1
|
Kuperman VY, Altundal Y, Kandel S, Kouskoulas TN. Dose conformity and falloff in single-lesion intracranial SRS with DCA and VMAT methods. J Appl Clin Med Phys 2024:e14415. [PMID: 38924344 DOI: 10.1002/acm2.14415] [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: 12/28/2023] [Revised: 04/25/2024] [Accepted: 05/06/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Intracranial stereotactic radiosurgery (SRS) aims at achieving highly conformal dose distribution and, at the same time, attaining rapid dose falloff outside the treatment target. SRS is performed using different techniques including dynamic conformal arcs (DCA) and volumetric modulated arc therapy (VMAT). PURPOSE In this study, we compare dose conformity and falloff in DCA and VMAT plans for SRS with a single target. METHODS To compare dose conformity in SRS plans, we employ a novel conformity indexC I d e x p $C{I}_{{d}_{exp}}$ , RTOG conformity index (C I R T O G $C{I}_{RTOG}$ ), and Riet-Paddick conformity index (C I R P $C{I}_{RP}$ ). In addition, we use indicesR 50 % $R50\% $ ,V 10 G y ${V}_{10Gy}$ , andV 12 G y ${V}_{12Gy}$ to evaluate dose falloff. For each of the considered 118 cases of SRS, two plans were created using DCA and VMAT. A two-tailed Student's t-test was used to evaluate the difference between the employed indices for the DCA and VMAT plans. RESULTS The studied VMAT plans were characterized by higher dose conformity than the DCA plans. The differences between the conformity indices for the DCA plans and VMAT plans were statistically significant. The DCA plans had a smaller number of monitor units (MUs) and smaller indices R50%, V10 Gy, and V12 Gy than the VMAT plans. However, the differences between R50%, V10 Gy, and V12 Gy for the DCA and VMAT plans were not statistically significant. CONCLUSIONS Although the studied VMAT plans had higher dose conformity, they also had larger MUs than the DCA plans. In terms of dose falloff characterized by parameters R50%, V10 Gy, and V12 Gy, DCA serves as a reasonable alternative to VMAT in the case of a single brain metastasis.
Collapse
Affiliation(s)
- Vadim Y Kuperman
- Florida Cancer Specialists & Research Institute, Hudson, Florida, USA
| | - Yücel Altundal
- Florida Cancer Specialists & Research Institute, Hudson, Florida, USA
| | - Sunil Kandel
- Florida Cancer Specialists & Research Institute, Hudson, Florida, USA
| | | |
Collapse
|
2
|
Buszek SM, Tran B, Long JP, Luo D, Suki D, Li J, Ferguson S, Chung C. Postoperative Management of Recurrence After Radiosurgery and Surgical Resection for Brain Metastases and Predicting Benefit From Adjuvant Radiation. Pract Radiat Oncol 2023; 13:e499-e503. [PMID: 37295724 DOI: 10.1016/j.prro.2023.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/01/2023] [Accepted: 05/21/2023] [Indexed: 06/12/2023]
Abstract
Stereotactic radiosurgery (SRS) is often used as upfront treatment for brain metastases. Progression or radionecrosis after SRS is common and can prompt resection. However, postoperative management strategies after resection for SRS failure vary widely, and no standard practice has been established. In this approved study, we retrospectively reviewed patients who received SRS for a brain metastasis followed by resection of the same lesion. We extracted patient-, disease-, and treatment-related variables and information on disease-related outcomes. Univariate and multivariate analyses of clinicopathologic variables were used to create a model to predict factors associated with local failure (LF). A total of 225 patients with brain metastases treated with SRS from 2009 to 2017 followed by surgical resection were identified. Overall, 65% of cases had gross total resection (GTR) on postoperative imaging review. Twenty-one patients (9.3%) received adjuvant radiation therapy to the surgical cavity, and 204 (90.7%) were observed. Of these 204 patients, 118 had GTR with evidence of tumor within the pathology specimen. With a median follow-up of 13 months after resection, 47 patients (40%) developed LF after surgery. After salvage resection of a brain metastasis initially treated with SRS, the observed LF rate was 40% among those who had a GTR and evidence of tumor on pathologic examination. This LF rate is sufficiently high that adjuvant radiation to the surgical bed after salvage resection should be considered in these cases when there is tumor in the pathology, even after a GTR.
Collapse
Affiliation(s)
- Samantha M Buszek
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Benjamin Tran
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - James P Long
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Dershan Luo
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Dima Suki
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sherise Ferguson
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Caroline Chung
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
| |
Collapse
|
3
|
Ito T, Kubo K, Monzen H, Yanagi Y, Nakamura K, Sakai Y, Nishimura Y. Overcoming Problems Caused by Offset Distance of Multiple Targets in Single-isocenter Volumetric Modulated Arc Therapy Planning for Stereotactic Radiosurgery. J Med Phys 2023; 48:365-372. [PMID: 38223796 PMCID: PMC10783189 DOI: 10.4103/jmp.jmp_8_23] [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: 01/21/2023] [Revised: 09/06/2023] [Accepted: 09/12/2023] [Indexed: 01/16/2024] Open
Abstract
Purpose The purpose of the study is to investigate the impact of large target offset distances on the dose distribution and gamma passing rate (GPR) in single-isocenter multiple-target stereotactic radiosurgery (SIMT SRS) using volumetric modulated arc therapy (VMAT) with a flattening filter-free (FFF) beam from a linear accelerator. Methods Two targets with a diameter of 1 cm were offset by "±2, ±4, and ±6 cm from the isocenter in a verification phantom for head SRS (20 Gy/fr). The VMAT plans were created using collimator angles that ensured the two targets did not share a leaf pair from the multi-leaf collimator. To evaluate the low-dose spread intermediate dose spill (R50%), GPRs were measured with a criterion of 3%/2 mm using an electronic portal imaging device and evaluated using monitor unit (MU), modulation complexity score for VMAT (MCSv), and leaf travel (LT) parameters. Results For offsets of 2, 4, and 6 cm, the respective parameters were: R50%, 4.75 ± 0.36, 5.13 ± 0.36, and 5.11 ± 0.33; GPR, 95.01%, 93.82%, and 90.67%; MU, 5893 ± 186, 5825 ± 286, and 5810 ± 396; MCSv, 0.24, 0.16, and 0.13; and LT, 189.21 ± 36.04, 327.69 ± 67.01, and 430.39 ± 114.34 mm. There was a spread in the low-dose region from offsets of ≥4 cm and the GPR negatively correlated with LT (r = -0.762). There was minimal correlation between GPR and MU or MCSv. Conclusions In SIMT SRS VMAT plans with an FFF beam from a linear accelerator, target offsets of <4 cm from the isocenter can minimize the volume of the low-dose region receiving 10 Gy or more. During treatment planning, it is important to choose gantry, couch, and collimator angles that minimize LT and thereby improve the GPR.
Collapse
Affiliation(s)
- Takaaki Ito
- Department of Medical Physics, Graduate School of Medical Sciences, Kindai University, Osakasayama, Osaka, Japan
- Department of Radiological Technology, Kobe City Nishi Kobe Medical Center, Kobe, Hyogo, Japan
| | - Kazuki Kubo
- Department of Medical Physics, Graduate School of Medical Sciences, Kindai University, Osakasayama, Osaka, Japan
| | - Hajime Monzen
- Department of Medical Physics, Graduate School of Medical Sciences, Kindai University, Osakasayama, Osaka, Japan
| | - Yuya Yanagi
- Department of Medical Physics, Graduate School of Medical Sciences, Kindai University, Osakasayama, Osaka, Japan
| | - Kenji Nakamura
- Department of Medical Physics, Graduate School of Medical Sciences, Kindai University, Osakasayama, Osaka, Japan
| | - Yusuke Sakai
- Department of Medical Physics, Graduate School of Medical Sciences, Kindai University, Osakasayama, Osaka, Japan
| | - Yasumasa Nishimura
- Department of Radiation Oncology, Faculty of Medicine, Kindai University, Osakasayama, Osaka, Japan
| |
Collapse
|
4
|
Beddok A, Loi M, Rivin Del Campo E, Dumas JL, Orthuon A, Créhange G, Huguet F. [Limits of dose constraint definition for organs at risk specific to stereotactic radiotherapy]. Cancer Radiother 2023:S1278-3218(23)00067-7. [PMID: 37208260 DOI: 10.1016/j.canrad.2023.01.006] [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: 11/23/2022] [Revised: 01/24/2023] [Accepted: 01/30/2023] [Indexed: 05/21/2023]
Abstract
Stereotactic radiotherapy is a very hypofractionated radiotherapy (>7.5Gy per fraction), and therefore is more likely to induce late toxicities than conventional normofractionated irradiations. The present study examines four frequent and potentially serious late toxicities: brain radionecrosis, radiation pneumonitis, radiation myelitis, and radiation-induced pelvic toxicities. The critical review focuses on the toxicity scales, the definition of the dose constrained volume, the dosimetric parameters, and the non-dosimetric risk factors. The most commonly used toxicity scales remain: RTOG/EORTC or common terminology criteria for adverse events (CTCAE). The definition of organ-at-risk volume requiring protection is often controversial, which limits the comparability of studies and the possibility of accurate dose constraints. Nevertheless, for the brain, whatever the indication (arteriovenous malformation, benign tumor, metastasis of solid tumors...), the association between the volume of brain receiving 12Gy (V12Gy) and the risk of cerebral radionecrosis is well established for both single and multi-fraction stereotactic irradiation. For the lung, the average dose received by both lungs and the V20 seem to correlate well with the risk of radiation-induced pneumonitis. For the spinal cord, the maximum dose is the most consensual parameter. Clinical trial protocols are useful for nonconsensual dose constraints. Non-dosimetric risk factors should be considered when validating the treatment plan.
Collapse
Affiliation(s)
- A Beddok
- Institut Curie, université PSL, université Paris Saclay, Inserm, Lito U1288, 75005 Orsay, France; Service de radiothérapie oncologique, institut Curie, université PSL, Paris, France.
| | - M Loi
- Radiotherapy Department, University of Florence, Florence, Italie
| | - E Rivin Del Campo
- Service de radiothérapie oncologique, hôpital Tenon, AP-HP, Sorbonne Université, 75020 Paris, France; Faculté de médecine, Sorbonne Université, 75013 Paris, France
| | - J-L Dumas
- Service de radiothérapie oncologique, institut Curie, université PSL, Paris, France
| | - A Orthuon
- Service de radiothérapie oncologique, hôpital Tenon, AP-HP, Sorbonne Université, 75020 Paris, France
| | - G Créhange
- Institut Curie, université PSL, université Paris Saclay, Inserm, Lito U1288, 75005 Orsay, France; Service de radiothérapie oncologique, institut Curie, université PSL, Paris, France
| | - F Huguet
- Service de radiothérapie oncologique, hôpital Tenon, AP-HP, Sorbonne Université, 75020 Paris, France; Faculté de médecine, Sorbonne Université, 75013 Paris, France
| |
Collapse
|
5
|
Scorsetti M, Navarria P, Cozzi L, Clerici E, Bellu L, Franceschini D, Marzo AM, Franzese C, Torri V, Reggiori G, Lobefalo F, Raspagliesi L, Attuati L, Pessina F, Franzini A, Picozzi P, Tomatis S. Radiosurgery of limited brain metastases from primary solid tumor: results of the randomized phase III trial (NCT02355613) comparing treatments executed with a specialized or a C-arm linac-based platform. Radiat Oncol 2023; 18:28. [PMID: 36750848 PMCID: PMC9906937 DOI: 10.1186/s13014-023-02216-5] [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: 11/16/2022] [Accepted: 01/30/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Comparative prospective data regarding different radiosurgery (SRS) modalities for treating brain metastases (BMs) from solid tumors are not available. To investigate with a single institute phase III randomized trial whether SRS executed with linac (Arm-B) is superior to a dedicated multi-source gamma-ray stereotactic platform (Arm-A). METHODS Adults patients with 1-4 BMs from solid tumors up to 30 mm in maximum diameter were randomly assigned to arms A and B. The primary endpoint was cumulative incidence of symptomatic (grade 2-3) radionecrosis (CIRN). Secondary endpoints were local progression cumulative incidence (CILP), distant brain failure, disease-free survival (DFS), and overall survival (OS). RESULTS A total of 251 patients were randomly assigned to Arm-A (121) or Arm-B (130). The 1-year RN cumulative incidence was 6.7% in whole cohort, 3.8% (95% CI 1.9-7.4%) in Arm-B, and 9.3% (95% CI 6.2-13.8%) in the Arm-A (p = 0.43). CIRN was influenced by target volume irradiated only for the Arm-A (p << 0.001; HR 1.36 [95% CI 1.25-1.48]). Symptomatic RN occurred in 56 cases at a median time of 10.3 months (range 1.15-54.8 months), 27 in the Arm-B at a median time of 15.9 months (range 4.9-54.8 months), and 29 in the Arm-A at a median time of 6.9 months (1.2-32.3 months), without statistically significant differences between the two arms. No statistically significant differences were recorded between the two arms in CILP, BDF, DFS or OS. The mean beam-on time to deliver SRS was 49.0 ± 36.2 min in Arm-A, and 3.1 ± 1.6 min in Arm-B. CONCLUSIONS Given the technical differences between the treatment platforms investigated in this single-institution study, linac-based SRS (Arm-B) did not lead to significantly lower grade 2-3 RN rates versus the multi-source gamma-ray system (Arm-A) in a population of patients with limited brain metastases of small volume. No significant difference in local control was observed between both arms. For Arm-B, the treatment delivery time was significantly lower than for Arm-A. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT02355613.
