients with 149 resected LBMs who underwent HF-SRT. Median baseline focal size was 22.5 and 28 mm, median target volume - 8.3 and 23.7 cm3, respectively. RESULTS Median follow-up was 13.9 months, median overall survival - 19.1 months. After 12 months, local recurrences developed in 17 and 31% of patients, respectively (p=0.0078). Local recurrence after 12 months developed in 23% of patients with residual tumor in postoperative cavity compared to 16% of patients after total resection (p=0.0073). After 12 months, incidence of leptomeningeal progression was 27 and 11%, respectively (p=0.033), incidence of symptomatic radiation-induced necrosis - 4 and 23%, respectively (p=0.0006). CONCLUSION Post-resection HF-SRT demonstrated better local control and less severe symptomatic radiation-induced necrosis compared to patients with intact LBMs. Incidence of leptomeningeal progression is significantly higher after resection of LBMs.
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Affiliation(s)
- E R Vetlova
- Burdenko Neurosurgical Center, Moscow, Russia
| | - S M Banov
- Burdenko Neurosurgical Center, Moscow, Russia
| | - A V Golanov
- Burdenko Neurosurgical Center, Moscow, Russia
- Russian Medical Academy of Continuing Professional Education, Moscow, Russia
| | - I N Pronin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - M V Galkin
- Burdenko Neurosurgical Center, Moscow, Russia
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Carpenter DJ, Fairchild AT, Adamson JD, Fecci PE, Sampson JH, Herndon JE, Torok JA, Mullikin TC, Kim GJ, Reitman ZJ, Kirkpatrick JP, Floyd SR. Outcomes in Patients with Intact and Resected Brain Metastasis Treated with 5-Fraction Stereotactic Radiosurgery. Adv Radiat Oncol 2022; 8:101166. [PMID: 36845614 PMCID: PMC9943776 DOI: 10.1016/j.adro.2022.101166] [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: 10/16/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022] Open
Abstract
Purpose Hypofractionated stereotactic radiosurgery (HF-SRS) with or without surgical resection is potentially a preferred treatment for larger or symptomatic brain metastases (BMs). Herein, we report clinical outcomes and predictive factors following HF-SRS. Methods and Materials Patients undergoing HF-SRS for intact (iHF-SRS) or resected (rHF-SRS) BMs from 2008 to 2018 were retrospectively identified. Linear accelerator-based image-guided HF-SRS consisted of 5 fractions at 5, 5.5, or 6 Gy per fraction. Time to local progression (LP), time to distant brain progression (DBP), and overall survival (OS) were calculated. Cox models assessed effect of clinical factors on OS. Fine and Gray's cumulative incidence model for competing events examined effect of factors on LP and DBP. The occurrence of leptomeningeal disease (LMD) was determined. Logistic regression examined predictors of LMD. Results Among 445 patients, median age was 63.5 years; 87% had Karnofsky performance status ≥70. Fifty-three % of patients underwent surgical resection, and 75% received 5 Gy per fraction. Patients with resected BMs had higher Karnofsky performance status (90-100, 41 vs 30%), less extracranial disease (absent, 25 vs 13%), and fewer BMs (multiple, 32 vs 67%). Median diameter of the dominant BM was 3.0 cm (interquartile range, 1.8-3.6 cm) for intact BMs and 4.6 cm (interquartile range, 3.9-5.5 cm) for resected BMs. Median OS was 5.1 months (95% confidence interval [CI], 4.3-6.0) following iHF-SRS and 12.8 months (95% CI, 10.8-16.2) following rHF-SRS (P < .01). Cumulative LP incidence was 14.5% at 18 months (95% CI, 11.4-18.0%), significantly associated with greater total GTV (hazard ratio, 1.12; 95% CI, 1.05-1.20) following iFR-SRS, and with recurrent versus newly diagnosed BMs across all patients (hazard ratio, 2.28; 95% CI, 1.01-5.15). Cumulative DBP incidence was significantly greater following rHF-SRS than iHF-SRS (P = .01), with respective 24-month rates of 50.0 (95% CI, 43.3-56.3) and 35.7% (95% CI, 29.2-42.2). LMD (57 events total; 33% nodular, 67% diffuse) was observed in 17.1% of rHF-SRS and 8.1% of iHF-SRS cases (odds ratio, 2.46; 95% CI, 1.34-4.53). Any radionecrosis and grade 2+ radionecrosis events were observed in 14 and 8% of cases, respectively. Conclusions HF-SRS demonstrated favorable rates of LC and radionecrosis in postoperative and intact settings. Corresponding LMD and RN rates were comparable to those of other studies.
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Affiliation(s)
- David J. Carpenter
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina,Corresponding author: Scott Floyd, MD, PhD
| | | | - Justus D. Adamson
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Peter E. Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - John H. Sampson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - James E. Herndon
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Jordan A. Torok
- Department of Radiation Oncology, St. Clair Hospital Cancer Center, Pittsburgh, Pennsylvania
| | - Trey C. Mullikin
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Grace J. Kim
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Zachary J. Reitman
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - John P. Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina,Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Scott R. Floyd
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
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Liu EK, Chen JJ, Braunstein S. Management of Adverse Radiation Effect Associated with Stereotactic Radiosurgery of Brain Metastasis in Multiple Sclerosis. Adv Radiat Oncol 2022; 8:101150. [PMID: 36691577 PMCID: PMC9860432 DOI: 10.1016/j.adro.2022.101150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 12/12/2022] [Indexed: 12/26/2022] Open
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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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Li AY, Gaebe K, Jerzak KJ, Cheema PK, Sahgal A, Das S. Intracranial Metastatic Disease: Present Challenges, Future Opportunities. Front Oncol 2022; 12:855182. [PMID: 35330715 PMCID: PMC8940535 DOI: 10.3389/fonc.2022.855182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/16/2022] [Indexed: 11/13/2022] Open
Abstract
Intracranial metastatic disease (IMD) is a prevalent complication of cancer that significantly limits patient survival and quality of life. Over the past half-century, our understanding of the epidemiology and pathogenesis of IMD has improved and enabled the development of surveillance and treatment algorithms based on prognostic factors and tumor biomolecular characteristics. In addition to advances in surgical resection and radiation therapy, the treatment of IMD has evolved to include monoclonal antibodies and small molecule antagonists of tumor-promoting proteins or endogenous immune checkpoint inhibitors. Moreover, improvements in the sensitivity and specificity of imaging as well as the development of new serological assays to detect brain metastases promise to revolutionize IMD diagnosis. In this review, we will explore current treatment principles in patients with IMD, including the emerging role of targeted and immunotherapy in select primary cancers, and discuss potential areas for further investigation.
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Affiliation(s)
- Alyssa Y Li
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Karolina Gaebe
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Katarzyna J Jerzak
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Oncology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Parneet K Cheema
- Division of Oncology, William Osler Health System, Brampton, ON, Canada
| | - Arjun Sahgal
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Sunit Das
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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Sankey EW, Grabowski MM, Srinivasan ES, Griffin AS, Howell EP, Otvos B, Tsvankin V, Barnett GH, Mohammadi AM, Fecci PE. Time to Steroid Independence After Laser Interstitial Thermal Therapy vs Medical Management for Treatment of Biopsy-Proven Radiation Necrosis Secondary to Stereotactic Radiosurgery for Brain Metastasis. Neurosurgery 2022; 90:684-690. [DOI: 10.1227/neu.0000000000001922] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 12/05/2021] [Indexed: 12/14/2022] Open
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Salvage Treatment for Progressive Brain Metastases in Breast Cancer. Cancers (Basel) 2022; 14:cancers14041096. [PMID: 35205844 PMCID: PMC8870695 DOI: 10.3390/cancers14041096] [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: 12/06/2021] [Revised: 01/31/2022] [Accepted: 02/17/2022] [Indexed: 11/24/2022] Open
Abstract
Simple Summary Thirty percent of patients with human epidermal growth factor receptor 2-positive breast cancer and triple-negative breast cancer, and 15% of patients with the remaining subtypes of breast cancer will develop brain metastases. Available treatment methods include surgery and radiotherapy. However, some individuals will experience intracranial progression despite prior local treatment. This situation remains a challenge. In the case of progressing lesions amenable to local therapy, the choice of a treatment method must consider performance status, cancer burden, possible toxicity, and previously applied therapy. Stereotactic radiosurgery or fractionated radiotherapy rather than whole-brain radiotherapy should be used only if feasible. If local therapy is unfeasible, selected patients, especially those with human epidermal growth factor receptor 2-positive breast cancer, may benefit from systemic therapy. Abstract Survival of patients with breast cancer has increased in recent years due to the improvement of systemic treatment options. Nevertheless, the occurrence of brain metastases is associated with a poor prognosis. Moreover, most drugs do not penetrate the central nervous system because of the blood–brain barrier. Thus, confirmed intracranial progression after local therapy is especially challenging. The available methods of salvage treatment include surgery, stereotactic radiosurgery (SRS), fractionated stereotactic radiotherapy (FSRT), whole-brain radiotherapy, and systemic therapies. This narrative review discusses possible strategies of salvage treatment for progressive brain metastases in breast cancer. It covers possibilities of repeated local treatment using the same method as applied previously, other methods of local therapy, and options of salvage systemic treatment. Repeated local therapy may provide a significant benefit in intracranial progression-free survival and overall survival. However, it could lead to significant toxicity. Thus, the choice of optimal methods should be carefully discussed within the multidisciplinary tumor board.
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Outcomes in Patients With 4 to 10 Brain Metastases Treated With Dose-Adapted Single-Isocenter Multitarget Stereotactic Radiosurgery: A Prospective Study. Adv Radiat Oncol 2021; 6:100760. [PMID: 34934856 PMCID: PMC8655418 DOI: 10.1016/j.adro.2021.100760] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/13/2021] [Indexed: 12/20/2022] Open
Abstract
Purpose To examine the effectiveness and safety of single-isocenter multitarget stereotactic radiosurgery using a volume-adapted dosing strategy in patients with 4 to 10 brain metastases. Methods and Materials Adult patients with 4 to 10 brain metastases were eligible for this prospective trial. The primary endpoint was overall survival. Secondary endpoints were local recurrence, distant brain failure, neurologic death, and rate of adverse events. Exploratory objectives were neurocognition, quality of life, dosimetric data, salvage rate, and radionecrosis. Dose was prescribed in a single fraction per RTOG 90-05 or as 5 Gy × 5 fractions for lesions ≥3 cm diameter, lesions involving critical structures, or single-fraction brain V12Gy >20 mL. Results Forty patients were treated with median age of 61 years, Karnofsky performance status 90, and 6 brain metastases. Twenty-two patients survived longer than expected from the time of protocol SRS, with 1 living patient who has not reached that milestone. Median overall survival was 8.1 months with a 1-year overall survival of 35.7%. The 1-year local recurrence rate was 5% (10 of 204 of evaluable lesions) in 12.5% (4 of 32) of the patients. Distant brain failure was observed in 19 of 32 patients with a 1-year rate of 35.8%. Grade 1-2 headache was the most common complaint, with no grade 3-5 treatment-related adverse events. Radionecrosis was observed in only 5 lesions, with a 1-year rate of 1.5%. Rate of neurologic death was 20%. Neurocognition and quality of life did not significantly change 3 months after SRS compared with pretreatment. Conclusions These results suggest that volume-adapted dosing single-isocenter multitarget stereotactic radiosurgery is an effective and safe treatment for patients with 4 to 10 brain metastases.
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Loo M, Clavier JB, Attal Khalifa J, Moyal E, Khalifa J. Dose-Response Effect and Dose-Toxicity in Stereotactic Radiotherapy for Brain Metastases: A Review. Cancers (Basel) 2021; 13:cancers13236086. [PMID: 34885193 PMCID: PMC8657210 DOI: 10.3390/cancers13236086] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 11/29/2022] Open
Abstract
Simple Summary Brain metastases are one of the most frequent complications for cancer patients. Stereotactic radiosurgery is considered a cornerstone treatment for patients with limited brain metastases and the ideal dose and fractionation schedule still remain unknown. The aim of this literature review is to discuss the dose-effect relation in brain metastases treated by stereotactic radiosurgery, accounting for fractionation and technical considerations. Abstract For more than two decades, stereotactic radiosurgery has been considered a cornerstone treatment for patients with limited brain metastases. Historically, radiosurgery in a single fraction has been the standard of care but recent technical advances have also enabled the delivery of hypofractionated stereotactic radiotherapy for dedicated situations. Only few studies have investigated the efficacy and toxicity profile of different hypofractionated schedules but, to date, the ideal dose and fractionation schedule still remains unknown. Moreover, the linear-quadratic model is being debated regarding high dose per fraction. Recent studies shown the radiation schedule is a critical factor in the immunomodulatory responses. The aim of this literature review was to discuss the dose–effect relation in brain metastases treated by stereotactic radiosurgery accounting for fractionation and technical considerations. Efficacy and toxicity data were analyzed in the light of recent published data. Only retrospective and heterogeneous data were available. We attempted to present the relevant data with caution. A BED10 of 40 to 50 Gy seems associated with a 12-month local control rate >70%. A BED10 of 50 to 60 Gy seems to achieve a 12-month local control rate at least of 80% at 12 months. In the brain metastases radiosurgery series, for single-fraction schedule, a V12 Gy < 5 to 10 cc was associated to 7.1–22.5% radionecrosis rate. For three-fractions schedule, V18 Gy < 26–30 cc, V21 Gy < 21 cc and V23 Gy < 5–7 cc were associated with about 0–14% radionecrosis rate. For five-fractions schedule, V30 Gy < 10–30 cc, V 28.8 Gy < 3–7 cc and V25 Gy < 16 cc were associated with about 2–14% symptomatic radionecrosis rate. There are still no prospective trials comparing radiosurgery to fractionated stereotactic irradiation.
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Affiliation(s)
- Maxime Loo
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
- Correspondence:
| | - Jean-Baptiste Clavier
- Radiotherapy Department, Strasbourg Europe Cancer Institute (ICANS), 67033 Strasbourg, France;
| | - Justine Attal Khalifa
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
| | - Elisabeth Moyal
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
| | - Jonathan Khalifa
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
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Park DJ, Unadkat P, Goenka A, Schulder M. Case Series: Cystic Brain Metastases Managed With Reservoir Placement and Stereotactic Radiosurgery. NEUROSURGERY OPEN 2021. [DOI: 10.1093/neuopn/okab028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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14
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Newman WC, Goldberg J, Guadix SW, Brown S, Reiner AS, Panageas K, Beal K, Brennan CW, Tabar V, Young RJ, Moss NS. The effect of surgery on radiation necrosis in irradiated brain metastases: extent of resection and long-term clinical and radiographic outcomes. J Neurooncol 2021; 153:507-518. [PMID: 34146223 DOI: 10.1007/s11060-021-03790-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/15/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Radiation therapy is a cornerstone of brain metastasis (BrM) management but carries the risk of radiation necrosis (RN), which can require resection for palliation or diagnosis. We sought to determine the relationship between extent of resection (EOR) of pathologically-confirmed RN and postoperative radiographic and symptomatic outcomes. METHODS A single-center retrospective review was performed at an NCI-designated Comprehensive Cancer Center to identify all surgically-resected, previously-irradiated necrotic BrM without admixed recurrent malignancy from 2003 to 2018. Clinical, pathologic and radiographic parameters were collected. Volumetric analysis determined EOR and longitudinally evaluated perilesional T2-FLAIR signal preoperatively, postoperatively, and at 3-, 6-, 12-, and 24-months postoperatively when available. Rates of time to 50% T2-FLAIR reduction was calculated using cumulative incidence in the competing risks setting with last follow-up and death as competing events. The Spearman method was used to calculate correlation coefficients, and continuous variables for T2-FLAIR signal change, including EOR, were compared across groups. RESULTS Forty-six patients were included. Most underwent prior stereotactic radiosurgery with or without whole-brain irradiation (N = 42, 91%). Twenty-seven operations resulted in gross-total resection (59%; GTR). For the full cohort, T2-FLAIR edema decreased by a mean of 78% by 6 months postoperatively that was durable to last follow-up (p < 0.05). EOR correlated with edema reduction at last follow-up, with significantly greater T2-FLAIR reduction with GTR versus subtotal resection (p < 0.05). Among surviving patients, a significant proportion were able to decrease their steroid use: steroid-dependency decreased from 54% preoperatively to 15% at 12 months postoperatively (p = 0.001). CONCLUSIONS RN resection conferred both durable T2-FLAIR reduction, which correlated with EOR; and reduced steroid dependency.
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Affiliation(s)
- William C Newman
- Department of Neurosurgery, Louisiana State University Health Sciences, Shreveport, LA, USA
| | - Jacob Goldberg
- Department of Neurological Surgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.,Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Sergio W Guadix
- Department of Neurological Surgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.,Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Samantha Brown
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anne S Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katherine Panageas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kathryn Beal
- Department of Radiation Oncology and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cameron W Brennan
- Department of Neurological Surgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Viviane Tabar
- Department of Neurological Surgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Robert J Young
- Department of Radiology and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nelson S Moss
- Department of Neurological Surgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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Reliability of Magnetic Resonance Spectroscopy and Positron Emission Tomography Computed Tomography in Differentiating Metastatic Brain Tumor Recurrence from Radiation Necrosis. World Neurosurg 2021; 151:e1059-e1068. [PMID: 34052453 DOI: 10.1016/j.wneu.2021.05.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/16/2021] [Accepted: 05/17/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Clinical and/or neuroimaging changes after whole-brain radiation therapy (WBRT) or stereotactic radiosurgery (SRS) for metastatic brain tumor(s) present the clinical dilemma of differentiating tumor recurrence from radiation necrosis. Several imaging modalities attempt to answer this clinical question, including magnetic resonance spectroscopy (MRS) and positron emission tomography (PET) computed tomography (CT). We evaluated our experience regarding the ability of MRS and PET CT to differentiate tumor recurrence from radiation necrosis in patients who have received WBRT or SRS. METHODS We retrospectively reviewed records of 242 patients with previous WBRT or SRS to identify those who had MRS and/or PET CT to differentiate tumor recurrence from radiation necrosis. Patients were sorted into true-positive, false-positive, false-negative, and true-negative groups on the basis of imaging interpretation and clinical course combined with surgical pathology results or reaction to nonsurgical treatments including SRS, dexamethasone, or observation. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were then calculated. RESULTS Of 25 patients presenting such diagnostic questions, 19 were evaluated with MRS and 13 with PET CT. MRS sensitivity was 100%, specificity was 50%, and accuracy was 81.8%, whereas PET CT sensitivity was 36.4%, specificity was 66.7%, and accuracy was 42.9%. CONCLUSIONS MRS has better accuracy than PET CT and a high negative predictive value, therefore making it more useful in distinguishing recurrent tumor from radiation necrosis. We encourage correlation with symptoms at imaging to aid in clinical decision making.
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Ren Y, Wang SB, Zhou L, Liu SQ, Du LY, Li T, Jiang MQ, Lei KJ, Tan BX, Jia YM. Continuous Low-Dose Apatinib Combined With WBRT Significantly Reduces Peritumoral Edema and Enhances the Efficacy of Symptomatic Multiple Brain Metastases in NSCLC. Technol Cancer Res Treat 2021; 20:15330338211011968. [PMID: 33955301 PMCID: PMC8111549 DOI: 10.1177/15330338211011968] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Symptomatic multiple brain metastases with peritumoral brain edema (PTBE) occur in non-small cell lung cancer patients (NSCLC) who are without driver mutations or are resistant to epidermal growth factor tyrosine kinase (EGFR-TKI) are often associated with an unfavorable prognosis. Whole brain radiation therapy (WBRT) which comes with many complications and unsatisfactory effects, is the only option for the treatment. Previous studies have shown that bevacizumab can reduce the volume of PTBE and improve efficiency of radiotherapy. This study evaluated the effects and safety of apatinib combined with WBRT in NSCLC patients with symptomatic multiple brain metastases and PTBE. METHODS We performed a retrospective review of 34 patients with symptomatic multiple brain metastases from NSCLC (number >4, and at least 1 measurable brain metastasis lesion with cerebral edema). Intracranial objective response rate (IORR), peritumoral edema and intracranial tumor volumetric measurement, Karnofsky performance status (KPS) and adverse events (AEs) were evaluated. Median intracranial progression-free survival (mIPFS) and median overall survival (mOS) were also analyzed. RESULTS Thirteen cases received apatinib (125 mg or 250 mg, QD, oral) combined with WBRT and 21 cases received chemotherapy combined with WBRT were inclued. Apatinib combination group can better reduce the volume of intracranial tumors and PTBE and total steroid dosage used. It was associated with a better IORR (84.6% vs 47.6%, P = 0.067), longer mIPFS (6.97 vs 4.77months; P = 0.014). There was no significant difference in mOS(7.70 vs 6.67 months; P = 0.14) between the 2 groups. The most common adverse events of apatinib combination WBRT included grade 1/2 nausea (4/13), fatigue (3/13), hypertension (2/13) and white blood cell decrease (2/13). No grade 3/4 AEs were observed. CONCLUSION Apatinib plus WBRT is well tolerated and may be a potential choice for relapsed or drug-resistant advanced NSCLC patients with symptomatic multiple brain metastases and PTBE.
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Affiliation(s)
- Yue Ren
- 74655North Sichuan Medical College, Nanchong, Sichuan, China.,Department of Oncology, The Second People's Hospital of Yibin, Yibin, Sichuan, China
| | - Shan-Bing Wang
- Department of Oncology, The Second People's Hospital of Yibin, Yibin, Sichuan, China
| | - Lin Zhou
- West China Hospital, 34753Sichuan University, Cheng du, China
| | - Si-Qiao Liu
- 12599University of Electronic Science and Technology of China, Sichuan, China
| | - Lei-Ya Du
- Department of Oncology, The Second People's Hospital of Yibin, Yibin, Sichuan, China
| | - Ting Li
- Department of Oncology, The Second People's Hospital of Yibin, Yibin, Sichuan, China
| | - Mao-Qiong Jiang
- Department of Oncology, The Second People's Hospital of Yibin, Yibin, Sichuan, China
| | - Kai-Jian Lei
- Department of Oncology, The Second People's Hospital of Yibin, Yibin, Sichuan, China
| | - Bang-Xian Tan
- 74655North Sichuan Medical College, Nanchong, Sichuan, China
| | - Yu-Ming Jia
- Department of Oncology, The Second People's Hospital of Yibin, Yibin, Sichuan, China
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Jablonska PA, Bosch-Barrera J, Serrano D, Valiente M, Calvo A, Aristu J. Challenges and Novel Opportunities of Radiation Therapy for Brain Metastases in Non-Small Cell Lung Cancer. Cancers (Basel) 2021; 13:cancers13092141. [PMID: 33946751 PMCID: PMC8124815 DOI: 10.3390/cancers13092141] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/18/2021] [Accepted: 04/26/2021] [Indexed: 12/25/2022] Open
Abstract
Simple Summary Lung cancer is the most common primary malignancy that tends to metastasize to the brain. Owing to improved survival of lung cancer patients, the prevalence of brain metastases is a matter of growing concern. Brain radiotherapy remains the mainstay in the management of metastatic CNS disease. However, new targeted therapies such as the tyrosine kinase or immune checkpoint inhibitors have demonstrated intracranial activity and promising tumor response rates. Here, we review the current and emerging therapeutical strategies for brain metastases from non-small cell lung cancer, both brain-directed and systemic, as well as the uncertainties that may arise from their combination. Abstract Approximately 20% patients with non-small cell lung cancer (NSCLC) present with CNS spread at the time of diagnosis and 25–50% are found to have brain metastases (BMs) during the course of the disease. The improvement in the diagnostic tools and screening, as well as the use of new systemic therapies have contributed to a more precise diagnosis and prolonged survival of lung cancer patients with more time for BMs development. In the past, most of the systemic therapies failed intracranially because of the inability to effectively cross the blood brain barrier. Some of the new targeted therapies, especially the group of tyrosine kinase inhibitors (TKIs) have shown durable CNS response. However, the use of ionizing radiation remains vital in the management of metastatic brain disease. Although a decrease in CNS-related deaths has been achieved over the past decade, many challenges arise from the need of multiple and repeated brain radiation treatments, which carry along not insignificant risks and toxicity. The combination of stereotactic radiotherapy and systemic treatments in terms of effectiveness and adverse effects, such as radionecrosis, remains a subject of ongoing investigation. This review discusses the challenges of the use of radiation therapy in NSCLC BMs in view of different systemic treatments such as chemotherapy, TKIs and immunotherapy. It also outlines the future perspectives and strategies for personalized BMs management.
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Affiliation(s)
- Paola Anna Jablonska
- Brain Metastases and CNS Oncology Radiation Medicine Program, Princess Margaret Cancer Center, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, Clinica Universidad de Navarra, 31008 Pamplona, Spain
- Correspondence: ; Tel.: +1-416-946-2000
| | - Joaquim Bosch-Barrera
- Department of Medical Oncology, Catalan Institute of Oncology, Doctor Josep Trueta University Hospital, 17007 Girona, Spain;
- Girona Biomedical Research Institute (IDIBGI), Salt, 17190 Girona, Spain
- Department of Medical Sciences, Medical School, University of Girona, 17071 Girona, Spain
| | - Diego Serrano
- IDISNA and Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain; (D.S.); (A.C.)