Collapse
Affiliation(s)
- Marta Scorsetti
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan Italy
| | - Pierina Navarria
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Luca Cozzi
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan Italy
| | - Elena Clerici
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Luisa Bellu
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Davide Franceschini
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Antonio Marco Marzo
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Ciro Franzese
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan Italy
| | - Valter Torri
- grid.4527.40000000106678902Oncology Department, IRCCS Istituto Mario Negri, Milan, Italy
| | - Giacomo Reggiori
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Francesca Lobefalo
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Luca Raspagliesi
- grid.417728.f0000 0004 1756 8807Neurosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan Italy
| | - Luca Attuati
- grid.417728.f0000 0004 1756 8807Neurosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan Italy
| | - Federico Pessina
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan Italy
| | - Andrea Franzini
- grid.417728.f0000 0004 1756 8807Neurosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan Italy
| | - Piero Picozzi
- grid.417728.f0000 0004 1756 8807Neurosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan Italy
| | - Stefano Tomatis
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy
| |
Collapse
|
6
|
Dosimetric Impact of Lesion Number, Size, and Volume on Mean Brain Dose with Stereotactic Radiosurgery for Multiple Brain Metastases. Cancers (Basel) 2023; 15:cancers15030780. [PMID: 36765738 PMCID: PMC9913147 DOI: 10.3390/cancers15030780] [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: 01/05/2023] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
We evaluated the effect of lesion number and volume for brain metastasis treated with SRS using GammaKnife® ICON™ (GK) and CyberKnife® M6™ (CK). Four sets of lesion sizes (<5 mm, 5-10 mm, >10-15 mm, and >15 mm) were contoured and prescribed a dose of 20 Gy/1 fraction. The number of lesions was increased until a threshold mean brain dose of 8 Gy was reached; then individually optimized to achieve maximum conformity. Across GK plans, mean brain dose was linearly proportional to the number of lesions and total GTV for all sizes. The numbers of lesions needed to reach this threshold for GK were 177, 57, 29, and 10 for each size group, respectively; corresponding total GTVs were 3.62 cc, 20.37 cc, 30.25 cc, and 57.96 cc, respectively. For CK, the threshold numbers of lesions were 135, 35, 18, and 8, with corresponding total GTVs of 2.32 cc, 12.09 cc, 18.24 cc, and 41.52 cc respectively. Mean brain dose increased linearly with number of lesions and total GTV while V8 Gy, V10 Gy, and V12 Gy showed quadratic correlations to the number of lesions and total GTV. Modern dedicated intracranial SRS systems allow for treatment of numerous brain metastases especially for ≤10 mm; clinical evidence to support this practice is critical to expansion in the clinic.
Collapse
|
7
|
Tsui SSW, Wu VWC, Cheung JSC. Comparison of dosimetric impact of intra-fractional setup discrepancy between multiple- and single-isocenter approaches in linac-based stereotactic radiotherapy of multiple brain metastases. J Appl Clin Med Phys 2021; 23:e13484. [PMID: 34931447 PMCID: PMC8833285 DOI: 10.1002/acm2.13484] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 04/23/2021] [Accepted: 11/09/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction Treatment of multiple brain metastases by linac‐based stereotactic radiotherapy (SRT) can employ either a multiple‐isocenter (MI) or single‐isocenter (SI) approach. The purposes of this study were to evaluate the dosimetric results of MI and SI approaches and compare the impacts of intra‐fractional setup discrepancies on the robustness of respective approaches using isocenter shifts, whether the same magnitude of translational and rotational effects could lead to a significant difference between the two approaches. Methods Twenty‐two patients with multiple brain metastases treated by linac‐based SRT were recruited. Treatment plans were computed with both the MI and SI approaches. For the MI approach, the isocenter was located at the geometric center of each planning target volumes (PTVs), whereas the isocenter of the SI approach was located midway between the PTV centroids. To simulate the intra‐fractional errors, isocenter displacements including translational and rotational shifts were hypothetically applied. Apart from the dosimetric outcomes of the two approaches, the impact of the isocenter shifts on PTVs and organs at risk (OARs) were recorded in terms of the differences (δ) in dose parameters relative to the reference plan and was then compared between the MI and SI approaches. Results Both MI and SI plans met the plan acceptance criteria. The mean Paddick conformity index (Paddick CI) and Dmax of most OARs between MI and SI plans did not show a significant difference, except that higher doses to the left optic nerve and optic chiasm were found in SI plans (p = 0.03). After the application of the isocenter shifts, δCI increased with an increase in the magnitude of the isocenter shift. When comparing between MI and SI plans, the δCIs were similar (p > 0.05) for all extents of translational shifts, but δCIs were significantly higher in SI plans after application of all rotations particularly ±1.5° and ±2.0° shifts. Despite the result that the majority of δDMax of OARs were higher in the SI plans, only the differences in the left optic nerve and chiasm showed generally consistent significance after both translational ≥±1 mm and rotational shifts of ≥±1∘. Conclusion Both MI and SI approaches could produce clinically acceptable plans. However, isocenter shifts brought dosimetric impacts to both MI and SI approaches and the effects increased with the increase of the shift magnitude. Although similar impacts were shown in plans of both approaches after translational isocenter shift, SI plans were relatively more vulnerable than MI plans to rotational shifts.
Collapse
Affiliation(s)
- Sylvia S W Tsui
- Department of Clinical Oncology, Prince of Wales Hospital, Shatin, Hong Kong
| | - Vincent W C Wu
- Department of Health Technology & Informatics, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Jerry S C Cheung
- Department of Clinical Oncology, Queen Mary Hospital, Pok Fu Lam, Hong Kong
| |
Collapse
|
8
|
Hellerbach A, Eichner M, Rueß D, Luyken K, Hoevels M, Judge M, Baues C, Ruge M, Kocher M, Treuer H. Impact of prescription isodose level and collimator selection on dose homogeneity and plan quality in robotic radiosurgery. Strahlenther Onkol 2021; 198:484-496. [PMID: 34888732 PMCID: PMC9038902 DOI: 10.1007/s00066-021-01872-4] [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: 04/08/2021] [Accepted: 10/17/2021] [Indexed: 11/28/2022]
Abstract
Purpose In stereotactic radiosurgery (SRS), prescription isodoses and resulting dose homogeneities vary widely across different platforms and clinical entities. Our goal was to investigate the physical limitations of generating dose distributions with an intended level of homogeneity in robotic SRS. Methods Treatment plans for non-isocentric irradiation of 4 spherical phantom targets (volume 0.27–7.70 ml) and 4 clinical targets (volume 0.50–5.70 ml) were calculated using Sequential (phantom) or VOLOTM (clinical) optimizers (Accuray, Sunnyvale, CA, USA). Dose conformity, volume of 12 Gy isodose (V12Gy) as a measure for dose gradient, and treatment time were recorded for different prescribed isodose levels (PILs) and collimator settings. In addition, isocentric irradiation of phantom targets was examined, with dose homogeneity modified by using different collimator sizes. Results Dose conformity was generally high (nCI ≤ 1.25) and varied little with PIL. For all targets and collimator sets, V12Gy was highest for PIL ≥ 80% and lowest for PIL ≤ 65%. The impact of PIL on V12Gy was highest for isocentric irradiation and lowest for clinical targets (VOLOTM optimization). The variability of V12Gy as a function of collimator selection was significantly higher than that of PIL. V12Gy and treatment time were negatively correlated. Plans utilizing a single collimator with a diameter in the range of 70–80% of the target diameter were fastest, but showed the strongest dependence on PIL. Conclusion Inhomogeneous dose distributions with PIL ≤ 70% can be used to minimize dose to normal tissue. PIL ≥ 90% is associated with a marked and significant increase in off-target dose exposure. Careful selection of collimators during planning is even more important. Supplementary Information The online version of this article (10.1007/s00066-021-01872-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Alexandra Hellerbach
- Faculty of Medicine and University Hospital Cologne, Department of Stereotaxy and Functional Neurosurgery, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany.
| | - Markus Eichner
- Faculty of Medicine and University Hospital Cologne, Department of Stereotaxy and Functional Neurosurgery, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Daniel Rueß
- Faculty of Medicine and University Hospital Cologne, Department of Stereotaxy and Functional Neurosurgery, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Klaus Luyken
- Faculty of Medicine and University Hospital Cologne, Department of Stereotaxy and Functional Neurosurgery, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Mauritius Hoevels
- Faculty of Medicine and University Hospital Cologne, Department of Stereotaxy and Functional Neurosurgery, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Michael Judge
- Faculty of Medicine and University Hospital Cologne, Institute of Radiation Oncology, University of Cologne, Cologne, Germany
| | - Christian Baues
- Faculty of Medicine and University Hospital Cologne, Institute of Radiation Oncology, University of Cologne, Cologne, Germany
| | - Maximilian Ruge
- Faculty of Medicine and University Hospital Cologne, Department of Stereotaxy and Functional Neurosurgery, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Martin Kocher
- Faculty of Medicine and University Hospital Cologne, Department of Stereotaxy and Functional Neurosurgery, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Harald Treuer
- Faculty of Medicine and University Hospital Cologne, Department of Stereotaxy and Functional Neurosurgery, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| |
Collapse
|
9
|
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.
Collapse
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.)
| |
Collapse
|
10
|
Beltaifa Y, Hamdi H, Spatola G, Balossier A, Merly L, Castillo L, Cretol A, Regis J. Is Real-Time Inverse Planning Optimizing Dose to the Normal Brain? A Prospective Comparative Trial in a Series of Brain Metastases Treated by Stereotactic Radiosurgery. Stereotact Funct Neurosurg 2021; 100:53-60. [PMID: 34818656 DOI: 10.1159/000519024] [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: 02/02/2021] [Accepted: 08/12/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Radiosurgery has demonstrated good safety and efficacy in the treatment of multiple brain metastases (BMs). However, multi-target dose planning can be challenging and time-consuming. A recently developed real-time inverse treatment planning (IP) by convex optimization has been demonstrated to produce high-quality treatment plans with good conformity and selectivity in single-target plans. We intended to test the capacity of this IP to rapidly generate efficient plans while optimizing the preservation of normal tissue in multiple BM. METHODS Seventy-nine patients (mean age 62.4, age range 22-85) with a total of 272 BMs were treated by Gamma Knife Radiosurgery. All subjects were treated using a forward planning (FP) technique by an expert neurosurgeon. The new Intuitive Plan was applied and able to automatically generate an alternative plan for each patient. All planning variables were collected from the IP to be compared with the corresponding measurements obtained from the FP. A paired sample t test was applied to compare the 2 plans for the following variables: brain volumes receiving 10 Gy (V10) (primary endpoint), and 12 Gy (V12), planning indices (selectivity, coverage, gradient, and Paddick Conformity Index [PCI]), beam-on time (BOT), and integral doses. Additionally, the noninferiority margin for each item was calculated, and the 2 plans were compared for noninferiority using a paired t test. RESULTS The mean age of patients was 62.4 years old (age range 22-85), with a sex ratio of 1.02. The average number of lesions per patient was 3.4 (range 1-12). The mean prescription dose was 21.46 Gy (range 14-24 Gy). Noninferiority of the IP was concluded for V10, V12, prescription isodose volume, BOT, PCI, and selectivity. The V10 (and V12) was significantly lower with the IP (p < 0.001). These volumes were 8.69 cm3 ± 11.39 and 5.47 cm3 ± 7.03, respectively, for the FP and 7.57 cm3 ± 9.44 and 4.78 cm3 ± 5.86 for the IP. Only the coverage was significantly lower with the IP (-2.3%, p < 0.001), but both selectivity (+17%) and PCI (+15%) were significantly higher with the IP than FP (p < 0.001). CONCLUSION This IP demonstrated its capacity to generate multi-target plans rapidly, with a dose to the brain (V10) and BOT noninferior to the one of a human expert planner. These results would benefit from confirmation in a larger prospective series.
Collapse
Affiliation(s)
- Yassine Beltaifa
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix Marseille Université, Marseille, France.,Inserm, L'Institut de Neurosciences des Systèmes (INS, UMR1106), Aix Marseille Université, Marseille, France.,Faculty of Medicine, University of Sousse, Sousse, Tunisia
| | - Hussein Hamdi
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix Marseille Université, Marseille, France.,Inserm, L'Institut de Neurosciences des Systèmes (INS, UMR1106), Aix Marseille Université, Marseille, France.,Neurosurgery Department, Tanta University, Tanta, Egypt
| | - Giorgio Spatola
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix Marseille Université, Marseille, France.,Inserm, L'Institut de Neurosciences des Systèmes (INS, UMR1106), Aix Marseille Université, Marseille, France
| | - Anne Balossier
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix Marseille Université, Marseille, France.,Inserm, L'Institut de Neurosciences des Systèmes (INS, UMR1106), Aix Marseille Université, Marseille, France
| | - Louise Merly
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix Marseille Université, Marseille, France
| | - Laura Castillo
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix Marseille Université, Marseille, France
| | - Axelle Cretol
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix Marseille Université, Marseille, France
| | - Jean Regis
- Department of Functional and Stereotactic Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix Marseille Université, Marseille, France.,Inserm, L'Institut de Neurosciences des Systèmes (INS, UMR1106), Aix Marseille Université, Marseille, France
| |
Collapse
|
11
|
Sayan M, Şahin B, Mustafayev TZ, Kefelioğlu EŞS, Vergalasova I, Gupta A, Balmuk A, Güngör G, Ohri N, Weiner J, Karaarslan E, Özyar E, Atalar B. Risk of symptomatic radiation necrosis in patients treated with stereotactic radiosurgery for brain metastases. ACTA ACUST UNITED AC 2021; 32:261-267. [PMID: 34743823 DOI: 10.1016/j.neucie.2020.08.007] [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: 06/01/2020] [Accepted: 08/31/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTIO Stereotactic radiosurgery (SRS) is a treatment option in the initial management of patients with brain metastases. While its efficacy has been demonstrated in several prior studies, treatment-related complications, particularly symptomatic radiation necrosis (RN), remains as an obstacle for wider implementation of this treatment modality. We thus examined risk factors associated with the development of symptomatic RN in patients treated with SRS for brain metastases. PATIENTS AND METHODS We performed a retrospective review of our institutional database to identify patients with brain metastases treated with SRS. Diagnosis of symptomatic RN was determined by appearance on serial MRIs, MR spectroscopy, requirement of therapy, and the development of new neurological complaints without evidence of disease progression. RESULTS We identified 323 brain metastases treated with SRS in 170 patients from 2009 to 2018. Thirteen patients (4%) experienced symptomatic RN after treatment of 23 (7%) lesions. After SRS, the median time to symptomatic RN was 8.3 months. Patients with symptomatic RN had a larger mean target volume (p<0.0001), and thus larger V100% (p<0.0001), V50% (p<0.0001), V12Gy (p<0.0001), and V10Gy (p=0.0002), compared to the rest of the cohort. Single-fraction treatment (p=0.0025) and diabetes (p=0.019) were also significantly associated with symptomatic RN. CONCLUSION SRS is an effective treatment option for patients with brain metastases; however, a subset of patients may develop symptomatic RN. We found that patients with larger tumor size, larger plan V100%, V50%, V12Gy, or V10Gy, who received single-fraction SRS, or who had diabetes were all at higher risk of symptomatic RN.
Collapse
Affiliation(s)
- Mutlay Sayan
- Department of Radiation Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY, USA.
| | - Bilgehan Şahin
- Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey
| | - Teuta Zoto Mustafayev
- Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey
| | | | - Irina Vergalasova
- Department of Radiation Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Apar Gupta
- Department of Radiation Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Aykut Balmuk
- Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey
| | - Görkem Güngör
- Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey
| | - Nisha Ohri
- Department of Radiation Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Joseph Weiner
- Department of Radiation Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Ercan Karaarslan
- Department of Radiology, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey
| | - Enis Özyar
- Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey
| | - Banu Atalar
- Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey
| |
Collapse
|
12
|
Image-Based Evaluation of Irradiation Effects in Brain Tissues by Measuring Absolute Electrical Conductivity Using MRI. Cancers (Basel) 2021; 13:cancers13215490. [PMID: 34771653 PMCID: PMC8583433 DOI: 10.3390/cancers13215490] [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: 09/19/2021] [Revised: 10/28/2021] [Accepted: 10/29/2021] [Indexed: 11/17/2022] Open
Abstract
Radiation-induced injury is damage to normal tissues caused by unintentional exposure to ionizing radiation. Image-based evaluation of tissue damage by irradiation has an advantage for the early assessment of therapeutic effects by providing sensitive information on minute tissue responses in situ. Recent magnetic resonance (MR)-based electrical conductivity imaging has shown potential as an effective early imaging biomarker for treatment response and radiation-induced injury. However, to be a tool for evaluating therapeutic effects, validation of its reliability and sensitivity according to various irradiation conditions is required. We performed MR-based electrical conductivity imaging on designed phantoms to confirm the effect of ionizing radiation at different doses and on in vivo mouse brains to distinguish tissue response depending on different doses and the elapsed time after irradiation. To quantify the irradiation effects, we measured the absolute conductivity of brain tissues and calculated relative conductivity changes based on the value of pre-irradiation. The conductivity of the phantoms with the distilled water and saline solution increased linearly with the irradiation doses. The conductivity of in vivo mouse brains showed different time-course variations and residual contrast depending on the irradiation doses. Future studies will focus on validation at long-term time points, including early and late delayed response and evaluation of irradiation effects in various tissue types.
Collapse
|
13
|
Significant correlation between gross tumor volume (GTV) D98% and local control in multifraction stereotactic radiotherapy (MF-SRT) for unresected brain metastases. Radiother Oncol 2020; 154:260-268. [PMID: 33245944 DOI: 10.1016/j.radonc.2020.11.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/10/2020] [Accepted: 11/16/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Stereotactic radiotherapy (SRT) should be applied with a biologically effective dose with an α/β of 12 (BED12) ≥ 40 Gy to reach a 1-year local control (LC) ≥ 70%. The aims of this retrospective study were to report a series of 81 unresected large brain metastases treated with Linac-based multifraction SRT according to the ICRU 91 and to identify predictive factors associated with LC. METHODS Included in this study were the first 81 brain metastases (BM) consecutively treated with Linac-based volumetric modulated arc therapy (VMAT) multifraction SRT from 2017 to 2019. The prescribed dose was 33 Gy for the GTV and 23.1 Gy (70% isodose line) for the PTV in 3 fractions (3f). Mean BM largest diameter and GTV were 25.1 mm and 7.2 cc respectively. Mean follow-up was 10.2 months. RESULTS LC was 79.7% and 69.7% at 1 and 2 years respectively. Significant predictive factors of LC were GTV D98% (HR = 0.84, CI 95% = 0.75-0.95, p = 0.004) and adenocarcinoma as the histological type (HR = 0.29, CI 95% = 0.09-0.96, p = 0.042) in univariate and multivariate analysis. A threshold of 29 Gy for GTV D98% was significantly correlated to LC (1-year LC = 91.9% for GTV D98% ≥ 29 Gy vs 69.6% for GTV D98% < 29 Gy (p = 0.030)), corresponding to a BED12 = 52.4 Gy. No tumor progression was observed for a BED12 ≥ 53.4 Gy, corresponding to a GTV D98% ≥ 20 Gy /1f and GTV D98% ≥ 29.4 Gy 3f. Median OS was 15 months. Symptomatic radionecrosis occurred in 4.9% of cases. CONCLUSION The GTV D98% is a strong reproducible significant predictive factor of LC for brain SRT. Dose prescription should lead to a GTV BED12 98% ≥ 52.4-53.4 Gy to significantly improve LC, corresponding to respectively a GTV D98% ≥ 19.7-20 Gy/1f and 29-29.4 Gy/3f.
Collapse
|
14
|
Brun L, Dupic G, Chassin V, Chautard E, Moreau J, Dedieu V, Khalil T, Verrelle P, Lapeyre M, Biau J. Hypofractionated stereotactic radiotherapy for large brain metastases: Optimizing the dosimetric parameters. Cancer Radiother 2020; 25:1-7. [PMID: 33257109 DOI: 10.1016/j.canrad.2020.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/14/2020] [Accepted: 04/27/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE Stereotactic radiotherapy plays a major role in the treatment of brain metastases (BM). We aimed to compare the dosimetric results of four plans for hypofractionated stereotactic radiotherapy (HFSRT) for large brain metastases. MATERIAL AND METHODS Ten patients treated with upfront NovalisTx® non-coplanar multiple dynamic conformal arcs (DCA) HFSRT for≥25mm diameter single BM were included. Three other volumetric modulated arc therapy (VMAT) treatment plans were evaluated: with coplanar arcs (Eclipse®, Varian, VMATcEclipse®), with coplanar and non-coplanar arcs (VMATncEclipse®), and with non-coplanar arcs (Elements Cranial SRS®, Brainlab, VMATncElements®). The marginal dose prescribed for the PTV was 23.1Gy (isodose 70%) in three fractions. The mean GTV was 27mm3. RESULTS Better conformity indices were found with all VMAT techniques compared to DCA (1.05 vs 1.28, P<0.05). Better gradient indices were found with VMATncElements® and DCA (2.43 vs 3.02, P<0.001). High-dose delivery in healthy brain was lower with all VMAT techniques compared to DCA (5.6 to 6.3 cc vs 9.4 cc, P<0.001). Low-dose delivery (V5Gy) was lower with VMATncEclipse® or VMATncElements® than with DCA (81 or 94 cc vs 110 cc, P=0.02). CONCLUSIONS NovalisTx® VMAT HFSRT for≥25mm diameter brain metastases provides the best dosimetric compromise in terms of target coverage, sparing of healthy brain tissue and low-dose delivery compared to DCA.