- Department of Pathology, Anatomy and Physiology, School of Medicine, University of Navarra, 31008 Pamplona, Spain
| | | | - Alfonso Calvo
- IDISNA and Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain; (D.S.); (A.C.)
- Department of Pathology, Anatomy and Physiology, School of Medicine, University of Navarra, 31008 Pamplona, Spain
- CIBERONC, ISCIII, 28029 Madrid, Spain
| | - Javier Aristu
- Department of Radiation Oncology and Protontherapy Unit, Clinica Universidad de Navarra, 28027 Madrid, Spain;
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Proescholdt MA, Schödel P, Doenitz C, Pukrop T, Höhne J, Schmidt NO, Schebesch KM. The Management of Brain Metastases-Systematic Review of Neurosurgical Aspects. Cancers (Basel) 2021; 13:1616. [PMID: 33807384 PMCID: PMC8036330 DOI: 10.3390/cancers13071616] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 02/07/2023] Open
Abstract
The multidisciplinary management of patients with brain metastases (BM) consists of surgical resection, different radiation treatment modalities, cytotoxic chemotherapy, and targeted molecular treatment. This review presents the current state of neurosurgical technology applied to achieve maximal resection with minimal morbidity as a treatment paradigm in patients with BM. In addition, we discuss the contribution of neurosurgical resection on functional outcome, advanced systemic treatment strategies, and enhanced understanding of the tumor biology.
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Affiliation(s)
- Martin A. Proescholdt
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Petra Schödel
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Christian Doenitz
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Tobias Pukrop
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
- Department of Medical Oncology, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Julius Höhne
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Nils Ole Schmidt
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Karl-Michael Schebesch
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
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Breast cancer subtype predicts clinical outcomes after stereotactic radiation for brain metastases. J Neurooncol 2021; 152:591-601. [PMID: 33742358 DOI: 10.1007/s11060-021-03735-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE We investigated the prognostic ability of tumor subtype for patients with breast cancer brain metastases (BCBM) treated with stereotactic radiation (SRT). METHODS This is a retrospective review of 181 patients who underwent SRT to 664 BCBM from 2004 to 2019. Patients were stratified by subtype: hormone receptor (HR)-positive, HER2-negative (HR+/HER2-), HR-positive, HER2-positive (HR+/HER2+), HR-negative, HER2-positive (HR-/HER2+), and triple negative (TN). The Kaplan-Meier method was used to calculate overall survival (OS), local control (LC), and distant intracranial control (DIC) from the date of SRT. Multivariate analysis (MVA) was conducted using the Cox proportional hazards model. RESULTS Median follow up from SRT was 11.4 months. Of the 181 patients, 47 (26%) were HR+/HER2+, 30 (17%) were HR-/HER2+, 60 (33%) were HR+/HER2-, and 44 (24%) were TN. Of the 664 BCBMs, 534 (80%) received single fraction stereotactic radiosurgery (SRS) with a median dose of 21 Gy (range 12-24 Gy), and 130 (20%) received fractionated stereotactic radiation therapy (FSRT), with a median dose of 25 Gy (range 12.5-35 Gy) delivered in 3 to 5 fractions. One-year LC was 90%. Two-year DIC was 35%, 23%, 27%, and 16% (log rank, p = 0.0003) and 2-year OS was 54%, 47%, 24%, and 12% (log rank, p < 0.0001) for HR+/HER2+, HR-/HER2+, HR+/HER2-, and TN subtypes, respectively. On MVA, the TN subtype predicted for inferior DIC (HR 1.62, 95% CI 1.00-2.60, p = 0.049). The modified breast-Graded Prognostic Assessment (GPA) significantly predicted DIC and OS (both p < 0.001). CONCLUSIONS Subtype is prognostic for OS and DIC for patients with BCBM treated with SRT.
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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.
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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.
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21
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Samanci Y, Sisman U, Altintas A, Sarioglu S, Sharifi S, Atasoy Aİ, Bolukbasi Y, Peker S. Hypofractionated frameless gamma knife radiosurgery for large metastatic brain tumors. Clin Exp Metastasis 2021; 38:31-46. [PMID: 33389335 DOI: 10.1007/s10585-020-10068-6] [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: 09/15/2020] [Accepted: 11/29/2020] [Indexed: 12/30/2022]
Abstract
Hypofractionated stereotactic radiosurgery has become an alternative for metastatic brain tumors (METs). We aimed to analyze the efficacy and safety of frameless hypofractionated Gamma Knife radiosurgery (hfGKRS) in the management of unresected, large METs. All patients who were managed with hfGKRS for unresected, large METs (> 4 cm3) between June 2017 and June 2020 at a single center were reviewed in this retrospective study. Local control (LC), progression-free survival (PFS), overall survival (OS), and toxicities were investigated. A total of 58 patients and 76 METs with regular follow-up were analyzed. LC rate was 98.5% at six months, 96.0% at one year, and 90.6% at 2 years during a median follow-up of 12 months (range, 2-37). The log-rank test indicated no difference in the distribution of LC for any clinical or treatment variable. PFS was 86.7% at 6 months, 66.6% at 1 year, and 58.5% at 2 years. OS was 81% at 6 months, 63.6% at one year, and 50.7% at 2 years. On the log-rank test, clinical parameters such as control status of primary cancer, presence of extracranial metastases, RTOG-RPA class, GPA group, and ds-GPA group were significantly associated with PFS and OS. Patients presented with grade 1 (19.0%), grade 2 (3.5%) and grade 3 (5.2%) side effects. Radiation necrosis was not observed in any patients. Our current results suggest that frameless hfGKRS for unresected, large METs is a rational alternative in selected patients with promising results.
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Affiliation(s)
- Yavuz Samanci
- Department of Neurosurgery, Koç University Hospital, Istanbul, Turkey
| | - Uluman Sisman
- School of Medicine, Koç University, Istanbul, Turkey
| | | | | | | | - Ali İhsan Atasoy
- Department of Radiation Oncology, Koç University Hospital, Istanbul, Turkey
| | - Yasemin Bolukbasi
- Department of Radiation Oncology, School of Medicine, Koç University, Istanbul, Turkey
| | - Selcuk Peker
- Department of Neurosurgery, School of Medicine, Koç University, Davutpasa Caddesi No:4, 34010, Zeytinburnu/İstanbul, Turkey.
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Gutschenritter T, Venur VA, Combs SE, Vellayappan B, Patel AP, Foote M, Redmond KJ, Wang TJC, Sahgal A, Chao ST, Suh JH, Chang EL, Ellenbogen RG, Lo SS. The Judicious Use of Stereotactic Radiosurgery and Hypofractionated Stereotactic Radiotherapy in the Management of Large Brain Metastases. Cancers (Basel) 2020; 13:cancers13010070. [PMID: 33383817 PMCID: PMC7795798 DOI: 10.3390/cancers13010070] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/11/2020] [Accepted: 12/18/2020] [Indexed: 12/31/2022] Open
Abstract
Simple Summary Brain metastases are the most common cause of cancerous brain tumors in adults. Large brain metastases are an especially difficult clinical scenario as patients often have debilitating symptoms from these tumors, and large tumors are more difficult to control with traditional single treatment radiation regimens alone or after surgery. Hypofractionated stereotactic radiotherapy is a novel way to deliver the higher doses of radiation to control large tumors either after surgery (most common), alone (common), or potentially before surgery (uncommon). Herein, we describe how delivering high doses over three or five treatments may improve tumor control and decrease complication rates compared to more traditional single treatment regimens for brain metastases larger than 2 cm in maximum dimension. Abstract Brain metastases are the most common intracranial malignant tumor in adults and are a cause of significant morbidity and mortality for cancer patients. Large brain metastases, defined as tumors with a maximum dimension >2 cm, present a unique clinical challenge for the delivery of stereotactic radiosurgery (SRS) as patients often present with neurologic symptoms that require expeditious treatment that must also be balanced against the potential consequences of surgery and radiation therapy—namely, leptomeningeal disease (LMD) and radionecrosis (RN). Hypofractionated stereotactic radiotherapy (HSRT) and pre-operative SRS have emerged as novel treatment techniques to help improve local control rates and reduce rates of RN and LMD for this patient population commonly managed with post-operative SRS. Recent literature suggests that pre-operative SRS can potentially half the risk of LMD compared to post-operative SRS and that HSRT can improve risk of RN to less than 10% while improving local control when meeting the appropriate goals for biologically effective dose (BED) and dose-volume constraints. We recommend a 3- or 5-fraction regimen in lieu of SRS delivering 15 Gy or less for large metastases or resection cavities. We provide a table comparing the BED of commonly used SRS and HSRT regimens, and provide an algorithm to help guide the management of these challenging clinical scenarios.
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Affiliation(s)
- Tyler Gutschenritter
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA 98195, USA;
| | - Vyshak A. Venur
- Division of Medical Oncology, University of Washington School of Medicine, Seattle, WA 98195, USA;
| | - Stephanie E. Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany;
- Institute for Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
| | - Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute, Singapore 119074, Singapore;
| | - Anoop P. Patel
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA 98195, USA; (A.P.P.); (R.G.E.)
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, University of Queensland, ICON Cancer Care, Brisbane 4072, Australia;
| | - Kristin J. Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, MD 21093, USA;
| | - Tony J. C. Wang
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY 10032, USA;
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Toronto, ON M4N 3M5, Canada;
| | - Samuel T. Chao
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA; (S.T.C.); (J.H.S.)
| | - John H. Suh
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA; (S.T.C.); (J.H.S.)
| | - Eric L. Chang
- Department of Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA;
| | - Richard G. Ellenbogen
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA 98195, USA; (A.P.P.); (R.G.E.)
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA 98195, USA;
- Correspondence: ; Tel.: +1-206-598-4100
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23
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Huang J, Milchenko M, Rao YJ, LaMontagne P, Abraham C, Robinson CG, Huang Y, Shimony JS, Rich KM, Benzinger T. A feasibility study to evaluate early treatment response of brain metastases one week after stereotactic radiosurgery using perfusion weighted imaging. PLoS One 2020; 15:e0241835. [PMID: 33141861 PMCID: PMC7608872 DOI: 10.1371/journal.pone.0241835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/20/2020] [Indexed: 01/06/2023] Open
Abstract
Background To explore if early perfusion-weighted magnetic resonance imaging (PWI) may be a promising imaging biomarker to predict local recurrence (LR) of brain metastases after stereotactic radiosurgery (SRS). Methods This is a prospective pilot study of adult brain metastasis patients who were treated with SRS and imaged with PWI before and 1 week later. Relative cerebral blood volume (rCBV) parameter maps were calculated by normalizing to the mean value of the contralateral white matter on PWI. Cox regression was conducted to explore factors associated with time to LR, with Bonferroni adjusted p<0.0006 for multiple testing correction. LR rates were estimated with the Kaplan-Meier method and compared using the log-rank test. Results Twenty-three patients were enrolled from 2013 through 2016, with 22 evaluable lesions from 16 patients. After a median follow-up of 13.1 months (range: 3.0–53.7), 5 lesions (21%) developed LR after a median of 3.4 months (range: 2.3–5.7). On univariable analysis, larger tumor volume (HR 1.48, 95% CI 1.02–2.15, p = 0.04), lower SRS dose (HR 0.45, 95% CI 0.21–0.97, p = 0.04), and higher rCBV at week 1 (HR 1.07, 95% CI 1.003–1.14, p = 0.04) had borderline association with shorter time to LR. Tumors >2.0cm3 had significantly higher LR than if ≤2.0cm3: 54% vs 0% at 1 year, respectively, p = 0.008. A future study to confirm the association of early PWI and LR of the high-risk cohort of lesions >2.0cm3 is estimated to require 258 patients. Conclusions PWI at week 1 after SRS may have borderline association with LR. Tumors <2.0cm3 have low risk of LR after SRS and may be low-yield for predictive biomarker studies. Information regarding sample size and potential challenges for future imaging biomarker studies may be gleaned from this pilot study.