Collapse
Affiliation(s)
- L Brun
- Department of radiation oncology, Jean-Perrin center, 63011 Clermont-Ferrand, France
| | - G Dupic
- Department of radiation oncology, Jean-Perrin center, 63011 Clermont-Ferrand, France.
| | - V Chassin
- Department of medical physics, Jean-Perrin center, Clermont-Ferrand, France
| | - E Chautard
- Clermont Auvergne university, INSERM, U1240 IMoST, 63000 Clermont-Ferrand, France; Department of pathology, Clermont Auvergne university, Jean-Perrin center, 63011 Clermont-Ferrand, France
| | - J Moreau
- Department of radiation oncology, Jean-Perrin center, 63011 Clermont-Ferrand, France
| | - V Dedieu
- Department of medical physics, Jean-Perrin center, Clermont-Ferrand, France
| | - T Khalil
- Department of neurosurgery, Clermont-Ferrand hospital, 63003 Clermont-Ferrand, France
| | - P Verrelle
- Department of radiation oncology, Jean-Perrin center, 63011 Clermont-Ferrand, France
| | - M Lapeyre
- Department of radiation oncology, Jean-Perrin center, 63011 Clermont-Ferrand, France
| | - J Biau
- Department of radiation oncology, Jean-Perrin center, 63011 Clermont-Ferrand, France; Clermont Auvergne university, INSERM, U1240 IMoST, 63000 Clermont-Ferrand, France
| |
Collapse
|
15
|
Sayan M, Şahin B, Mustafayev TZ, Kefelioğlu EŞS, Vergalasova I, Gupta A, Balmuk A, Güngör G, Ohri N, Weiner J, Karaarslan E, Özyar E, Atalar B. Risk of symptomatic radiation necrosis in patients treated with stereotactic radiosurgery for brain metastases. Neurocirugia (Astur) 2020; 32:S1130-1473(20)30111-1. [PMID: 33082103 DOI: 10.1016/j.neucir.2020.08.009] [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: 06/01/2020] [Revised: 08/05/2020] [Accepted: 08/31/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTIO Stereotactic radiosurgery (SRS) is a treatment option in the initial management of patients with brain metastases. While its efficacy has been demonstrated in several prior studies, treatment-related complications, particularly symptomatic radiation necrosis (RN), remains as an obstacle for wider implementation of this treatment modality. We thus examined risk factors associated with the development of symptomatic RN in patients treated with SRS for brain metastases. PATIENTS AND METHODS We performed a retrospective review of our institutional database to identify patients with brain metastases treated with SRS. Diagnosis of symptomatic RN was determined by appearance on serial MRIs, MR spectroscopy, requirement of therapy, and the development of new neurological complaints without evidence of disease progression. RESULTS We identified 323 brain metastases treated with SRS in 170 patients from 2009 to 2018. Thirteen patients (4%) experienced symptomatic RN after treatment of 23 (7%) lesions. After SRS, the median time to symptomatic RN was 8.3 months. Patients with symptomatic RN had a larger mean target volume (p<0.0001), and thus larger V100% (p<0.0001), V50% (p<0.0001), V12Gy (p<0.0001), and V10Gy (p=0.0002), compared to the rest of the cohort. Single-fraction treatment (p=0.0025) and diabetes (p=0.019) were also significantly associated with symptomatic RN. CONCLUSION SRS is an effective treatment option for patients with brain metastases; however, a subset of patients may develop symptomatic RN. We found that patients with larger tumor size, larger plan V100%, V50%, V12Gy, or V10Gy, who received single-fraction SRS, or who had diabetes were all at higher risk of symptomatic RN.
Collapse
Affiliation(s)
- Mutlay Sayan
- Department of Radiation Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY, USA.
| | - Bilgehan Şahin
- Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey
| | - Teuta Zoto Mustafayev
- Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey
| | | | - Irina Vergalasova
- Department of Radiation Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Apar Gupta
- Department of Radiation Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Aykut Balmuk
- Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey
| | - Görkem Güngör
- Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey
| | - Nisha Ohri
- Department of Radiation Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Joseph Weiner
- Department of Radiation Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Ercan Karaarslan
- Department of Radiology, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey
| | - Enis Özyar
- Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey
| | - Banu Atalar
- Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey
| |
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
Stereotactic Radiotherapy for Brain Metastases: Imaging Tools and Dosimetric Predictive Factors for Radionecrosis. J Pers Med 2020; 10:jpm10030059. [PMID: 32635476 PMCID: PMC7565332 DOI: 10.3390/jpm10030059] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/21/2020] [Accepted: 07/02/2020] [Indexed: 12/29/2022] Open
Abstract
Radionecrosis (RN) is the most important side effect after stereotactic radiotherapy (SRT) for brain metastases, with a reported incidence ranging from 3% to 24%. To date, there are no unanimously accepted criteria for iconographic diagnosis of RN, as well as no definitive dose-constraints correlated with the onset of this late effect. We reviewed the current literature and gave an overview report on imaging options for the diagnosis of RN and on dosimetric parameters correlated with the onset of RN. We performed a PubMed literature search according to the preferred reporting items and meta-analysis (PRISMA) guidelines, and identified articles published within the last ten years, up to 31 December 2019. When analyzing data on diagnostic tools, perfusion magnetic resonance imaging (MRI) seems to be very useful allowing evaluation of the blood flow in the lesion using the relative cerebral blood volume (rCBV) and blood vessel integrity using relative peak weight (rPH). It is necessary to combine morphological with functional imaging in order to match information about lesion morphology, metabolism and blood-flow. Eventually, serial imaging follow-up is needed. Regarding dosimetric parameters, in radiosurgery (SRS) V12 < 8 cm3 and V10 < 10.5 cm3 of normal brain are the most reliable prognostic factors, whereas in hypo-fractionated stereotactic radiotherapy (HSRT) V18 and V21 are considered the main predictive independent risk factors of RN.
Collapse
|
18
|
Xu Q, Luo D, Mulvihill D, Goldman W, Turtz A, Kubicek GJ. Dosimetric comparison of inverse and forward planning for Gamma Knife stereotactic radiosurgery of brain metastases. Med Dosim 2020; 45:317-320. [PMID: 32522429 DOI: 10.1016/j.meddos.2020.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/03/2020] [Accepted: 03/17/2020] [Indexed: 11/16/2022]
Abstract
The Leksell GammaPlan (LGP) with an inverse planning (IP) tool has been upgraded to version 11.1 since its launch in 2010. We evaluated its IP planning performance by re-planning 16 targets that had been planned using forward planning (FP). The FP and IP plans were compared. A planning guideline for IP process was developed aiming for an unbiased comparison. Sixteen brain metastases (BMs) without nearby critical structures were included in the study (size > 1 cm for all targets). All prior FP were re-planned in the LGP using IP and maintaining the same beam-on time and coverage. The dose to all the targets was scaled to 20 Gy in a single fraction at 50% isodose line (IDL) for FP and IP comparison purpose. The coverage and beam-on time were nearly the same for both the FP and IP plans. For all the IP plans, the mean selectivity was 0.85 ± 0.04 (vs 0.83 ± 0.04 in FP plans, p = 0.02), the mean GI was 2.92 ± 0.21 (vs 3.18 ± 0.60 in FP plans, p = 0.047), the mean V12Gy was 8.18 ± 8.57 cc (vs 9.09 ± 9.08 cc in FP plans, p = 0.001), the mean V8Gy was 14.63 ± 15.14 cc (vs 16.34 ± 16.17 cc in FP plans, p = 0.001), and the mean V5Gy was 29.01 ± 28.77 cc (vs 32.77 ± 31.41 cc in FP plans, p = 0.001). The number of shots was higher in IP plans (means of 16.69 ± 8.11 vs 10.81 ± 6.87 in FP plans, p = 0.001). We retrospectively re-planned 16 FP plans using the IP tool while meeting the quality limiting factors for the FP plans. The dosimetry parameters from the IP plans outperformed the treated FP plans and the IP tool should be preferred for tumors with size > 1 cm.
Collapse
Affiliation(s)
- Qianyi Xu
- Department of Radiation Oncology, MD Anderson Cancer Center at Cooper, Camden, NJ.
| | - Dershan Luo
- Department of Radiation Physics, UT MD Anderson Cancer Center, Houston, TX
| | - David Mulvihill
- Department of Radiation Oncology, MD Anderson Cancer Center at Cooper, Camden, NJ
| | - Warren Goldman
- Department of Neurosurgery, Cooper Medical School, Rowan University, Camden, NJ
| | - Alan Turtz
- Department of Neurosurgery, Cooper Medical School, Rowan University, Camden, NJ
| | - Gregory J Kubicek
- Department of Radiation Oncology, MD Anderson Cancer Center at Cooper, Camden, NJ
| |
Collapse
|
19
|
Opposits G, Aranyi C, Glavák C, Cselik Z, Trón L, Sipos D, Hadjiev J, Berényi E, Repa I, Emri M, Kovács Á. OAR sparing 3D radiotherapy planning supported by fMRI brain mapping investigations. Med Dosim 2020; 45:e1-e8. [PMID: 32505630 DOI: 10.1016/j.meddos.2020.04.003] [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: 12/06/2019] [Revised: 03/21/2020] [Accepted: 04/08/2020] [Indexed: 11/28/2022]
Abstract
The human brain as an organ has numerous functions; some of them can be visualized by functional imaging techniques (e.g., functional MRI [fMRI] or positron emission tomography). The localization of the appropriate activity clusters requires sophisticated instrumentation and complex measuring protocol. As the inclusion of the activation pattern in modern self-tailored 3D based radiotherapy has notable advantages, this method is applied frequently. Unfortunately, no standardized method has been published yet for the integration of the fMRI data into the planning process and the detailed description of the individual applications is usually missing. Thirteen patients with brain tumors, receiving fMRI based RT planning were enrolled in this study. The delivered dose maps were exported from the treatment planning system and processed for further statistical analysis. Two parameters were introduced to measure the geometrical distance Hausdorff Distance (HD), and volumetric overlap Dice Similarity Coefficient (DSC) of fMRI corrected and not corrected dose matrices as calculated by 3D planning to characterize similarity and/or dissimilarity of these dose matrices. Statistical analysis of bootstrapped HD and DSC data was performed to determine confidence intervals of these parameters. The calculated confidence intervals for HD and DSC were (5.04, 7.09), (0.79, 0.86), respectively for the 40 Gy and (5.2, 7.85), (0.74, 0.83), respectively for the 60 Gy dose volumes. These data indicate that in the case of HD < 5.04 and/or DSC > 0.86, the 40 Gy dose volumes obtained with and without fMRI activation pattern do not show a significant difference (5% significance level). The same conditions for the 60 Gy dose volumes were HD < 5.2 and/or DSC > 0.83. At the same time, with HD > 7.09 and/or DSC < 0.79 for 40 Gy and HD > 7.85 and/or DSC < 0.74 for 60 Gy the impact of fMRI utilization in RT planning is excessive. The fMRI activation clusters can be used in daily RT planning routine to spare activation clusters as critical areas in the brain and avoid their high dose irradiation. Parameters HD (as distance) and DSC (as overlap) can be used to characterize the difference and similarity between the radiotherapy planning target volumes and indicate whether the fMRI delivered activation patterns and consequent fMRI corrected planning volumes are reliable or not.
Collapse
Affiliation(s)
- Gábor Opposits
- University of Debrecen, Faculty of Medicine, Department of Medical Imaging, Division of Nuclear Medicine and Translational Imaging, Nagyerdei krt. 98., Debrecen 4032, Hungary.
| | - Csaba Aranyi
- University of Debrecen, Faculty of Medicine, Department of Medical Imaging, Division of Nuclear Medicine and Translational Imaging, Nagyerdei krt. 98., Debrecen 4032, Hungary
| | - Csaba Glavák
- Kaposi Somogy County Teaching Hospital Dr. József Baka Diagnostic, Radiation Oncology, Research and Teaching Center, Kaposvár, Hungary
| | - Zsolt Cselik
- Veszprém County Hospital, Oncoradiology, Veszprém, Hungary
| | - Lajos Trón
- University of Debrecen, Faculty of Medicine, Department of Medical Imaging, Division of Nuclear Medicine and Translational Imaging, Nagyerdei krt. 98., Debrecen 4032, Hungary
| | - Dávid Sipos
- Kaposi Somogy County Teaching Hospital Dr. József Baka Diagnostic, Radiation Oncology, Research and Teaching Center, Kaposvár, Hungary; University of Pécs Doctoral School of Health Sciences, Pécs, Hungary
| | - Janaki Hadjiev
- Kaposi Somogy County Teaching Hospital Dr. József Baka Diagnostic, Radiation Oncology, Research and Teaching Center, Kaposvár, Hungary
| | - Ervin Berényi
- University of Debrecen, Faculty of Medicine, Department of Medical Imaging, Division of Nuclear Medicine and Translational Imaging, Nagyerdei krt. 98., Debrecen 4032, Hungary
| | - Imre Repa
- Kaposi Somogy County Teaching Hospital Dr. József Baka Diagnostic, Radiation Oncology, Research and Teaching Center, Kaposvár, Hungary
| | - Miklós Emri
- University of Debrecen, Faculty of Medicine, Department of Medical Imaging, Division of Nuclear Medicine and Translational Imaging, Nagyerdei krt. 98., Debrecen 4032, Hungary
| | - Árpád Kovács
- University of Debrecen, Faculty of Medicine, Department of Oncoradiology, Debrecen, Hungary; Kaposi Somogy County Teaching Hospital Dr. József Baka Diagnostic, Radiation Oncology, Research and Teaching Center, Kaposvár, Hungary; University of Pécs Doctoral School of Health Sciences, Pécs, Hungary
| |
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
Noel G, Keller A, Antoni D. [Stereotactic radiotherapy of brain metastases in complex situations]. Cancer Radiother 2019; 23:708-715. [PMID: 31477442 DOI: 10.1016/j.canrad.2019.07.146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 07/11/2019] [Indexed: 02/07/2023]
Abstract
Stereotactic radiation therapy of brain metastases is a treatment recognized as effective, well tolerated, applicable for therapeutic indications codified and validated by national and international guidelines. However, the effectiveness of this irradiation, the evolution of patient care and the technical improvements enabling its implementation make it possible to consider it in more complex situations: proximity of brain metastases to organs at risk; large, cystic, haemorrhagic or multiple brain metastases, combination with targeted therapies and immunotherapy, stereotactic radiotherapy in patients with a pacemaker. This article aims to put forward the arguments available to date in the literature and those resulting from clinical practice to provide decision support for the radiation oncologists.
Collapse
Affiliation(s)
- G Noel
- Department of radiotherapy, comprehensive cancer center Paul-Strauss, UNICANCER, 3, rue de la porte de l'Hôpital, 67065 Strasbourg cedex, France; Strasbourg University, CNRS, IPHC UMR 7178, Centre Paul-Strauss, UNICANCER, 67000 Strasbourg, France.
| | - A Keller
- Department of radiotherapy, comprehensive cancer center Paul-Strauss, UNICANCER, 3, rue de la porte de l'Hôpital, 67065 Strasbourg cedex, France
| | - D Antoni
- Department of radiotherapy, comprehensive cancer center Paul-Strauss, UNICANCER, 3, rue de la porte de l'Hôpital, 67065 Strasbourg cedex, France; Strasbourg University, CNRS, IPHC UMR 7178, Centre Paul-Strauss, UNICANCER, 67000 Strasbourg, France
| |
Collapse
|
22
|
Dose Hypofractionated Stereotactic Radiotherapy for Intracranial Arteriovenous Malformations: A Case Series and Review of the Literature. World Neurosurg 2019; 126:e1456-e1467. [DOI: 10.1016/j.wneu.2019.03.119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 11/17/2022]
|
23
|
|
24
|
Kailaya-Vasan A, Samuthrat T, Walsh DC. Severe adverse radiation effects complicating radiosurgical treatment of brain arteriovenous malformations and the potential benefit of early surgical treatment. J Clin Neurosci 2018; 55:25-31. [PMID: 30029956 DOI: 10.1016/j.jocn.2018.06.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 06/06/2018] [Indexed: 10/28/2022]
Abstract
Treatment of brain arteriovenous malformations (AVM) with stereotactic radiosurgery is rarely complicated by severe adverse radiation effects (ARE). The treatment of these sequelae is varied and often ineffectual. We present three cases of brain AVMs treated with SRS, all complicated by severe AREs. All three cases failed to respond to what is currently considered the standard treatment - corticosteroids - and indeed one patient died as a result of the side effects of their extended use. Two cases were successfully treated with surgical excision of the necrotic lesion resulting in immediate clinical improvement. Having considered the experience described in this paper and reviewed the published literature to date we suggest that surgical treatment of AREs should be considered early in the management of this condition should steroid therapy not result in early improvement.
Collapse
Affiliation(s)
- Ahilan Kailaya-Vasan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK.
| | - Thiti Samuthrat
- The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Daniel C Walsh
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK; Institute of Psychiatry, King's College London, DeCrespigny Park, London, UK
| |
Collapse
|
25
|
Meneghelli P, Pasqualin A, Zampieri P, Longhi M, Foroni R, Sini A, Tommasi N, Nicolato A. Surgical Management of Adverse Radiation Effects After Gamma Knife Radiosurgery for Cerebral Arteriovenous Malformations: A Population-Based Cohort Study. World Neurosurg 2018; 114:e840-e850. [PMID: 29572169 DOI: 10.1016/j.wneu.2018.03.097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 03/12/2018] [Accepted: 03/14/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The goal of this study is to report our experience in the surgical treatment of cerebral arteriovenous malformations (cAVMs) related permanent symptomatic adverse radiation effects (PSAREs), to clarify an appropriate surgical management and to identify the risk factors related to their development. METHODS We evaluated 549 patients treated with Gamma Knife radiosurgery (GKRS) for cAVMs with a follow-up of at least 8 years. Univariate and multivariate analyses were used to test different risk factors related to the development of PSARE. We retrospectively reviewed the records of these patients to analyze the clinical outcome. RESULTS Fourteen patients (2.5%) developed PSARE and were submitted to surgery. Higher average treated volume represents a significant risk factors for the development of PSARE (P < 0.05); on the other hand, older age and higher average dose reduce the risk of PSARE (P < 0.05). A favorable clinical outcome was achieved in 13 patients (93%) after surgery; in 1 patient, the unfavorable outcome was due to hemorrhage that occurred months after GKRS. Serial MRI scans following either surgical removal of the nodule or Ommaya reservoir positioning showed progressive reduction of brain edema in all cases. CONCLUSIONS The management of PSARE is controversial, especially for cAVMs treated with SRS. Surgical removal is rarely needed, but-if unavoidable-it can be a valuable option in experienced hands. A careful preoperative planning is always necessary to detect pathologic blood flow through the PSARE.
Collapse
Affiliation(s)
- Pietro Meneghelli
- Institute of Neurosurgery, University and City Hospital, Verona, Italy.
| | - Alberto Pasqualin
- Section of Vascular Neurosurgery, Institute of Neurological Surgery, University and City Hospital, Verona, Italy
| | - Piergiuseppe Zampieri
- Section of Neuroradiology, Department of Diagnosis and Pathology, University and City Hospital, Verona, Italy
| | - Michele Longhi
- Section of Radiosurgery and Stereotactic Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Roberto Foroni
- Section of Radiosurgery and Stereotactic Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Antonio Sini
- Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Nicola Tommasi
- Centro interdipartimentale di documentazione economica, University of Verona, Verona, Italy
| | - Antonio Nicolato
- Section of Radiosurgery and Stereotactic Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy
| |
Collapse
|
26
|
Xu Q, Fan J, Grimm J, LaCouture T, Asbell S, Park JH, Kubicek G. The dosimetric impact of the prescription isodose line (IDL) on the quality of robotic stereotactic radiosurgery (SRS) plans. Med Phys 2017; 44:6159-6165. [DOI: 10.1002/mp.12630] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 09/13/2017] [Accepted: 10/09/2017] [Indexed: 01/11/2023] Open
Affiliation(s)
- Qianyi Xu
- Department of Radiation Oncology; MD Anderson Cancer Center at Cooper; Camden NJ 08103 USA
| | - Jiajin Fan
- Department of Radiation Oncology; Fox Chase Cancer Center; Philadelphia PA 19111 USA
| | - Jimm Grimm
- Department of Radiation Oncology; Johns Hopkins University; Baltimore MD 21231 USA
| | - Tamara LaCouture
- Department of Radiation Oncology; Kennedy Health System; Sewell NJ 08080 USA
| | - Sucha Asbell
- Department of Radiation Oncology; MD Anderson Cancer Center at Cooper; Camden NJ 08103 USA
| | - Joo Han Park
- Department of Radiation Oncology; MD Anderson Cancer Center at Cooper; Camden NJ 08103 USA
| | - Gregory Kubicek
- Department of Radiation Oncology; MD Anderson Cancer Center at Cooper; Camden NJ 08103 USA
| |
Collapse
|
27
|
Hellerbach A, Luyken K, Hoevels M, Gierich A, Rueß D, Baus WW, Kocher M, Ruge MI, Treuer H. Radiotoxicity in robotic radiosurgery: proposing a new quality index for optimizing the treatment planning of brain metastases. Radiat Oncol 2017; 12:136. [PMID: 28818094 PMCID: PMC5561581 DOI: 10.1186/s13014-017-0867-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 08/09/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND As irradiated brain volume at 12 Gy (V12) is a predictor for radionecrosis, the purpose of the study was to develop a model for Cyberknife (CK) plans that is able to predict the lowest achievable V12 at a given tumor size and prescription dose (PD), and to suggest a new quality index regarding V12 for optimizing the treatment planning of brain metastases. METHOD In our model V12 was approximated as a spherical shell around the tumor volume. The radial distance between tumor surface and the 12 Gy isodose line was calculated using an approximation of the mean dose gradient in that area. Assuming a radially symmetrical irradiation from the upper half space, the dose distribution is given by the superposition of single fields. The dose profiles of a single field were derived by the measured off-center ratios (OCR) of the CK system. Using the calculated gradients of the sum dose profiles, minimal-V12 was estimated for different tumor sizes. The model calculation was tested using a phantom dataset and retrospectively applied on clinical cases. RESULTS Our model allows the prediction of a best-case scenario for V12 at a given tumor size and PD which was confirmed by the results of the isocentric phantom plans. The results of the non-isocentric phantom plans showed that an optimization of coverage caused an increase in V12. This was in accordance with the results of the retrospective analysis. V12 s of the clinical cases were on average twice that of the predicted model calculation. A good agreement was achieved for plans with an optimal conformity index (nCI). Re-planning of cases with high V12 showed that lower values could be reached by selecting smaller collimators and by allowing a larger number of total MU and more MU per beam. CONCLUSIONS V12 is a main parameter for assessing plan quality in terms of radiotoxicity. The index f12 defined as the ratio of V12 from the actual plan with the evaluated V12 from our model describes the conformity of an optimally possible V12 and thus can be used as a new quality index for optimizing treatment plans.