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Affiliation(s)
- Jiayi Huang
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Mikhail Milchenko
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Yuan J Rao
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Pamela LaMontagne
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Christopher Abraham
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Clifford G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Yi Huang
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Joshua S Shimony
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Keith M Rich
- Department of Neurosurgery, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Tammie Benzinger
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
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24
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Milano MT, Grimm J, Niemierko A, Soltys SG, Moiseenko V, Redmond KJ, Yorke E, Sahgal A, Xue J, Mahadevan A, Muacevic A, Marks LB, Kleinberg LR. Single- and Multifraction Stereotactic Radiosurgery Dose/Volume Tolerances of the Brain. Int J Radiat Oncol Biol Phys 2020; 110:68-86. [PMID: 32921513 DOI: 10.1016/j.ijrobp.2020.08.013] [Citation(s) in RCA: 158] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/03/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE As part of the American Association of Physicists in Medicine Working Group on Stereotactic Body Radiotherapy investigating normal tissue complication probability (NTCP) after hypofractionated radiation therapy, data from published reports (PubMed indexed 1995-2018) were pooled to identify dosimetric and clinical predictors of radiation-induced brain toxicity after single-fraction stereotactic radiosurgery (SRS) or fractionated stereotactic radiosurgery (fSRS). METHODS AND MATERIALS Eligible studies provided NTCPs for the endpoints of radionecrosis, edema, or symptoms after cranial SRS/fSRS and quantitative dose-volume metrics. Studies of patients with only glioma, meningioma, vestibular schwannoma, or brainstem targets were excluded. The data summary and analyses focused on arteriovenous malformations (AVM) and brain metastases. RESULTS Data from 51 reports are summarized. There was wide variability in reported rates of radionecrosis. Available data for SRS/fSRS for brain metastases were more amenable to NTCP modeling than AVM data. In the setting of brain metastases, SRS/fSRS-associated radionecrosis can be difficult to differentiate from tumor progression. For single-fraction SRS to brain metastases, tissue volumes (including target volumes) receiving 12 Gy (V12) of 5 cm3, 10 cm3, or >15 cm3 were associated with risks of symptomatic radionecrosis of approximately 10%, 15%, and 20%, respectively. SRS for AVM was associated with modestly lower rates of symptomatic radionecrosis for equivalent V12. For brain metastases, brain plus target volume V20 (3-fractions) or V24 (5-fractions) <20 cm3 was associated with <10% risk of any necrosis or edema, and <4% risk of radionecrosis requiring resection. CONCLUSIONS The risk of radionecrosis after SRS and fSRS can be modeled as a function of dose and volume treated. The use of fSRS appears to reduce risks of radionecrosis for larger treatment volumes relative to SRS. More standardized dosimetric and toxicity reporting is needed to facilitate future pooled analyses that can refine predictive models of brain toxicity risks.
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Affiliation(s)
- Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York.
| | - Jimm Grimm
- Department of Radiation Oncology, Geisinger Cancer Institute, Danville, Pennsylvania
| | - Andrzej Niemierko
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, California
| | - Vitali Moiseenko
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York City, New York
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Jinyu Xue
- Department of Radiation Oncology, NYU Langone Medical Center, New York City, NY
| | - Anand Mahadevan
- Department of Radiation Oncology, Geisinger Cancer Institute, Danville, Pennsylvania
| | | | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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25
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Salem Ghahfarrokhi S, Khodadadi H. Human brain tumor diagnosis using the combination of the complexity measures and texture features through magnetic resonance image. Biomed Signal Process Control 2020. [DOI: 10.1016/j.bspc.2020.102025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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26
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Remick JS, Kowalski E, Khairnar R, Sun K, Morse E, Cherng HRR, Poirier Y, Lamichhane N, Becker SJ, Chen S, Patel AN, Kwok Y, Nichols E, Mohindra P, Woodworth GF, Regine WF, Mishra MV. A multi-center analysis of single-fraction versus hypofractionated stereotactic radiosurgery for the treatment of brain metastasis. Radiat Oncol 2020; 15:128. [PMID: 32466775 PMCID: PMC7257186 DOI: 10.1186/s13014-020-01522-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/24/2020] [Indexed: 12/22/2022] Open
Abstract
Background Hypofractionated-SRS (HF-SRS) may allow for improved local control and a reduced risk of radiation necrosis compared to single-fraction-SRS (SF-SRS). However, data comparing these two treatment approaches are limited. The purpose of this study was to compare clinical outcomes between SF-SRS versus HF-SRS across our multi-center academic network. Methods Patients treated with SF-SRS or HF-SRS for brain metastasis from 2013 to 2018 across 5 radiation oncology centers were retrospectively reviewed. SF-SRS dosing was standardized, whereas HF-SRS dosing regimens were variable. The co-primary endpoints of local control and radiation necrosis were estimated using the Kaplan Meier method. Multivariate analysis using Cox proportional hazards modeling was performed to evaluate the impact of select independent variables on the outcomes of interest. Propensity score adjustments were used to reduce the effects confounding variables. To assess dose response for HF-SRS, Biologic Effective Dose (BED) assuming an α/β of 10 (BED10) was used as a surrogate for total dose. Results One-hundred and fifty six patients with 335 brain metastasis treated with SF-SRS (n = 222 lesions) or HF-SRS (n = 113 lesions) were included. Prior whole brain radiation was given in 33% (n = 74) and 34% (n = 38) of lesions treated with SF-SRS and HF-SRS, respectively (p = 0.30). After a median follow up time of 12 months in each cohort, the adjusted 1-year rate of local control and incidence of radiation necrosis was 91% (95% CI 86–96%) and 85% (95% CI 75–95%) (p = 0.26) and 10% (95% CI 5–15%) and 7% (95% CI 0.1–14%) (p = 0.73) for SF-SRS and HF-SRS, respectively. For lesions > 2 cm, the adjusted 1 year local control was 97% (95% CI 84–100%) for SF-SRS and 64% (95% CI 43–85%) for HF-SRS (p = 0.06). On multivariate analysis, SRS fractionation was not associated with local control and only size ≤2 cm was associated with a decreased risk of developing radiation necrosis (HR 0.21; 95% CI 0.07–0.58, p < 0.01). For HF-SRS, 1 year local control was 100% for lesions treated with a BED10 ≥ 50 compared to 77% (95% CI 65–88%) for lesions that received a BED10 < 50 (p = 0.09). Conclusions In this comparison study of dose fractionation for the treatment of brain metastases, there was no difference in local control or radiation necrosis between HF-SRS and SF-SRS. For HF-SRS, a BED10 ≥ 50 may improve local control.
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Affiliation(s)
- Jill S Remick
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Emily Kowalski
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Rahul Khairnar
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Kai Sun
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emily Morse
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hua-Ren R Cherng
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Yannick Poirier
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Narottam Lamichhane
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Stewart J Becker
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shifeng Chen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Akshar N Patel
- Chesapeake Oncology Hematology Associates, Glen Bernie, MD, USA
| | - Young Kwok
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Elizabeth Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Graeme F Woodworth
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA.
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27
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Zhou G, Xu Y, He B, Ma R, Wang Y, Chang Y, Xie Y, Wu L, Huang J, Xiao Z. Ionizing radiation modulates vascular endothelial growth factor expression through STAT3 signaling pathway in rat neonatal primary astrocyte cultures. Brain Behav 2020; 10:e01529. [PMID: 32106359 PMCID: PMC7177558 DOI: 10.1002/brb3.1529] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/30/2019] [Accepted: 12/03/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND PURPOSE Radiation-induced brain injury (RBI) usually occurs six months to three years after irradiation, often shows cognitive dysfunction, epilepsy, and other neurological dysfunction. In severe cases, it can cause a wide range of cerebral edema, even herniation. It seriously threatens the survival of patients and their quality of life, and it becomes a key factor in limiting the radiation dose and lowering the therapeutic efficacy in recent years. Therefore, studying the pathogenesis of RBI and exploring new therapeutic targets are of great significance. METHODS In our study, we observed the activation and secretory function in astrocytes as well as the intracellular signal transducer and activator of transcription 3 (STAT3) signal transduction pathway activation status after exposing different doses of X-ray irradiation by using MTT, Immunocytologic analysis, and Western blot analysis. Further, we used the same way to explore the role of vascular endothelial growth factor (VEGF) in signal transduction pathways playing in the activation of astrocytes after irradiating through the use of specificInhivascular endothelial growth factorbitors of STAT3. RESULTS Ast can be directly activated, reactive hyperplasia and hypertrophy, the expression of the activation marker glial fibrillary acidic protein is increased, and the expression of vascular endothelial growth factor (VEGF) in the cells is increased, which may lead to RBI. After the addition of STAT3 pathway inhibitor, most of the Ast radiation activation was suppressed, and the expression of high-level expression of VEGF decreased after irradiation. CONCLUSION Our findings demonstrated that X-ray irradiation directly induced the activation of astrocytes in a persistent manner and X-ray irradiation activated STAT3 signaling pathway. As the same time, we found that X-ray irradiation induced the activation of astrocytes and secretion cytokine. The STAT3 signaling pathway may participate in the pathogenesis of radiation-induced brain injury.
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Affiliation(s)
- Guijuan Zhou
- The First Afliated Hospital of University of South China, University of South China, Hengyang, China
| | - Yan Xu
- The First Afliated Hospital of University of South China, University of South China, Hengyang, China
| | - Bing He
- The First Afliated Hospital of University of South China, University of South China, Hengyang, China
| | - Rundong Ma
- The First Afliated Hospital of University of South China, University of South China, Hengyang, China
| | - Yilin Wang
- The First Afliated Hospital of University of South China, University of South China, Hengyang, China
| | - Yunqian Chang
- The First Afliated Hospital of University of South China, University of South China, Hengyang, China
| | - Yangzhi Xie
- The First Afliated Hospital of University of South China, University of South China, Hengyang, China.,Leiyang People's Hospital, Leiyang, China
| | - Lin Wu
- The First Afliated Hospital of University of South China, University of South China, Hengyang, China
| | - Jianghua Huang
- The First Afliated Hospital of University of South China, University of South China, Hengyang, China
| | - Zijian Xiao
- The First Afliated Hospital of University of South China, University of South China, Hengyang, China
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28
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Hughes RT, McTyre ER, LeCompte M, Cramer CK, Munley MT, Laxton AW, Tatter SB, Ruiz J, Pasche B, Watabe K, Chan MD. Clinical Outcomes of Upfront Stereotactic Radiosurgery Alone for Patients With 5 to 15 Brain Metastases. Neurosurgery 2020; 85:257-263. [PMID: 29982831 DOI: 10.1093/neuros/nyy276] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 05/30/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The role of primary stereotactic radiosurgery (SRS) for patients with >4 brain metastases (BM) remains controversial. OBJECTIVE To compare the outcomes of patients treated with upfront SRS alone for 1, 2 to 4, and 5 to 15 BM and assess for predictors of clinical outcomes in the 5 to 15 BM group. METHODS A total of 478 patients treated with upfront SRS were stratified by number of lesions: 220 had 1 BM, 190 had 2 to 4 BM, and 68 patients had 5 to 15 BM. Overall survival and whole brain radiotherapy-free survival were estimated using the Kaplan-Meier method. The cumulative incidences of local failure and distant brain failure (DBF) were estimated using competing risks methodology. Clinicopathologic and dosimetric parameters were evaluated as predictors of survival and DBF in patients with 5 to 15 BM using Cox proportional hazards. RESULTS Median overall survival was 8.0, 6.3, and 4.7 mo for patients with 1, 2 to 4, and 5 to 15 BM, respectively (P = .14). One-year DBF was 27%, 44%, and 40%, respectively (P = .01). Salvage SRS and whole brain radiotherapy rates did not differ. Progressive extracranial disease and gastrointestinal primary were associated with poor survival while RCC primary was associated with increased risk of DBF. No evaluated dose-volume parameters predicted for death, neurologic death or toxicity. CONCLUSION SRS for 5 to 15 BM is well tolerated without evidence of an associated increase in toxicity, treatment failure, or salvage therapy. Further prospective, randomized studies are warranted to clarify the role of SRS for these patients.
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Affiliation(s)
- Ryan T Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Emory R McTyre
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Michael LeCompte
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Christina K Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Michael T Munley
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Jimmy Ruiz
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Boris Pasche
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston Salem, North Carolina.,Department of Cancer Biology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Kounosuke Watabe
- Department of Cancer Biology, 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
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29
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Siddiqui ZA, Squires BS, Johnson MD, Baschnagel AM, Chen PY, Krauss DJ, Olson RE, Meyer KD, Grills IS. Predictors of radiation necrosis in long-term survivors after Gamma Knife stereotactic radiosurgery for brain metastases. Neurooncol Pract 2019; 7:400-408. [PMID: 32765891 DOI: 10.1093/nop/npz067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background The long-term risk of necrosis after radiosurgery for brain metastases is uncertain. We aimed to investigate incidence and predictors of radiation necrosis for individuals with more than 1 year of survival after radiosurgery for brain metastases. Methods Patients who had a diagnosis of brain metastases treated between December 2006 and December 2014, who had at least 1 year of survival after first radiosurgery were retrospectively reviewed. Survival was analyzed using the Kaplan-Meier estimator, and the incidence of radiation necrosis was estimated with death or surgical resection as competing risks. Patient and treatment factors associated with radiation necrosis were also analyzed. Results A total of 198 patients with 732 lesions were analyzed. Thirty-four lesions required salvage radiosurgery and 10 required salvage surgical resection. Median follow-up was 24 months. The estimated median survival for this population was 25.4 months. The estimated per-lesion incidence of radiation necrosis at 4 years was 6.8%. Medical or surgical therapy was required for 60% of necrosis events. Tumor volume and male sex were significant factors associated with radiation necrosis. The per-lesions incidence of necrosis for patients undergoing repeat radiosurgery was 33.3% at 4 years. Conclusions In this large series of patients undergoing radiosurgery for brain metastases, patients continued to be at risk for radiation necrosis throughout their first 4 years of survival. Repeat radiosurgery of recurrent lesions greatly exacerbates the risk of radiation necrosis, whereas treatment of larger target volumes increases the risk modestly.