Collapse
Affiliation(s)
- Alexandra Hellerbach
- Department of Stereotaxy and Functional Neurosurgery, University Hospital Cologne, Cologne, Germany
| | - Klaus Luyken
- Department of Stereotaxy and Functional Neurosurgery, University Hospital Cologne, Cologne, Germany
| | - Mauritius Hoevels
- Department of Stereotaxy and Functional Neurosurgery, University Hospital Cologne, Cologne, Germany
| | - Andreas Gierich
- Department of Stereotaxy and Functional Neurosurgery, University Hospital Cologne, Cologne, Germany
| | - Daniel Rueß
- Department of Stereotaxy and Functional Neurosurgery, University Hospital Cologne, Cologne, Germany
| | - Wolfgang W. Baus
- Department of Radiotherapy, University Hospital Cologne, Cologne, Germany
| | - Martin Kocher
- Department of Radiotherapy, University Hospital Cologne, Cologne, Germany
| | - Maximilian I. Ruge
- Department of Stereotaxy and Functional Neurosurgery, University Hospital Cologne, Cologne, Germany
| | - Harald Treuer
- Department of Stereotaxy and Functional Neurosurgery, University Hospital Cologne, Cologne, Germany
| |
Collapse
|
28
|
Hatiboglu MA, Akdur K. Evaluating Critical Brain Radiation Doses in the Treatment of Multiple Brain Lesions with Gamma Knife Radiosurgery. Stereotact Funct Neurosurg 2017; 95:268-278. [DOI: 10.1159/000478272] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 06/08/2017] [Indexed: 11/19/2022]
|
29
|
Keller A, Doré M, Antoni D, Menoux I, Thillays F, Clavier JB, Delpon G, Jarnet D, Bourrier C, Lefebvre F, Chibbaro S, Darié I, Proust F, Noël G. [Risk of radionecrosis after hypofractionated stereotactic radiotherapy targeting the postoperative resection cavity of brain metastases]. Cancer Radiother 2017; 21:377-388. [PMID: 28551018 DOI: 10.1016/j.canrad.2017.01.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 01/02/2017] [Accepted: 01/31/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To investigate the factors that potentially lead to brain radionecrosis after hypofractionated stereotactic radiotherapy targeting the postoperative resection cavity of brain metastases. METHODS AND MATERIALS A retrospective analysis conducted in two French centres, was performed in patients treated with trifractionated stereotactic radiotherapy (3×7.7Gy prescribed to the 70% isodose line) for resected brain metastases. Patients with previous whole-brain irradiation were excluded of the analysis. Radionecrosis was diagnosed according to a combination of criteria including clinical, serial imaging or, in some cases, histology. Univariate and multivariate analyses were performed to determine the predictive factors of radionecrosis including clinical and dosimetric variables such as volume of brain receiving a specific dose (V8Gy-V22Gy). RESULTS One hundred eighty-one patients, with a total of 189 cavities were treated between March 2008 and February 2015. Thirty-five patients (18.5%) developed radionecrosis after a median follow-up of 15 months (range: 3-38 months) after hypofractionated stereotactic radiotherapy. One third of patients with radionecrosis were symptomatic. Multivariate analysis showed that infra-tentorial location was predictive of radionecrosis (hazard ratio [HR]: 2.97; 95% confidence interval [95% CI]: 1.47-6.01; P=0.0025). None V8Gy-V22Gy was associated with appearance of radionecrosis, even if V14Gy trended toward significance (P=0.059). CONCLUSION Analysis of patients and treatment variables revealed that infratentorial location of brain metastases was predictive for radionecrosis after hypofractionated stereotactic radiotherapy for postoperative resection cavities.
Collapse
Affiliation(s)
- A Keller
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France
| | - M Doré
- Département de radiothérapie, institut de cancérologie de l'Ouest, boulevard Jacques-Monod, 44805 Saint-Herblain, France
| | - D Antoni
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France; Laboratoire EA 3430, fédération de médecine translationnelle de Strasbourg, université de Strasbourg, 67000 Strasbourg, France
| | - I Menoux
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France
| | - F Thillays
- Département de radiothérapie, institut de cancérologie de l'Ouest, boulevard Jacques-Monod, 44805 Saint-Herblain, France
| | - J B Clavier
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France
| | - G Delpon
- Département de radiothérapie, institut de cancérologie de l'Ouest, boulevard Jacques-Monod, 44805 Saint-Herblain, France
| | - D Jarnet
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France
| | - C Bourrier
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France
| | - F Lefebvre
- Laboratoire de biostatistiques, faculté de médecine, 4, rue Kirschleger, 67085 Strasbourg cedex, France
| | - S Chibbaro
- Département de neurochirurgie, hôpital de Hautepierre, avenue Molière, 67200 Strasbourg, France
| | - I Darié
- Service de neurochirurgie, centre hospitalier régional d'Orléans, 1, rue Porte-Madeleine, 45000 Orléans, France
| | - F Proust
- Département de neurochirurgie, hôpital de Hautepierre, avenue Molière, 67200 Strasbourg, France
| | - G Noël
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France; Laboratoire EA 3430, fédération de médecine translationnelle de Strasbourg, université de Strasbourg, 67000 Strasbourg, France.
| |
Collapse
|
30
|
Kano H, Flickinger JC, Tonetti D, Hsu A, Yang HC, Flannery TJ, Niranjan A, Lunsford LD. Estimating the Risks of Adverse Radiation Effects After Gamma Knife Radiosurgery for Arteriovenous Malformations. Stroke 2017; 48:84-90. [DOI: 10.1161/strokeaha.116.014825] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/08/2016] [Accepted: 10/18/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
We evaluated risk factors associated with the development of adverse radiation effects (ARE) after stereotactic radiosurgery (SRS) for cerebral arteriovenous malformations (AVMs).
Methods—
We evaluated 755 patients with AVM who underwent a single Gamma Knife SRS procedure with at least a 2-year minimum follow-up. Eighty-seven patients (12%) underwent previous resection and 128 (17%) had previous embolization. The median target volume was 3.6 mL (range, 0.1–26.3 mL). The median margin dose was 20 Gy (range, 13–27 Gy).
Results—
Fifty-five patients (7%) developed symptomatic ARE at a median follow-up of 75 months. The cumulative rates of symptomatic ARE were 3.2%, 5.8%, 6.7%, and 7.5% at 1, 2, 3, and 5 years, respectively. Factors associated with a higher rate of developing symptomatic ARE included larger AVM volume, higher margin dose, larger 12-Gy volume, higher Spetzler–Martin grade, and higher radiosurgery-based score. The rates of developing symptomatic ARE were higher in the brain stem (22%) or thalamus (16%), compared with AVMs located in other brain locations (4%–8%). Nineteen patients (3%) sustained irreversible new neurological deficits related to ARE, and 1 patient died. The rates of irreversible symptomatic ARE were 0.8%, 1.9%, 2.1%, and 2.8% at 1, 2, 3, and 5 years, respectively. The 5-year cumulative rates of irreversible symptomatic ARE were 9.1% in thalamus, 12.1% in brain stem, and 1.4% in other locations.
Conclusions—
The knowledge of ARE risk rates after AVM radiosurgery can assist informed consent for patients with AVM, their families, and healthcare providers.
Collapse
Affiliation(s)
- Hideyuki Kano
- From the Departments of Neurological Surgery (H.K., D.T., A.H., H.-c.Y., T.J.F., A.N., L.D.L.), Radiation Oncology (J.C.F.), and the Center for Image-Guided Neurosurgery (H.K., J.C.F., D.T., A.H., H.-c.Y., T.J.F., A.N., L.D.L.), University of Pittsburgh School of Medicine, PA
| | - John C. Flickinger
- From the Departments of Neurological Surgery (H.K., D.T., A.H., H.-c.Y., T.J.F., A.N., L.D.L.), Radiation Oncology (J.C.F.), and the Center for Image-Guided Neurosurgery (H.K., J.C.F., D.T., A.H., H.-c.Y., T.J.F., A.N., L.D.L.), University of Pittsburgh School of Medicine, PA
| | - Daniel Tonetti
- From the Departments of Neurological Surgery (H.K., D.T., A.H., H.-c.Y., T.J.F., A.N., L.D.L.), Radiation Oncology (J.C.F.), and the Center for Image-Guided Neurosurgery (H.K., J.C.F., D.T., A.H., H.-c.Y., T.J.F., A.N., L.D.L.), University of Pittsburgh School of Medicine, PA
| | - Alan Hsu
- From the Departments of Neurological Surgery (H.K., D.T., A.H., H.-c.Y., T.J.F., A.N., L.D.L.), Radiation Oncology (J.C.F.), and the Center for Image-Guided Neurosurgery (H.K., J.C.F., D.T., A.H., H.-c.Y., T.J.F., A.N., L.D.L.), University of Pittsburgh School of Medicine, PA
| | - Huai-che Yang
- From the Departments of Neurological Surgery (H.K., D.T., A.H., H.-c.Y., T.J.F., A.N., L.D.L.), Radiation Oncology (J.C.F.), and the Center for Image-Guided Neurosurgery (H.K., J.C.F., D.T., A.H., H.-c.Y., T.J.F., A.N., L.D.L.), University of Pittsburgh School of Medicine, PA
| | - Thomas J. Flannery
- From the Departments of Neurological Surgery (H.K., D.T., A.H., H.-c.Y., T.J.F., A.N., L.D.L.), Radiation Oncology (J.C.F.), and the Center for Image-Guided Neurosurgery (H.K., J.C.F., D.T., A.H., H.-c.Y., T.J.F., A.N., L.D.L.), University of Pittsburgh School of Medicine, PA
| | - Ajay Niranjan
- From the Departments of Neurological Surgery (H.K., D.T., A.H., H.-c.Y., T.J.F., A.N., L.D.L.), Radiation Oncology (J.C.F.), and the Center for Image-Guided Neurosurgery (H.K., J.C.F., D.T., A.H., H.-c.Y., T.J.F., A.N., L.D.L.), University of Pittsburgh School of Medicine, PA
| | - L. Dade Lunsford
- From the Departments of Neurological Surgery (H.K., D.T., A.H., H.-c.Y., T.J.F., A.N., L.D.L.), Radiation Oncology (J.C.F.), and the Center for Image-Guided Neurosurgery (H.K., J.C.F., D.T., A.H., H.-c.Y., T.J.F., A.N., L.D.L.), University of Pittsburgh School of Medicine, PA
| |
Collapse
|
31
|
A comparison of clinical and radiologic outcomes between frame-based and frameless stereotactic radiosurgery for brain metastases. Pract Radiat Oncol 2016; 6:e283-e290. [DOI: 10.1016/j.prro.2016.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 04/26/2016] [Accepted: 05/05/2016] [Indexed: 11/18/2022]
|
32
|
[Imaging methods used in the differential diagnosis between brain tumour relapse and radiation necrosis after stereotactic radiosurgery of brain metastases: Literature review]. Cancer Radiother 2016; 20:837-845. [PMID: 28270324 DOI: 10.1016/j.canrad.2016.07.098] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 06/22/2016] [Accepted: 07/01/2016] [Indexed: 11/20/2022]
Abstract
After stereotactic radiosurgery for a cerebral metastasis, one of the dreaded toxicities is radionecrosis. In the follow-up of these patients, it is impossible to distinguish radiation necrosis from tumour relapse either clinically or with MRI. In current practice, many imaging methods are designed such as special sequences of MRI (dynamic susceptibility contrast perfusion and susceptibility-weighted imaging, diffusion), proton magnetic resonance spectroscopy, positron emission tomography, or more seldom 201-thallium single-photon emission computerized tomography. This article is a required literature analysis in order to establish a decision tree with the analysis of retrospective and prospective data.
Collapse
|
33
|
Optimization of Treatment Geometry to Reduce Normal Brain Dose in Radiosurgery of Multiple Brain Metastases with Single-Isocenter Volumetric Modulated Arc Therapy. Sci Rep 2016; 6:34511. [PMID: 27688047 PMCID: PMC5043272 DOI: 10.1038/srep34511] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 09/15/2016] [Indexed: 11/09/2022] Open
Abstract
Treatment of patients with multiple brain metastases using a single-isocenter volumetric modulated arc therapy (VMAT) has been shown to decrease treatment time with the tradeoff of larger low dose to the normal brain tissue. We have developed an efficient Projection Summing Optimization Algorithm to optimize the treatment geometry in order to reduce dose to normal brain tissue for radiosurgery of multiple metastases with single-isocenter VMAT. The algorithm: (a) measures coordinates of outer boundary points of each lesion to be treated using the Eclipse Scripting Application Programming Interface, (b) determines the rotations of couch, collimator, and gantry using three matrices about the cardinal axes, (c) projects the outer boundary points of the lesion on to Beam Eye View projection plane, (d) optimizes couch and collimator angles by selecting the least total unblocked area for each specific treatment arc, and (e) generates a treatment plan with the optimized angles. The results showed significant reduction in the mean dose and low dose volume to normal brain, while maintaining the similar treatment plan qualities on the thirteen patients treated previously. The algorithm has the flexibility with regard to the beam arrangements and can be integrated in the treatment planning system for clinical application directly.
Collapse
|
34
|
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.
Collapse
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
| |
Collapse
|
35
|
Le Rhun E, Dhermain F, Vogin G, Reyns N, Metellus P. Radionecrosis after stereotactic radiotherapy for brain metastases. Expert Rev Neurother 2016; 16:903-14. [DOI: 10.1080/14737175.2016.1184572] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
|
36
|
Minniti G, Scaringi C, Paolini S, Clarke E, Cicone F, Esposito V, Romano A, Osti M, Enrici RM. Repeated stereotactic radiosurgery for patients with progressive brain metastases. J Neurooncol 2015; 126:91-97. [DOI: 10.1007/s11060-015-1937-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 09/08/2015] [Indexed: 11/25/2022]
|
37
|
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.
Collapse
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.
| |
Collapse
|
38
|
Changes in functional MRI signals after 3D based radiotherapy of glioblastoma multiforme. J Neurooncol 2015; 125:157-66. [DOI: 10.1007/s11060-015-1882-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 08/08/2015] [Indexed: 10/23/2022]
|
39
|
El Majdoub F, Hunsche S, Igressa A, Kocher M, Sturm V, Maarouf M. Stereotactic LINAC-Radiosurgery for Glomus Jugulare Tumors: A Long-Term Follow-Up of 27 Patients. PLoS One 2015; 10:e0129057. [PMID: 26069957 PMCID: PMC4466539 DOI: 10.1371/journal.pone.0129057] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 05/04/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The optimal treatment of glomus jugulare tumors (GJTs) remains controversial. Due to the critical location, microsurgery still provides high treatment-related morbidity and a decreased quality of life. Thus, we performed stereotactical radiosurgery (SRS) for the treatment of GJTs and evaluated the long-term outcome. METHODS Between 1991 and 2011, 32 patients with GJTs underwent SRS using a linear accelerator (LINAC) either as primary or salvage therapy. Twenty-seven patients (median age 59.9 years, range 28.7-79.9 years) with a follow-up greater than five years (median 11 years, range 5.3-22.1 years) were selected for retrospective analysis. The median therapeutic single dose applied to the tumor surface was 15 Gy (range 11-20 Gy) and the median tumor volume was 9.5 ml (range 2.8-51 ml). RESULTS Following LINAC-SRS, 10 of 27 patients showed a significant improvement of their previous neurological complaints, whereas 12 patients remained unchanged. Five patients died during follow-up due to old age or other, not treatment-related reasons. MR-imaging showed a partial remission in 12 and a stable disease in 15 patients. No tumor progression was observed. The actuarial overall survival rates after five, ten and 20 years were 100%, 95.2% and 79.4%, respectively. CONCLUSIONS Stereotactic LINAC-Radiosurgery can achieve an excellent long-term tumor control beside a low rate of morbidity in the treatment of GJTs. It should be considered as an alternative therapy regime to surgical resection or fractionated external beam radiation either as primary, adjuvant or salvage therapy.
Collapse
Affiliation(s)
- Faycal El Majdoub
- Department of Stereotaxy and Functional Neurosurgery, University Hospital of Cologne, Cologne, Germany
- Department of Stereotaxy and Functional Neurosurgery, University of Witten-Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany
- * E-mail:
| | - Stefan Hunsche
- Department of Stereotaxy and Functional Neurosurgery, University Hospital of Cologne, Cologne, Germany
- Department of Stereotaxy and Functional Neurosurgery, University of Witten-Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany
| | - Alhadi Igressa
- Department of Neurosurgery, University of Witten-Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany
| | - Martin Kocher
- Department of Radiation Oncology, University Hospital of Cologne, Cologne, Germany
| | - Volker Sturm
- Department of Stereotaxy and Functional Neurosurgery, University Hospital of Cologne, Cologne, Germany
- Department of Neurosurgery, University Hospital of Wurzburg, Wurzburg, Germany
| | - Mohammad Maarouf
- Department of Stereotaxy and Functional Neurosurgery, University Hospital of Cologne, Cologne, Germany
- Department of Stereotaxy and Functional Neurosurgery, University of Witten-Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany
| |
Collapse
|
40
|
Wang M, Ma H, Wang X, Guo Y, Xia X, Xia H, Guo Y, Huang X, He H, Jia X, Xie Y. Integration of BOLD-fMRI and DTI into radiation treatment planning for high-grade gliomas located near the primary motor cortexes and corticospinal tracts. Radiat Oncol 2015; 10:64. [PMID: 25884395 PMCID: PMC4357178 DOI: 10.1186/s13014-015-0364-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 02/19/2015] [Indexed: 01/03/2023] Open
Abstract
Background The main objective of this study was to evaluate the efficacy of integrating the blood oxygen level dependent functional magnetic resonance imaging (BOLD-fMRI) and diffusion tensor imaging (DTI) data into radiation treatment planning for high-grade gliomas located near the primary motor cortexes (PMCs) and corticospinal tracts (CSTs). Methods A total of 20 patients with high-grade gliomas adjacent to PMCs and CSTs between 2012 and 2014 were recruited. The bilateral PMCs and CSTs were located in the normal regions without any overlapping with target volume of the lesions. BOLD-fMRI, DTI and conventional MRI were performed on patients (Karnofsky performance score ≥ 70) before radical radiotherapy treatment. Four different imaging studies were conducted in each patient: a planning computed tomography (CT), an anatomical MRI, a DTI and a BOLD-fMRI. For each case, three treatment plans (3DCRT, IMRT and IMRT_PMC&CST) were developed by 3 different physicists using the Pinnacle planning system. Results Our study has shown that there was no significant difference between the 3DCRT and IMRT plans in terms of dose homogeneity, but IMRT displayed better planning target volume (PTV) dose conformity. In addition, we have found that the Dmax and Dmean to the ipsilateral and contralateral PMC and CST regions were considerably decreased in IMRT_PMC&CST group (p < 0.001). Conclusions In conclusion, integration of BOLD-fMRI and DTI into radiation treatment planning is feasible and beneficial. With the assistance of the above-described techniques, the bilateral PMCs and CSTs adjacent to the target volume could be clearly marked as OARs and spared during treatment.
Collapse
Affiliation(s)
- Minglei Wang
- Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan, China.
| | - Hui Ma
- Ningxia Key Laboratory for Cerebrocranial Diseases, Yinchuan, China. .,Department of Neurosurgery, General Hospital of Ningxia Medical University, Yinchuan, China.
| | - Xiaodong Wang
- Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan, China. .,Ningxia Key Laboratory for Cerebrocranial Diseases, Yinchuan, China.
| | - Yanhong Guo
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, Yinchuan, China.
| | - Xinshe Xia
- Department of Radiation Oncology, General Hospital of Ningxia Medical University, Yinchuan, China.
| | - Hechun Xia
- Ningxia Key Laboratory for Cerebrocranial Diseases, Yinchuan, China. .,Department of Neurosurgery, General Hospital of Ningxia Medical University, Yinchuan, China.
| | - Yulin Guo
- Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan, China.
| | - Xueying Huang
- Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan, China.
| | - Hong He
- Department of Radiology, Xi'an NO.1 Hospital, Xi'an, China.
| | - Xiaoxiong Jia
- Department of Neurosurgery, General Hospital of Ningxia Medical University, Yinchuan, China.
| | - Yan Xie
- Tissue Organ Bank & Tissue Engineering Centre, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China. .,Tissue Repair and Regeneration Program, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, QLD, Australia.
| |
Collapse
|
41
|
Demir P, Akkas SB, Severcan M, Zorlu F, Severcan F. Ionizing radiation induces structural and functional damage on the molecules of rat brain homogenate membranes: a Fourier transform infrared (FT-IR) spectroscopic study. APPLIED SPECTROSCOPY 2015; 69:154-164. [PMID: 25588232 DOI: 10.1366/13-07154] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Humans can be exposed to ionizing radiation, due to various reasons, whose structural effects on biological membranes are not well defined. The current study aims to understand the ionizing radiation-induced structural and functional alterations in biomolecules of brain membranes using Fourier transform infrared (FT-IR) spectroscopy using rat animal models. For this purpose, 1000 cGy of ionizing radiation was specifically directed to the head of Sprague Dawley rats. The rats were decapitated after 24 h. The results revealed that the lipid-to-protein ratio decreased and that irradiation caused lipid peroxidation and increases in the amounts of olefinic =CH, carbonyl, and methylene groups of lipids. In addition, ionizing radiation induced a decrease in membrane fluidity, disordering of membrane lipids, strengthening of the hydrogen bonding of the phosphate groups of lipid head-groups, and weakening in the hydrogen bonding of the interfacial carbonyl groups of lipids. Radiation further caused significant decrements in the α-helix and turns, and significant increments in the β-sheet and random coil contents in the protein structure. Hierarchical cluster analyses, performed in the whole region (3030-1000 cm(-1)), lipid (3030-2800 cm(-1)), and protein (1700-1600 cm(-1)) regions separately, successfully differentiated the control and irradiated groups of rat brain membranes and showed that proteins in the membranes are affected more than lipids from the damages induced with ionizing radiation. As a result, the current study showed that FT-IR spectroscopy can be used successfully as a novel method to monitor radiation-induced alterations on biological membranes.
Collapse
Affiliation(s)
- Pinar Demir
- Department of Biological Sciences, Middle East Technical University, Dumlupınar Bulvarı No. 1, 06800, Ankara, Turkey
| | | | | | | | | |
Collapse
|
42
|
Tamari K, Suzuki O, Hashimoto N, Kagawa N, Fujiwara M, Sumida I, Seo Y, Isohashi F, Yoshioka Y, Yoshimine T, Ogawa K. Treatment outcomes using CyberKnife for brain metastases from lung cancer. JOURNAL OF RADIATION RESEARCH 2015; 56:151-158. [PMID: 25344929 PMCID: PMC4572587 DOI: 10.1093/jrr/rru092] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 09/03/2014] [Accepted: 09/10/2014] [Indexed: 06/04/2023]
Abstract
We investigated the clinical outcomes following treatment using stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (SRT) for brain metastases from lung cancer. A total of 67 patients with 109 brain metastases from lung cancer treated using CyberKnife between 1998 and 2011 were retrospectively analyzed. SRS (median dose, 24 Gy) was used to treat 79 lesions, and 3-fraction SRT (median dose, 30 Gy) was used to treat 30 lesions. The median follow-up time was 9.4 months (range, 0.4-125 months). The 1-year local control rate was 83.3%, and the 1-year distant brain failure rate was 30.1%. The median survival time was 13.1 months, and the 1- and 3-year overall survival (OS) rates were 54.8% and 25.9%, respectively. On multivariate analysis, three factors were found to be statistically significant predictors of OS: (i) presence of uncontrolled primary disease [hazard ratio (HR) = 3.04; P = 0.002]; (ii) Brinkman index (BI) ≥ 1000 (HR = 2.75; P = 0.007); and (iii) pulmonary metastases (HR = 3.54; P = 0.009). Radionecrosis and worsening of neurocognitive function after radiosurgery were observed in 5 (7%) and 3 (4%) patients, respectively. Our results indicated that SRS/SRT for brain metastases from lung cancer was effective. Uncontrolled primary disease, high BI, and pulmonary metastases at treatment were significant risk factors for OS.