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Affiliation(s)
- Zaid A Siddiqui
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Bryan S Squires
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Matt D Johnson
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Andrew M Baschnagel
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Peter Y Chen
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Daniel J Krauss
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Ricky E Olson
- Department of Neurological Surgery, Beaumont Health System, Royal Oak, Michigan
| | - Kurt D Meyer
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
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30
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Cummings M, Youn P, Bergsma DP, Usuki KY, Walter K, Sharma M, Okunieff P, Schell MC, Milano MT. Single-Fraction Radiosurgery Using Conservative Doses for Brain Metastases: Durable Responses in Select Primaries With Limited Toxicity. Neurosurgery 2019; 83:437-444. [PMID: 28945885 DOI: 10.1093/neuros/nyx427] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 07/11/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Optimal doses for single-fraction stereotactic radiosurgery (SRS) in the treatment of brain metastases are not well established. Our institution utilized conservative dosing compared to maximum-tolerated doses from the Radiation Therapy Oncology Group 90-05 Phase I study. OBJECTIVE To report individual lesion control (LC) from conservative single-fraction doses and determine factors affecting LC. METHODS From 2003 to 2015, patients who underwent linear accelerator-based single-fraction SRS for cerebral/cerebellar metastases and receiving at least 1 follow-up magnetic resonance imaging (MRI) were identified. Lesion response was assessed by a size-based rating system and modified "Response Assessment in Neuro-Oncology Brain Metastases" (RANO-BM) criteria. RESULTS Among 188 patients with 519 lesions, median survival was 13.1 mo; median follow-up time with MRI was 9.6 mo per course. Median tumor-periphery dose was 15 Gy (range: 7.5-20.7). Median lesion volume was 0.5 cc and diameter was 9 mm (range: 2-45). Concordance between RANO-BM and size-based system was 93%. Crude 1-yr LC was 80%, 73%, 56%, and 38% for lesions 1 to 10, 11 to 20, 21 to 30, >31 mm, respectively. On multivariate analysis, increased size, melanoma and colorectal histology, and progression after whole brain radiation therapy predicted worse LC. When excluding lesions treated as a boost, dose was a significant predictor of LC in multivariate models (hazard ratio 0.89, P = .01). Symptomatic radiation necrosis occurred in 10 lesions in 10 patients. CONCLUSION Histology predicts LC after conservative SRS doses with evidence of a dose-response relationship. Conservative single-fraction SRS doses confer minimal toxicity and acceptable control in certain subgroups (breast cancer, <5 mm), with suboptimal control in larger lesions and in combination with whole brain radiation therapy.
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Affiliation(s)
- Michael Cummings
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Paul Youn
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Derek P Bergsma
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Kenneth Y Usuki
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Kevin Walter
- Department of Neurosurgery, University of Rochester, Rochester, New York
| | - Manju Sharma
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Paul Okunieff
- Department of Radiation Oncology, University of Florida, Gainesville, Florida
| | - Michael C Schell
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
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Lovo EE, Torres LB, Campos FJ, Caceros VE, Barahona KE, Minervini MH, Reyes WA. Two-session Radiosurgery as Initial Treatment for Newly Diagnosed Large, Symptomatic Brain Metastases from Breast and Lung Histology. Cureus 2019; 11:e5472. [PMID: 31485386 PMCID: PMC6710487 DOI: 10.7759/cureus.5472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Introduction Surgery is considered the treatment of choice for patients with large, symptomatic brain metastases. This report describes a series of patients treated with upfront two-session radiosurgery rather than surgery for large brain metastases from breast and lung histology. Methods From October 2016 to January 2019, 10 consecutive patients with neurologic symptoms from large brain metastases producing mass effects underwent two sessions of radiosurgical treatments 30 days apart. The response was assessed by imaging and clinical evaluations. Results Ten patients had a total of 36 tumors; of these, 22 lesions with a mean volume of 12.3 ml (range, 7-78.4 ml) underwent two-session radiosurgery. The mean prescription dose for the first treatment was 13 Gy (range, 9-18 Gy) to the 50% isodose line, and the intratumoral mean dose was 17.9 Gy (12-22.9). All 10 patients had neurological symptoms, with a mean Karnofsky physical score (KPS) of 60 (range, 50-70) on the day of treatment. None of these patients required neurosurgical or emergency consultation related to worsening of neurological symptoms between the first and second treatments. At 30 days, the mean KPS was 80 and maintained at 80 at the last follow-up (range, 60-100; P=0.002), and mean lesion volume was 4.1 ml (range, 1.3-70 ml). The mean prescription dose for the second treatment was 12 Gy (range, 9-18 Gy) to the 50% isodose line, and the intratumoral mean dose was 17.9 Gy (11-22.4). The mean overall survival was 24 months (range, 3-32 months). At last follow-up, three patients (30%) had died, two of systemic progression and one of tumor progression, and at one year, local tumor control was 91% and 19 (86%) lesions showed documented local control at last follow up. In those tumors that progressed, the mean time to progression was eight months (range, 5-20 months), and the mean time to surgery was nine months (range, 5-32 months). Conclusion Two-session radiosurgery proved to be a safe treatment for patients with large, symptomatic metastases in this series. Neurological worsening after radiosurgery for large lesions of breast and lung histology may be an infrequent event. This strategy in radiosurgery may have neurological benefits for these patients providing adequate local tumor control while reducing the need of upfront surgery at diagnosis.
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Affiliation(s)
- Eduardo E Lovo
- Radiosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | - Leonel B Torres
- Nerosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | - Fidel J Campos
- Radiosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | - Victor E Caceros
- Radiosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | - Kaory E Barahona
- Radiation Oncology, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | - Mario H Minervini
- Radiosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
| | - William A Reyes
- Radiosurgery, International Cancer Center, Diagnostic Hospital, San Salvador, SLV
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Lehrer EJ, Peterson JL, Zaorsky NG, Brown PD, Sahgal A, Chiang VL, Chao ST, Sheehan JP, Trifiletti DM. Single versus Multifraction Stereotactic Radiosurgery for Large Brain Metastases: An International Meta-analysis of 24 Trials. Int J Radiat Oncol Biol Phys 2018; 103:618-630. [PMID: 30395902 DOI: 10.1016/j.ijrobp.2018.10.038] [Citation(s) in RCA: 148] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 10/09/2018] [Accepted: 10/24/2018] [Indexed: 02/03/2023]
Abstract
PURPOSE Multifraction (MF) stereotactic radiosurgery (SRS) purportedly reduces radionecrosis risk over single-fraction (SF) SRS in the treatment of large brain metastases. The purpose of the current work is to compare local control (LC) and radionecrosis rates of SF-SRS and MF-SRS in the definitive (SF-SRSD and MF-SRSD) and postoperative (SF-SRSP and MF-SRSP) settings. METHODS AND MATERIALS Population, Intervention, Control, Outcomes, Study Design/Preferred Reporting Items for Systematic Reviews and Meta-analyses and Meta-analysis of Observational Studies in Epidemiology guidelines were used to select articles in which patients had "large" brain metastases (Group A: 4-14 cm3, or about 2-3 cm in diameter; Group B: >14 cm3, or about >3 cm in diameter); 1-year LC and/or rates of radionecrosis were reported; radiosurgery was administered definitively or postoperatively. Random effects meta-analyses using fractionation scheme and size as covariates were conducted. Meta-regression and Wald-type tests were used to determine the effect of increasing tumor size and fractionation on the summary estimate, where the null hypothesis was rejected for P < .05. RESULTS Twenty-four studies were included, published between 2008 and 2017, with 1887 brain metastases. LC random effects estimate at 1 year was 77.6% for Group A/SF-SRSD and 92.9% for Group A/MF-SRSD (P = .18). LC random effects estimate at 1 year was 77.1% for Group B/SF-SRSD and 79.2% for Group B/MF-SRSD (P = .76). LC random effects estimate at 1 year was 62.4% for Group B/SF-SRSP and 85.7% for Group B/MF-SRSP (P = .13). Radionecrosis incidence random effects estimate was 23.1% for Group A/SF-SRSD and 7.3% for Group A/MF-SRSD (P = .003). Radionecrosis incidence random effects estimate was 11.7% for Group B/SF-SRSD and 6.5% for Group B/MF-SRSD (P = .29). Radionecrosis incidence random effects estimate was 7.3% for Group B/SF-SRSP and 7.5% for Group B/MF-SRSP (P = .85). Metaregression assessing 1-year LC and radionecrosis as a continuous function of increasing tumor volume was not statistically significant. CONCLUSIONS Treatment for large brain metastases with MF-SRS regimens may offer a relative reduction of radionecrosis while maintaining or improving relative rates of 1-year LC compared with SF-SRS. These findings are hypothesis-generating and require validation by ongoing and planned prospective clinical trials.
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Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jennifer L Peterson
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida; Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Arjun Sahgal
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Veronica L Chiang
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Samuel T Chao
- Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida; Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida.
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Aiyama H, Yamamoto M, Kawabe T, Watanabe S, Koiso T, Sato Y, Higuchi Y, Ishikawa E, Yamamoto T, Matsumura A, Kasuya H, Barfod BE. Complications after stereotactic radiosurgery for brain metastases: Incidences, correlating factors, treatments and outcomes. Radiother Oncol 2018; 129:364-369. [PMID: 30293644 DOI: 10.1016/j.radonc.2018.08.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 07/31/2018] [Accepted: 08/27/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND PURPOSE Complications after stereotactic radiosurgery (SRS) for brain metastases (BMs) were analyzed in detail using our database including nearly 3000 BM patients. MATERIALS AND METHODS This was an institutional review board-approved, retrospective cohort study using our prospectively accumulated database including 3271 consecutive patients who underwent gamma knife SRS for BMs during the 1998-2016 period. Excluding four patients lost to follow-up, 112 with three-staged treatment and 189 with post-operative irradiation, 2966 who underwent a single-session of SRS only as radical irradiation were studied. RESULTS The overall median survival time after SRS was 7.8 (95% CI; 7.4-8.1) months. Post-SRS complications occurred in 86 patients (2.9%) 1.9-211.4 (median; 24.0, IQR; 12.0-64.6) months after treatment. RTOG neurotoxicity grades were 2, 3 and 4 in 58, 25 and 3 patients, respectively. Cumulative incidences determined with a competing risk analysis were 1.4%, 2.2%, 2.4%, 2.6% and 2.9% at the 12th, 24th, 36th, 48th and 60th post-SRS month, respectively. Among various pre-SRS clinical factors and radiosurgical parameters, multivariable analyses demonstrated solitary tumor (Adjusted HR; 0.584, 95% CI; 0.381-0.894, p = 0.0133), controlled primary cancer (Adjusted HR; 2.595, 95% CI; 1.646-4.091, p < 0.0001), no extra-cerebral metastases (Adjusted HR; 1.608, 95% CI; 1.028-2.514, p = 0.0374), KPS ≥80% (Adjusted HR; 2.715, 95% CI; 1.245-5.924, p = 0.0121) and largest tumor volume ≥3.3 cc (Adjusted HR; 0.516, 95% CI; 0.318-0.836, p = 0.0072) to be independently significant predictors of a higher incidence of complications. CONCLUSION The post-SRS complication incidence is acceptably low (2.9%). Meticulous long-term follow-up after SRS is crucial for all patients.
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Affiliation(s)
- Hitoshi Aiyama
- Katsuta Hospital Mito GammaHouse, Hitachi-naka, Japan; Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Masaaki Yamamoto
- Katsuta Hospital Mito GammaHouse, Hitachi-naka, Japan; Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan.
| | - Takuya Kawabe
- Department of Neurosurgery, Rakusai Shimizu Hospital, Kyoto, Japan
| | - Shinya Watanabe
- Tsukuba Clinical Research and Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Takao Koiso
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Yoshinori Higuchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Graduate School of Medicine, Yokohama City University, Yokoyama, Japan
| | - Akira Matsumura
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hidetoshi Kasuya
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
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Vellayappan B, Tan CL, Yong C, Khor LK, Koh WY, Yeo TT, Detsky J, Lo S, Sahgal A. Diagnosis and Management of Radiation Necrosis in Patients With Brain Metastases. Front Oncol 2018; 8:395. [PMID: 30324090 PMCID: PMC6172328 DOI: 10.3389/fonc.2018.00395] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 08/31/2018] [Indexed: 12/25/2022] Open
Abstract
The use of radiotherapy, either in the form of stereotactic radiosurgery (SRS) or whole-brain radiotherapy (WBRT), remains the cornerstone for the treatment of brain metastases (BM). As the survival of patients with BM is being prolonged, due to improved systemic therapy (i.e., for better extra-cranial control) and increased use of SRS (i.e., for improved intra-cranial control), patients are clinically manifesting late effects of radiotherapy. One of these late effects is radiation necrosis (RN). Unfortunately, symptomatic RN is notoriously hard to diagnose and manage. The features of RN overlap considerably with tumor recurrence, and misdiagnosing RN as tumor recurrence may lead to deleterious treatment which may cause detrimental effects to the patient. In this review, we will explore the pathophysiology of RN, risk factors for its development, and the strategies to evaluate and manage RN.
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Affiliation(s)
- Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
| | - Char Loo Tan
- Department of Pathology, National University Hospital, Singapore, Singapore
| | - Clement Yong
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Lih Kin Khor
- Nuclear Medicine, Advanced Medicine Imaging, Singapore Institute of Advanced Medicine Holdings, Singapore, Singapore
| | - Wee Yao Koh
- Department of Radiation Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
| | - Tseng Tsai Yeo
- Department of Neurosurgery, National University Hospital, Singapore, Singapore
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | - Simon Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, United States
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
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Bilger A, Frenzel F, Oehlke O, Wiehle R, Milanovic D, Prokic V, Nieder C, Grosu AL. Local control and overall survival after frameless radiosurgery: A single center experience. Clin Transl Radiat Oncol 2017; 7:55-61. [PMID: 29594230 PMCID: PMC5862646 DOI: 10.1016/j.ctro.2017.09.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/20/2017] [Accepted: 09/23/2017] [Indexed: 12/26/2022] Open
Abstract
Introduction Stereotactic radiosurgery (SRS) has been increasingly advocated for 1-3 small brain metastases. The goal of this study was to evaluate the clinical results in patients with brain metastases treated with LINAC-based SRS using a thermoplastic mask (non-invasive fixation system) and Image-Guided Radiotherapy (IGRT). Material and Methods In this single-institution study 48 patients with 77 brain metastases were treated between February 2012 and January 2014. The prescribed dose was 20 Gy or 18 Gy as a single fraction. SRS was performed with a True Beam STX Novalis Radiosurgery LINAC (Varian Medical Systems). The verification of positioning was done using the BrainLAB ExacTrac ® X-ray 6D system and cone-beam CT. Results In 69 of 77 treated brain metastases (90%) the follow-up was documented on MR imaging performed every 3 months. Mean follow-up time was 10.86 months. Estimated 1-year local control was 83%, using the Kaplan-Meier method. In 7/69 brain metastases (10%) local failure (LF) was diagnosed. Median progression free survival (PFS) was 3.73 months, largely due to distant brain relapse. A GTV of ≤2.0 cm3 was significantly associated with a better PFS than a GTV >2.0 cm3. Extracranial stable disease and GTV ≤2.5 cm³ were significant predictors of OS.We observed 2 cases of radiation necrosis diagnosed by histology after surgical resection. No other cases of severe side effects (CTACE ≥ 3) were observed. Conclusion LINAC-based frameless SRS with the BrainLAB Mask using the BrainLAB ExacTrac ® X-ray 6D system for patient positioning is well tolerated, safe and leads to favorable crude local control of 90%. In our experience, local control after frameless (ringless) SRS is as good as ring-based SRS reported in literature. Without invasive head fixation, radiotherapy is more comfortable for patients.
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Key Words
- Brain metastases
- CBCT, cone-beam CT
- CT, computed tomography
- CTCAE, Common Terminology Criteria for Adverse Events v4.0
- DC, distant intracranial tumor control
- DRR, digitally reconstructed radiographs
- GTV, Gross Tumor Volume
- IGRT, Image-Guided Radiotherapy
- LC, Local Control
- LINAC
- LINAC, Linear Accelerator
- OS, Overall Survival
- PFS, progression-free survival
- PTV, planning target volume
- RPA, recursive partitioning analysis
- Radiosurgery
- SRS, Stereotactic radiosurgery
- WBRT, Whole Brain Radiotherapy
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Affiliation(s)
- Angelika Bilger
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany
| | - Florian Frenzel
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany
| | - Oliver Oehlke
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany
| | - Rolf Wiehle
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany
| | - Dusan Milanovic
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany
| | - Vesna Prokic
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany.,University of Applied Sciences Koblenz, Joseph-Rovan-Allee 2, 53424 Remagen, Germany
| | - Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092 Bodø, Norway.,Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, 9037 Tromsø, Norway
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Germany
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36
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Angelov L, Mohammadi AM, Bennett EE, Abbassy M, Elson P, Chao ST, Montgomery JS, Habboub G, Vogelbaum MA, Suh JH, Murphy ES, Ahluwalia MS, Nagel SJ, Barnett GH. Impact of 2-staged stereotactic radiosurgery for treatment of brain metastases ≥ 2 cm. J Neurosurg 2017; 129:366-382. [PMID: 28937324 DOI: 10.3171/2017.3.jns162532] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) is the primary modality for treating brain metastases. However, effective radiosurgical control of brain metastases ≥ 2 cm in maximum diameter remains challenging and is associated with suboptimal local control (LC) rates of 37%-62% and an increased risk of treatment-related toxicity. To enhance LC while limiting adverse effects (AEs) of radiation in these patients, a dose-dense treatment regimen using 2-staged SRS (2-SSRS) was used. The objective of this study was to evaluate the efficacy and toxicity of this treatment strategy. METHODS Fifty-four patients (with 63 brain metastases ≥ 2 cm) treated with 2-SSRS were evaluated as part of an institutional review board-approved retrospective review. Volumetric measurements at first-stage stereotactic radiosurgery (first SSRS) and second-stage SRS (second SSRS) treatments and on follow-up imaging studies were determined. In addition to patient demographic data and tumor characteristics, the study evaluated 3 primary outcomes: 1) response at first follow-up MRI, 2) time to local progression (TTP), and 3) overall survival (OS) with 2-SSRS. Response was analyzed using methods for binary data, TTP was analyzed using competing-risks methods to account for patients who died without disease progression, and OS was analyzed using conventional time-to-event methods. When needed, analyses accounted for multiple lesions in the same patient. RESULTS Among 54 patients, 46 (85%) had 1 brain metastasis treated with 2-SSRS, 7 patients (13%) had 2 brain metastases concurrently treated with 2-SSRS, and 1 patient underwent 2-SSRS for 3 concurrent brain metastases ≥ 2 cm. The median age was 63 years (range 23-83 years), 23 patients (43%) had non-small cell lung cancer, and 14 patients (26%) had radioresistant tumors (renal or melanoma). The median doses at first and second SSRS were 15 Gy (range 12-18 Gy) and 15 Gy (range 12-15 Gy), respectively. The median duration between stages was 34 days, and median tumor volumes at the first and second SSRS were 10.5 cm3 (range 2.4-31.3 cm3) and 7.0 cm3 (range 1.0-29.7 cm3). Three-month follow-up imaging results were available for 43 lesions; the median volume was 4.0 cm3 (range 0.1-23.1 cm3). The median change in volume compared with baseline was a decrease of 54.9% (range -98.2% to 66.1%; p < 0.001). Overall, 9 lesions (14.3%) demonstrated local progression, with a median of 5.2 months (range 1.3-7.4 months), and 7 (11.1%) demonstrated AEs (6.4% Grade 1 and 2 toxicity; 4.8% Grade 3). The estimated cumulative incidence of local progression at 6 months was 12% ± 4%, corresponding to an LC rate of 88%. Shorter TTP was associated with greater tumor volume at baseline (p = 0.01) and smaller absolute (p = 0.006) and relative (p = 0.05) decreases in tumor volume from baseline to second SSRS. Estimated OS rates at 6 and 12 months were 65% ± 7% and 49% ± 8%, respectively. CONCLUSIONS 2-SSRS is an effective treatment modality that resulted in significant reduction of brain metastases ≥ 2 cm, with excellent 3-month (95%) and 6-month (88%) LC rates and an overall AE rate of 11%. Prospective studies with larger cohorts and longer follow-up are necessary to assess the durability and toxicities of 2-SSRS.
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Affiliation(s)
- Lilyana Angelov
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,2Department of Neurosurgery, Neurological Institute
| | - Alireza M Mohammadi
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,2Department of Neurosurgery, Neurological Institute
| | | | - Mahmoud Abbassy
- 4Department of Neurosurgery, Alexandria University, Alexandria, Egypt
| | - Paul Elson
- 3Quantitative Health Sciences, Taussig Cancer Institute, and
| | - Samuel T Chao
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,5Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; and
| | - Joshua S Montgomery
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute
| | | | - Michael A Vogelbaum
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,2Department of Neurosurgery, Neurological Institute
| | - John H Suh
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,5Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; and
| | - Erin S Murphy
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,5Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; and
| | - Manmeet S Ahluwalia
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute
| | - Sean J Nagel
- 2Department of Neurosurgery, Neurological Institute
| | - Gene H Barnett
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,2Department of Neurosurgery, Neurological Institute
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Single fraction stereotactic radiosurgery for multiple brain metastases. Adv Radiat Oncol 2017; 2:555-563. [PMID: 29204522 PMCID: PMC5707418 DOI: 10.1016/j.adro.2017.09.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 08/27/2017] [Accepted: 09/05/2017] [Indexed: 12/25/2022] Open
Abstract
Introduction Due to the neurocognitive side effects of whole brain radiation therapy (WBRT), stereotactic radiosurgery (SRS) is being used with increasing frequency. The use of SRS is expanding for patients with multiple (>4) brain metastases (BM). This study summarizes our institutional experience with single-fraction, linear-accelerator-based SRS for multiple BM. Methods and materials All patients who were treated between January 1, 2013, and September 30, 2015, with single-fraction SRS for ≥4 BM were included in this institutional review board–approved, retrospective, single-institution study. Patients were treated with linear accelerator–based image guided SRS. Results A total of 59 patients with ≥4 BM were treated with single-fraction SRS. The median follow-up was 15.2 months, and the median overall survival for the entire cohort was 5.8 months. The median number of treated lesions per patient was 5 (range, 4-23). Per patient, the median planning target volume (PTV) was 4.8 cc (range, 0.7-28.8 cc). The prescribed dose across all 380 BM for the 59 patients ranged from 7 to 20 Gy. The median of the mean dose to the total PTV was 19.5 Gy. Although the number of treated lesions (4-5 vs ≥6) did not influence survival, better survival was noted for a total PTV <10 cc versus ≥10 cc (7.1 vs 4.2 months, respectively; P = .0001). A mean dose of ≥19 Gy to the entire PTV was also associated with increased survival (6.6 vs 5.0 months, respectively; P = .0172). Patients receiving a dose of >12 Gy to ≥10 cc of normal brain had worse survival (5.1 vs 8.6 months, respectively; P = .0028). Conclusion In single-fraction SRS for patients with multiple BM, smaller total tumor volume, higher total dose, and lower volume of normal brain receiving >12 Gy were associated with increased survival. These data suggest that using SRS for the treatment of multiple BM is efficacious and that outcomes may be affected more by total tumor volume than by the number of lesions.