Collapse
Affiliation(s)
- Keisuke Tamari
- Department of Radiation Oncology, Osaka University, 2-2 (D10) Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Osamu Suzuki
- Department of Radiation Oncology, Osaka University, 2-2 (D10) Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Naoya Hashimoto
- Department of Neurosurgery, Osaka University, 2-2 (D10) Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Naoki Kagawa
- Department of Neurosurgery, Osaka University, 2-2 (D10) Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Masateru Fujiwara
- Department of Radiation Oncology, Osaka University, 2-2 (D10) Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Iori Sumida
- Department of Radiation Oncology, Osaka University, 2-2 (D10) Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Yuji Seo
- Department of Radiation Oncology, Osaka University, 2-2 (D10) Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Fumiaki Isohashi
- Department of Radiation Oncology, Osaka University, 2-2 (D10) Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Yasuo Yoshioka
- Department of Radiation Oncology, Osaka University, 2-2 (D10) Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Toshiki Yoshimine
- Department of Neurosurgery, Osaka University, 2-2 (D10) Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University, 2-2 (D10) Yamadaoka, Suita, Osaka 565-0871, Japan
| |
Collapse
|
43
|
Treuer H, Hoevels M, Luyken K, Visser-Vandewalle V, Wirths J, Kocher M, Ruge M. Intracranial stereotactic radiosurgery with an adapted linear accelerator vs. robotic radiosurgery. Strahlenther Onkol 2014; 191:470-6. [DOI: 10.1007/s00066-014-0786-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 10/31/2014] [Indexed: 11/29/2022]
|
44
|
Zhang Q, Zheng D, Lei Y, Morgan B, Driewer J, Zhang M, Li S, Zhou S, Zhen W, Thompson R, Wahl A, Lin C, Enke C. A new variable for SRS plan quality evaluation based on normal tissue sparing: the effect of prescription isodose levels. Br J Radiol 2014; 87:20140362. [PMID: 25226047 DOI: 10.1259/bjr.20140362] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE A new dosimetric variable, dose-dropping speed (DDS), was proposed and used to evaluate normal tissue sparing among stereotactic radiosurgery (SRS) plans with different prescription isodose lines. METHODS 40 plans were generated for 8 intracranial SRS cases, prescribing to isodose levels (IDLs) ranging from 50% to 90% in 10% increments. Whilst maintaining similar coverage and conformity, plans at different IDLs were evaluated in terms of normal tissue sparing using the proposed DDS. The DDS was defined as the greater decay coefficient in a double exponential decay fit of the dose drop-off outside the planning target volume (PTV), which models the steep portion of the drop-off. Provided that the prescription dose covers the whole PTV, a greater DDS indicates better normal tissue sparing. RESULTS Among all plans, the DDS was found to be the lowest for the prescription at 90% IDL and the highest for the prescription at 60% or 70%. The beam profile slope change in the penumbra and its field size dependence were explored and given as the physical basis of the findings. CONCLUSION A variable was proposed for SRS plan quality evaluation. Using this measure, prescriptions at 60% and 70% IDLs were found to provide best normal tissue sparing. ADVANCES IN KNOWLEDGE A new variable was proposed based on which normal tissue sparing was quantitatively evaluated, comparing different prescription IDLs in SRS.
Collapse
Affiliation(s)
- Q Zhang
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Schüttrumpf LH, Niyazi M, Nachbichler SB, Manapov F, Jansen N, Siefert A, Belka C. Prognostic factors for survival and radiation necrosis after stereotactic radiosurgery alone or in combination with whole brain radiation therapy for 1-3 cerebral metastases. Radiat Oncol 2014; 9:105. [PMID: 24885624 PMCID: PMC4036428 DOI: 10.1186/1748-717x-9-105] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 04/22/2014] [Indexed: 11/30/2022] Open
Abstract
Background In the present study factors affecting survival and toxicity in cerebral metastasized patients treated with stereotactic radiosurgery (SRS) were analyzed with special focus on radiation necrosis. Patients and methods 340 patients with 1–3 cerebral metastases having been treated with SRS were retrospectively analyzed. Radiation necrosis was diagnosed by MRI und PET imaging. Univariate and multivariate analysis using a Cox proportional hazards regression model and log-rank test were performed to determine the prognostic value of treatment-related and individual factors for outcome and SRS-related complications. Results Median overall survival was 282 days and median follow-up 721 days. 44% of patients received WBRT during the course of disease. Concerning univariate analysis a significant difference in overall survival was found for Karnofsky Performance Status (KPS ≤ 70: 122 days; KPS > 70: 342 days), for RPA (recursive partitioning analysis) class (RPA class I: 1800 days; RPA class II: 281 days; RPA class III: 130 days), irradiated volume (≤2.5 ml: 354 days; > 2.5 ml: 234 days), prescribed dose (≤18 Gy: 235 days; > 18 Gy: 351 days), gender (male: 235 days; female: 327 days) and whole brain radiotherapy (+WBRT: 341 days/-WBRT: 231 days). In multivariate analysis significance was confirmed for KPS, RPA class and gender. MRI and clinical symptoms suggested radiation necrosis in 21 patients after SRS +/− whole brain radiotherapy (WBRT). In five patients clinically relevant radiation necrosis was confirmed by PET imaging. Conclusions SRS alone or in combination with WBRT represents a feasible option as initial treatment for patients with brain metastases; however a significant subset of patients may develop neurological complications. Performance status, RPA class and gender were identified to predict improved survival in cerebral metastasized patients.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Claus Belka
- Department of Radiation Oncology, University of Munich, Marchioninistr 15, Munich 81377, Germany.
| |
Collapse
|
46
|
Kocher M, Wittig A, Piroth MD, Treuer H, Seegenschmiedt H, Ruge M, Grosu AL, Guckenberger M. Stereotactic radiosurgery for treatment of brain metastases. A report of the DEGRO Working Group on Stereotactic Radiotherapy. Strahlenther Onkol 2014; 190:521-32. [PMID: 24715242 DOI: 10.1007/s00066-014-0648-7] [Citation(s) in RCA: 145] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 02/25/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND This report from the Working Group on Stereotaktische Radiotherapie of the German Society of Radiation Oncology (Deutsche Gesellschaft für Radioonkologie, DEGRO) provides recommendations for the use of stereotactic radiosurgery (SRS) on patients with brain metastases. It considers existing international guidelines and details them where appropriate. RESULTS AND DISCUSSION The main recommendations are: Patients with solid tumors except germ cell tumors and small-cell lung cancer with a life expectancy of more than 3 months suffering from a single brain metastasis of less than 3 cm in diameter should be considered for SRS. Especially when metastases are not amenable to surgery, are located in the brain stem, and have no mass effect, SRS should be offered to the patient. For multiple (two to four) metastases--all less than 2.5 cm in diameter--in patients with a life expectancy of more than 3 months, SRS should be used rather than whole-brain radiotherapy (WBRT). Adjuvant WBRT after SRS for both single and multiple (two to four) metastases increases local control and reduces the frequency of distant brain metastases, but does not prolong survival when compared with SRS and salvage treatment. As WBRT carries the risk of inducing neurocognitive damage, it seems reasonable to withhold WBRT for as long as possible. CONCLUSION A single (marginal) dose of 20 Gy is a reasonable choice that balances the effect on the treated lesion (local control, partial remission) against the risk of late side effects (radionecrosis). Higher doses (22-25 Gy) may be used for smaller (< 1 cm) lesions, while a dose reduction to 18 Gy may be necessary for lesions greater than 2.5-3 cm. As the infiltration zone of the brain metastases is usually small, the GTV-CTV (gross tumor volume-clinical target volume) margin should be in the range of 0-1 mm. The CTV-PTV (planning target volume) margin depends on the treatment technique and should lie in the range of 0-2 mm. Distant brain recurrences fulfilling the aforementioned criteria can be treated with SRS irrespective of previous WBRT.
Collapse
Affiliation(s)
- Martin Kocher
- Department of Radiation Oncology, University Hospital Cologne, Joseph-Stelzmann-Str. 9, 50924, Köln, Germany,
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Wowra B, Muacevic A, Jess-Hempen A, Tonn JC. Safety and efficacy of outpatient gamma knife radiosurgery for multiple cerebral metastases. Expert Rev Neurother 2014; 4:673-9. [PMID: 15853586 DOI: 10.1586/14737175.4.4.673] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This review highlights the experience of a single institution using the Leksell gamma knife for 8 years. More than 500 patients with multiple cerebral metastases received outpatient radiosurgery. The results prove that there is a high efficacy and attractively low morbidity of modern outpatient radiosurgery. When compared with whole brain radiation therapy, radiosurgery improved survival in patients with cerebral metastases. Most importantly, the number of brain metastases had no prognostic impact in patients with non-small cell lung cancer, renal cell cancer, malignant melanoma and gastrointestinal cancer.
Collapse
Affiliation(s)
- Berndt Wowra
- Gamma Knife Center, Ingolstädter Str. 166, D 80939 München, Germany.
| | | | | | | |
Collapse
|
48
|
Lin NU, Lee EQ, Aoyama H, Barani IJ, Baumert BG, Brown PD, Camidge DR, Chang SM, Dancey J, Gaspar LE, Harris GJ, Hodi FS, Kalkanis SN, Lamborn KR, Linskey ME, Macdonald DR, Margolin K, Mehta MP, Schiff D, Soffietti R, Suh JH, van den Bent MJ, Vogelbaum MA, Wefel JS, Wen PY. Challenges relating to solid tumour brain metastases in clinical trials, part 1: patient population, response, and progression. A report from the RANO group. Lancet Oncol 2013; 14:e396-406. [PMID: 23993384 DOI: 10.1016/s1470-2045(13)70311-5] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Therapeutic outcomes for patients with brain metastases need to improve. A critical review of trials specifically addressing brain metastases shows key issues that could prevent acceptance of results by regulatory agencies, including enrolment of heterogeneous groups of patients and varying definitions of clinical endpoints. Considerations specific to disease, modality, and treatment are not consistently addressed. Additionally, the schedule of CNS imaging and consequences of detection of new or progressive brain metastases in trials mainly exploring the extra-CNS activity of systemic drugs are highly variable. The Response Assessment in Neuro-Oncology (RANO) working group is an independent, international, collaborative effort to improve the design of trials in patients with brain tumours. In this two-part series, we review the state of clinical trials of brain metastases and suggest a consensus recommendation for the development of criteria for future clinical trials.
Collapse
Affiliation(s)
- Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Yen CP, Matsumoto JA, Wintermark M, Schwyzer L, Evans AJ, Jensen ME, Shaffrey ME, Sheehan JP. Radiation-induced imaging changes following Gamma Knife surgery for cerebral arteriovenous malformations. J Neurosurg 2013; 118:63-73. [PMID: 23140155 DOI: 10.3171/2012.10.jns12402] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The objective of this study was to evaluate the incidence, severity, clinical manifestations, and risk factors of radiation-induced imaging changes (RIICs) following Gamma Knife surgery (GKS) for cerebral arteriovenous malformations (AVMs).
Methods
A total of 1426 GKS procedures performed for AVMs with imaging follow-up available were analyzed. Radiation-induced imaging changes were defined as newly developed increased T2 signal surrounding the treated AVM nidi. A grading system was developed to categorize the severity of RIICs. Grade I RIICs were mild imaging changes imposing no mass effect on the surrounding brain. Grade II RIICs were moderate changes causing effacement of the sulci or compression of the ventricles. Grade III RIICs were severe changes causing midline shift of the brain. Univariate and multivariate logistic regression analyses were applied to test factors potentially affecting the occurrence, severity, and associated symptoms of RIICs.
Results
A total of 482 nidi (33.8%) developed RIICs following GKS, with 281 classified as Grade I, 164 as Grade II, and 37 as Grade III. The median duration from GKS to the development of RIICs was 13 months (range 2–124 months). The imaging changes disappeared completely within 2–128 months (median 22 months) following the development of RIICs. The RIICs were symptomatic in 122 patients, yielding an overall incidence of symptomatic RIICs of 8.6%. Twenty-six patients (1.8%) with RIICs had permanent deficits. A negative history of prior surgery, no prior hemorrhage, large nidus, and a single draining vein were associated with a higher risk of RIICs.
Conclusions
Radiation-induced imaging changes are the most common adverse effects following GKS. Fortunately, few of the RIICs are symptomatic and most of the symptoms are reversible. Patients with a relatively healthy brain and nidi that are large, or with a single draining vein, are more likely to develop RIICs.
Collapse
Affiliation(s)
| | - Julie A. Matsumoto
- 2Neuroradiology Division, Department of Radiology, University of Virginia, Charlottesville, Virginia
| | - Max Wintermark
- 2Neuroradiology Division, Department of Radiology, University of Virginia, Charlottesville, Virginia
| | | | - Avery J. Evans
- 2Neuroradiology Division, Department of Radiology, University of Virginia, Charlottesville, Virginia
| | - Mary E. Jensen
- 2Neuroradiology Division, Department of Radiology, University of Virginia, Charlottesville, Virginia
| | | | | |
Collapse
|
50
|
Cetin I, Ates R, Dhaens J, Storme G. Retrospective analysis of linac-based radiosurgery for arteriovenous malformations and testing of the Flickinger formula in predicting radiation injury. Strahlenther Onkol 2012; 188:1133-8. [DOI: 10.1007/s00066-012-0180-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 07/02/2012] [Indexed: 11/24/2022]
|