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Yamamoto M, Serizawa T, Higuchi Y, Sato Y, Kawagishi J, Yamanaka K, Shuto T, Akabane A, Jokura H, Yomo S, Nagano O, Aoyama H. A Multi-institutional Prospective Observational Study of Stereotactic Radiosurgery for Patients With Multiple Brain Metastases (JLGK0901 Study Update): Irradiation-related Complications and Long-term Maintenance of Mini-Mental State Examination Scores. Int J Radiat Oncol Biol Phys 2017; 99:31-40. [DOI: 10.1016/j.ijrobp.2017.04.037] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/29/2017] [Accepted: 04/24/2017] [Indexed: 11/24/2022]
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Koffer P, Chan J, Rava P, Gorovets D, Ebner D, Savir G, Kinsella T, Cielo D, Hepel JT. Repeat Stereotactic Radiosurgery for Locally Recurrent Brain Metastases. World Neurosurg 2017; 104:589-593. [DOI: 10.1016/j.wneu.2017.04.103] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 04/14/2017] [Accepted: 04/17/2017] [Indexed: 10/19/2022]
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40
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Primary central nervous system lymphoma as a neurosurgical problem. Neurol Neurochir Pol 2017; 51:319-323. [DOI: 10.1016/j.pjnns.2017.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/10/2017] [Indexed: 11/21/2022]
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Oshima A, Kimura T, Akabane A, Kawai K. Optimal implantation of Ommaya reservoirs for cystic metastatic brain tumors preceding Gamma Knife radiosurgery. J Clin Neurosci 2017; 39:199-202. [PMID: 28117259 DOI: 10.1016/j.jocn.2016.12.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 12/27/2016] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Although Ommaya reservoir implantation is effective in reducing the target volume of cystic brain metastases preceding stereotactic radiosurgery, adequate volume reduction cannot be achieved in some cases, and the factors leading to failure in volume reduction have not been clearly identified. In this study, we investigated the factors leading to failure in volume reduction after use of the Ommaya reservoir. MATERIALS AND METHODS Between December 2007 and February 2015, 38 consecutive patients with 40 cystic metastases underwent Ommaya reservoir implantation at our institution. The patient characteristics, treatment parameters, and all available clinical and neuroimaging follow-ups were analyzed retrospectively. RESULTS The rate of volume reduction was significantly related to the location of the tube tip inside the cyst. By placing the tip at or near the center, 58.7% reduction was achieved, whereas reduction of 42.6% and 7.7% occurred with deep and shallow tip placement, respectively (p=0.011). Although there was no additional surgery in the center placement group, additional surgeries were performed in 5 out of the 23 deep and shallow cases due to inadequate volume reduction. No other factors were correlated with successful volume reduction. CONCLUSION For adequate volume reduction using the Ommaya reservoir in the treatment of cystic brain metastases prior to stereotactic radiosurgery, the tip of the reservoir tube should be placed at the center of the cyst.
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Affiliation(s)
- Akito Oshima
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan.
| | - Toshikazu Kimura
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan
| | - Atsuya Akabane
- Gamma Knife Center, NTT Medical Center Tokyo, Tokyo, Japan
| | - Kensuke Kawai
- Department of Neurosurgery, Jichi Medical University, Tochigi, Japan
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Rae A, Gorovets D, Rava P, Ebner D, Cielo D, Kinsella TJ, DiPetrillo TA, Hepel JT. Management approach for recurrent brain metastases following upfront radiosurgery may affect risk of subsequent radiation necrosis. Adv Radiat Oncol 2016; 1:294-299. [PMID: 28740900 PMCID: PMC5514163 DOI: 10.1016/j.adro.2016.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 07/07/2016] [Accepted: 08/14/2016] [Indexed: 11/26/2022] Open
Abstract
Purpose Many patients treated with stereotactic radiosurgery (SRS) alone as initial treatment require 1 or more subsequent salvage therapies. This study aimed to determine if commonly used salvage strategies are associated with differing risks of radiation necrosis (RN). Methods and materials All patients treated with upfront SRS alone for brain metastases at our institution were retrospectively analyzed. Salvage treatment details were obtained for brain failures. Patients who underwent repeat SRS to the same lesion were excluded. RN was determined based on pathological confirmation or advanced brain imaging consistent with RN in a symptomatic patient. Patients were grouped according to salvage treatment and rates of RN were compared via Fisher's exact tests. Results Of 284 patients treated with upfront SRS alone, 132 received salvage therapy and 44 received multiple salvage treatments. This included 31 repeat SRS alone, 58 whole brain radiation therapy (WBRT) alone, 28 SRS and WBRT, 7 surgery alone, and 8 surgery with adjuvant radiation. With a median follow-up of 10 months, the rate of RN among all patients was 3.17% (9/284), salvaged patients 4.55% (6/132), and never salvaged patients 1.97% (3/152). Receiving salvage therapy did not significantly increase RN risk (P = .31). Of the patients requiring salvage treatments, the highest RN rate was among patients that had both salvage SRS and WBRT (delivered as separate salvage therapies) (6/28, 21.42%). RN rate in this group was significantly higher than in those treated with repeat SRS alone (0/31), WBRT alone (0/58), surgery alone (0/7), and surgery with adjuvant radiation (0/8). Comparing salvage WBRT doses <30 Gy versus ≥30 Gy revealed no effect of dose on RN rate. Additionally, among patients who received multiple SRS treatments, number of treated lesions was not predictive of RN incidence. Conclusion Our results suggest that initial management approach for recurrent brain metastasis after upfront SRS does not affect the rate of RN. However, the risk of RN significantly increases when patients are treated with both repeat SRS and salvage WBRT. Methods to improve prediction of toxicity and optimize patient selection for salvage treatments are needed.
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Affiliation(s)
- Ali Rae
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Daniel Gorovets
- Department of Radiation Oncology, Rhode Island Hospital, Brown University, Providence, RI.,Department of Radiation Oncology, Tufts Medical Center, Tufts University, Boston, MA
| | - Paul Rava
- Department of Radiation Oncology, Memorial Cancer Center, University of Massachusetts, Worcester, MA
| | - Daniel Ebner
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Deus Cielo
- Department of Neurosurgery, Rhode Island Hospital, Brown University, Providence, RI
| | - Timothy J Kinsella
- Department of Radiation Oncology, Rhode Island Hospital, Brown University, Providence, RI.,Department of Radiation Oncology, Tufts Medical Center, Tufts University, Boston, MA
| | - Thomas A DiPetrillo
- Department of Radiation Oncology, Rhode Island Hospital, Brown University, Providence, RI.,Department of Radiation Oncology, Tufts Medical Center, Tufts University, Boston, MA
| | - Jaroslaw T Hepel
- Department of Radiation Oncology, Rhode Island Hospital, Brown University, Providence, RI.,Department of Radiation Oncology, Tufts Medical Center, Tufts University, Boston, MA
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Fuss M, Salter BJ. Intensity-Modulated Radiosurgery: Improving Dose Gradients and Maximum Dose Using Post Inverse-Optimization Interactive Dose Shaping. Technol Cancer Res Treat 2016; 6:197-204. [PMID: 17535028 DOI: 10.1177/153303460700600307] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Intensity-modulated radiosurgery (IMRS) for brain metastases and arterio-venous malformations (AVM) using a serial tomotherapy system (Nomos Corp., Cranberry Township, PA) has been delivered in >150 cases over the last 5 years. A new software tool provided within the Corvus inverse planning software (ActiveRx) allows for post inverse planning re-optimization and individualization of the dose distribution. We analyzed this tool with respect to increasing the steepness of the dose gradient and in-target dose inhomogeneity while maintaining conformity. Fifteen clinically delivered IMRS plans for solitary brain metastases provided the basis for this analysis. The clinical IMRS plans were copied and the ActiveRx module was opened. The toolset in ActiveRx includes a hot spot eraser, a pencil tool to redefine isodose lines and a drag and drop tool, allowing reshaping of existing isodose lines. To assess changes in the steepness of the dose gradient and dose homogeneity, the 100%, 90%, 50% and 25% isodose volume, the volume of the target, maximum dose and mean dose to the target were recorded. We also recorded total monitor units and calculated treatment delivery times. Target volumes ranged from 0.6 to 14.1 cm3 (mean/median 3.9/1.8 cm3). Mean RTOG conformity index (CI) of plans clinically delivered was 1.23±0.31; mean homogeneity index (HI) was 115±5%. After using the ActiveRx tool-set, the mean CI was slightly improved to 1.14±0.1, with an associated increase in HI to 141±10%. The average, respective Ian Paddick CI for the 100%, 90% 50% and 25% isodose lines were 0.79 vs. 0.83, 0.44 vs. 0.59, 0.12 vs. 0.19, and 0.04 vs. 0.07, representing significant improvements after using ActiveRx post-optimization. Total MU were reduced by a mean of 12.3% using ActiveRx, shortening estimated treatment delivery times by 3.2 minutes on average. A post inverse planning optimization tool for IMRS plans allowed for statistically significant improvements in the steepness of the dose gradient, and increased maximum and mean target doses compared to clinically delivered plans that were already considered excellent. Gains were especially pronounced in the reduction of normal brain tissue included into the 90%, and 50% isodose lines. We have since made this process part of the clinical routine for all cranial IMRS procedures.
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Affiliation(s)
- Martin Fuss
- Department of Radiation Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, Oregon 97239, USA.
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Minniti G, Scaringi C, Paolini S, Lanzetta G, Romano A, Cicone F, Osti M, Enrici RM, Esposito V. Single-Fraction Versus Multifraction (3 × 9 Gy) Stereotactic Radiosurgery for Large (>2 cm) Brain Metastases: A Comparative Analysis of Local Control and Risk of Radiation-Induced Brain Necrosis. Int J Radiat Oncol Biol Phys 2016; 95:1142-8. [PMID: 27209508 DOI: 10.1016/j.ijrobp.2016.03.013] [Citation(s) in RCA: 292] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 02/06/2016] [Accepted: 03/11/2016] [Indexed: 11/12/2022]
Abstract
PURPOSE To investigate the local control and radiation-induced brain necrosis in patients with brain metastases >2 cm in size who received single-fraction or multifraction stereotactic radiosurgery (SRS); factors associated with clinical outcomes and the development of brain radionecrosis were assessed. METHODS AND MATERIALS Two hundred eighty-nine consecutive patients with brain metastases >2.0 cm who received SRS as primary treatment at Sant'Andrea Hospital, University of Rome Sapienza, Rome, Italy, were analyzed. Cumulative incidence analysis was used to compare local control and radiation-induced brain necrosis between groups from the time of SRS. To achieve a balanced distribution of baseline covariates between treatment groups, a propensity score analysis was used. RESULTS The 1-year cumulative local control rates were 77% in the single-fraction SRS (SF-SRS) group and 91% in the multifraction SRS (MF-SRS) group (P=.01). Recurrences occurred in 25 and 11 patients who received SF-SRS or MF-SRS (P=.03), respectively. Thirty-one patients (20%) undergoing SF-SRS and 11 (8%) subjected to MF-SRS experienced brain radionecrosis (P=.004); the 1-year cumulative incidence rate of radionecrosis was 18% and 9% (P=.01), respectively. Significant differences between the 2 groups in terms of local control and risk of radionecrosis were maintained after propensity score adjustment. CONCLUSIONS Multifraction SRS at a dose of 27 Gy in 3 daily fractions seems to be an effective treatment modality for large brain metastases, associated with better local control and a reduced risk of radiation-induced radionecrosis as compared with SF-SRS.
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Affiliation(s)
- Giuseppe Minniti
- Unit of Radiation Oncology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy; IRCCS Neuromed, Pozzilli, Italy.
| | - Claudia Scaringi
- Unit of Radiation Oncology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | | | | | - Andrea Romano
- Unit of Neuroradiology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Francesco Cicone
- Unit of Nuclear Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Mattia Osti
- Unit of Radiation Oncology, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
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Specht HM, Kessel KA, Oechsner M, Meyer B, Zimmer C, Combs SE. HFSRT of the resection cavity in patients with brain metastases. Strahlenther Onkol 2016; 192:368-76. [PMID: 26964777 DOI: 10.1007/s00066-016-0955-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 02/03/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE Aim of this single center, retrospective study was to assess the efficacy and safety of linear accelerator-based hypofractionated stereotactic radiotherapy (HFSRT) to the resection cavity of brain metastases after surgical resection. Local control (LC), locoregional control (LRC = new brain metastases outside of the treatment volume), overall survival (OS) as well as acute and late toxicity were evaluated. PATIENTS AND METHODS 46 patients with large (> 3 cm) or symptomatic brain metastases were treated with HFSRT. Median resection cavity volume was 14.16 cm(3) (range 1.44-38.68 cm(3)) and median planning target volume (PTV) was 26.19 cm(3) (range 3.45-63.97 cm(3)). Patients were treated with 35 Gy in 7 fractions prescribed to the 95-100 % isodose line in a stereotactic treatment setup. LC and LRC were assessed by follow-up magnetic resonance imaging. RESULTS The 1-year LC rate was 88 % and LRC was 48 %; 57% of all patients showed cranial progression after HFSRT (4% local, 44% locoregional, 9% local and locoregional). The median follow-up was 19 months; median OS for the whole cohort was 25 months. Tumor histology and recursive partitioning analysis score were significant predictors for OS. HFSRT was tolerated well without any severe acute side effects > grade 2 according to CTCAE criteria. CONCLUSION HFSRT after surgical resection of brain metastases was tolerated well without any severe acute side effects and led to excellent LC and a favorable OS. Since more than half of the patients showed cranial progression after local irradiation of the resection cavity, close patient follow-up is warranted. A prospective evaluation in clinical trials is currently being performed.
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Affiliation(s)
- Hanno M Specht
- Klinik für RadioOnkologie und Strahlentherapie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany
| | - Kerstin A Kessel
- Klinik für RadioOnkologie und Strahlentherapie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany.,Institut für Innovative Radiotherapie, Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Oberschleißheim, Germany
| | - Markus Oechsner
- Klinik für RadioOnkologie und Strahlentherapie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, 81675, Munich, Germany
| | - Claus Zimmer
- Abteilung Neuroradiologie, Klinikum rechts der Isar, Technische Universität München, 81675, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung, Technische Universität München, 81675, Munich, Germany
| | - Stephanie E Combs
- Klinik für RadioOnkologie und Strahlentherapie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany. .,Institut für Innovative Radiotherapie, Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Oberschleißheim, Germany. .,Deutsches Konsortium für Translationale Krebsforschung, Technische Universität München, 81675, Munich, Germany.
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46
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Jani A, Rozenblat T, Yaeh AM, Nanda T, Saad S, Qureshi YH, Feng W, Sisti MB, Bruce JN, McKhann GM, Lesser J, Lassman AB, Isaacson SR, Wang TJC. The Energy Index Does Not Affect Local Control of Brain Metastases Treated by Gamma Knife Stereotactic Radiosurgery. Neurosurgery 2016; 77:119-25; discussion 125. [PMID: 25830600 DOI: 10.1227/neu.0000000000000750] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The energy index (EI) is a measure of dose homogeneity within a target volume calculated by the integral dose divided by the product of prescription dose and tumor volume. OBJECTIVE To assess whether a higher EI is associated with greater local control for brain metastases (BMs) treated by Gamma Knife radiosurgery (GKRS). METHODS We reviewed all patients treated with GKRS for BM at our institution between January 2009 and February 2014. Data on the prescription dose, prescription isodose line, minimum dose, mean dose, integral dose, tumor volume, and EI were collected. Tumor response was assessed by reviewing follow-up brain imaging studies and classified according to the Response Evaluation Criteria in Solid Tumors. Local control per lesion and dosimetric prognostic factors for local control were assessed by univariate and multivariate Cox proportional hazards regression analyses. RESULTS Of 213 patients treated, 126 had follow-up imaging available with a median follow-up of 6 months. Three hundred seventy-three individual tumors were analyzed. Of these, 133 showed a complete response, 157 showed a partial response, 46 remained stable, and 37 developed local failure. Tumors with EI ≥1.6 mJ·mL(-1)·Gy(-1) showed a higher rate of complete response. Local control rates at 6, 11, and 17 months were 95.4%, 86.5%, and 81.5%, respectively. On univariate analysis, the following factors were associated with higher rates of local failure: prescription doses of 16 and 18 Gy compared with a prescription dose of 20 Gy. The following factors were associated with a greater rate of local control: maximum dose and mean dose. On multivariate analysis, the only statistically significant factor associated with a greater rate of local failure was prescription dose of 16 Gy compared with 20 Gy. CONCLUSION GKRS for BM results in a high rate of local control with an 11-month rate of 86.5%. A higher EI was not significantly associated with a higher rate of local control on multivariate analysis. Prescription dose was found to be the only significant predictor of local control on multivariate analysis.
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Affiliation(s)
- Ashish Jani
- ‡Department of Radiation Oncology, §The Taub Institute for Research on Alzheimer's Disease and the Aging Brain, ¶Herbert Irving Comprehensive Cancer, ‖Department of Neurological Surgery, and #Department of Neurology, Columbia University Medical Center, New York, New York
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Duregon E, Senetta R, Pittaro A, Verdun di Cantogno L, Stella G, De Blasi P, Zorzetto M, Mantovani C, Papotti M, Cassoni P. CAVEOLIN-1 expression in brain metastasis from lung cancer predicts worse outcome and radioresistance, irrespective of tumor histotype. Oncotarget 2015; 6:29626-36. [PMID: 26315660 PMCID: PMC4745751 DOI: 10.18632/oncotarget.4988] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 07/16/2015] [Indexed: 02/02/2023] Open
Abstract
Brain metastases develop in one-third of patients with non-small-cell lung cancer and are associated with a dismal prognosis, irrespective of surgery or chemo-radiotherapy. Pathological markers for predicting outcomes after surgical resection and radiotherapy responsiveness are still lacking. Caveolin 1 has been associated with chemo- and radioresistance in various tumors, including non-small-cell lung cancer. Here, caveolin 1 expression was assessed in a series of 69 brain metastases from non-small-cell lung cancer and matched primary tumors to determine its role in predicting survival and radiotherapy responsiveness. Only caveolin 1 expression in brain metastasis was associated with poor prognosis and an increased risk of death (log rank test, p = 0.015). Moreover, in the younger patients (median age of <54 years), caveolin 1 expression neutralized the favorable effect of young age on survival compared with the older patients. Among the radiotherapy-treated patients, an increased risk of death was detected in the group with caveolin 1-positive brain metastasis (14 out of 22 patients, HR=6.839, 95% CI 1.849 to 25.301, Wald test p = 0.004). Overall, caveolin 1 expression in brain metastasis from non-small-cell lung cancer is independently predictive of worse outcome and radioresistance and could become an additional tool for personalized therapy in the critical subset of brain-metastatic non-small-cell lung cancer patients.
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Affiliation(s)
- Eleonora Duregon
- Department of Oncology, University of Torino at San Luigi Hospital, Orbassano, Turin, Italy
| | | | | | | | - Giulia Stella
- Laboratory of Biochemistry and Genetics, Pneumology Unit, Department of Molecular Medicine University and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Michele Zorzetto
- Laboratory of Biochemistry and Genetics, Pneumology Unit, Department of Molecular Medicine University and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Mauro Papotti
- Department of Oncology, University of Torino at San Luigi Hospital, Orbassano, Turin, Italy
| | - Paola Cassoni
- Department of Medical Sciences, University of Torino, Italy
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Kohutek ZA, Yamada Y, Chan TA, Brennan CW, Tabar V, Gutin PH, Yang TJ, Rosenblum MK, Ballangrud Å, Young RJ, Zhang Z, Beal K. Long-term risk of radionecrosis and imaging changes after stereotactic radiosurgery for brain metastases. J Neurooncol 2015; 125:149-56. [PMID: 26307446 DOI: 10.1007/s11060-015-1881-3] [Citation(s) in RCA: 198] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 08/10/2015] [Indexed: 10/23/2022]
Abstract
Radionecrosis is a well-characterized effect of stereotactic radiosurgery (SRS) and is occasionally associated with serious neurologic sequelae. Here, we investigated the incidence of and clinical variables associated with the development of radionecrosis and related radiographic changes after SRS for brain metastases in a cohort of patients with long-term follow up. 271 brain metastases treated with single-fraction linear accelerator-based SRS were analyzed. Radionecrosis was diagnosed either pathologically or radiographically. Univariate and multivariate Cox regression was performed to determine the association between radionecrosis and clinical factors available prior to treatment planning. After median follow up of 17.2 months, radionecrosis was observed in 70 (25.8%) lesions, including 47 (17.3%) symptomatic cases. 22 of 70 cases (31.4%) were diagnosed pathologically and 48 (68.6%) were diagnosed radiographically. The actuarial incidence of radionecrosis was 5.2% at 6 months, 17.2% at 12 months and 34.0% at 24 months. On univariate analysis, radionecrosis was associated with maximum tumor diameter (HR 3.55, p < 0.001), prior whole brain radiotherapy (HR 2.21, p = 0.004), prescription dose (HR 0.56, p = 0.02) and histology other than non-small cell lung, breast or melanoma (HR 1.85, p = 0.04). On multivariate analysis, only maximum tumor diameter (HR 3.10, p < 0.001) was associated with radionecrosis risk. This data demonstrates that with close imaging follow-up, radionecrosis after single-fraction SRS for brain metastases is not uncommon. Maximum tumor diameter on pre-treatment MR imaging can provide a reliable estimate of radionecrosis risk prior to treatment planning, with the greatest risk among tumors measuring >1 cm.
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Affiliation(s)
- Zachary A Kohutek
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Timothy A Chan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA.,Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cameron W Brennan
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Viviane Tabar
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Philip H Gutin
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - T Jonathan Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Marc K Rosenblum
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Åse Ballangrud
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert J Young
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA.
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Abstract
We evaluated patient outcomes following stereotactic radiosurgery (SRS)-treatment of large brain metastasis (⩾3 cm) at our institution. SRS is an established treatment for limited brain metastases. However, large tumors pose a challenge for this approach. For this study, 343 patients with 754 total brain metastases were treated with SRS, of which 93 had large tumors. The tumor size was 3-3.5, 3.5-4, and ⩾4 cm in 29%, 32%, and 39% of these patients. Surgical resection was performed prior to SRS in 68% of patients, and 53% achieved a gross total resection. The local control of large metastases was inferior compared to smaller tumors, with 1 year local control of 68 versus 86%, respectively (p<0.001). Among the patients with large metastases, no correlation between local control and surgical resection (p=0.747), or extent of surgery (gross total versus subtotal resection; p=0.120), was identified. Histology (p=0.939), tumor size (3-4 versus >4 cm; p=0.551), and SRS dose (⩽16 versus >16 Gy; p=0.539) also showed no correlation with local failure. The overall survival at 1, 2, and 5 years was 46%, 29% and 5%, respectively. Prolonged survival was seen in patients with age <65 years (p=0.009), primary treatment compared with salvage (p=0.077), and controlled primary tumors (p=0.022). Radiation necrosis developed in 10 patients (11.8%). For patients with large brain metastases, SRS is well tolerated and can achieve local central nervous system disease control in the majority of patients, and extended survival in some, though the local control rate is suboptimal. Further strategies to improve the outcomes in this subgroup of patients are needed.
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Affiliation(s)
- Daniel Ebner
- Alpert Medical School of Brown University, Providence, RI, USA
| | - Paul Rava
- Department of Radiation Oncology, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Daniel Gorovets
- Department of Radiation Oncology, Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA; Department of Radiation Oncology, Tufts Medical Center, Boston, MA, USA
| | - Deus Cielo
- Department of Neurosurgery, Brown Alpert Medical School, Providence, RI, USA
| | - Jaroslaw T Hepel
- Department of Radiation Oncology, Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA; Department of Radiation Oncology, Tufts Medical Center, Boston, MA, USA.
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50
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Qin H, Wang C, Jiang Y, Zhang X, Zhang Y, Ruan Z. Patients with single brain metastasis from non-small cell lung cancer equally benefit from stereotactic radiosurgery and surgery: a systematic review. Med Sci Monit 2015; 21:144-52. [PMID: 25579245 PMCID: PMC4299005 DOI: 10.12659/msm.892405] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background The appropriate treatment of non-small cell lung cancer (NSCLC) with single brain metastasis (SBM) is still controversial. A systematic review was designed to evaluate the effectiveness of neurosurgery and stereotactic radiosurgery (SRS) in patients with SBM from NSCLC. Material/Methods PUBMED, EMBASE, the Cochrane Library, Web of Knowledge, Current Controlled Trials, Clinical Trials, and 2 conference websites were searched to select NSCLC patients with only SBM who received brain surgery or SRS. SPSS 18.0 software was used to analyze the mean median survival time (MST) and Stata 11.0 software was used to calculate the overall survival (OS). Results A total of 18 trials including 713 patients were systematically reviewed. The MST of the patients was 12.7 months in surgery group and 14.85 months in SRS group, respectively. The 1, 2, and 5 years OS of the patients were 59%, 33%, and 19% in surgery group, and 62%, 33%, and 14% in SRS group, respectively. Furthermore, in the surgery group, the 1 and 3 years OS were 68% and 15% in patients with controlled primary tumors, and 50% and 13% in the other patients with uncontrolled primary tumors, respectively. Interestingly, the 5-year OS was up to 21% in patients with controlled primary tumors. Conclusions There was no significant difference in MST or OS between patients treated with neurosurgery and SRS. Patients with resectable lung tumors and SBM may benefit from the resection of both primary lesions and metastasis.
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Affiliation(s)
- Hong Qin
- Department of Oncology, Southwest Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Cancan Wang
- Department of Oncology, Southwest Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Yongyuan Jiang
- Department of Respiratory, Southwest Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Xiaoli Zhang
- Department of Oncology, Southwest Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Yao Zhang
- Department of Epidemiology, Third Military Medical University, Chongqing, China (mainland)
| | - Zhihua Ruan
- Department of Oncology, Southwest Hospital, Third Military Medical University, Chongqing, China (mainland)
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