1
|
Phillips C, Pinkham MB, Moore A, Sia J, Jeffree RL, Khasraw M, Kam A, Bressel M, Haworth A. Local hero: A phase II study of local therapy only (stereotactic radiosurgery and / or surgery) for treatment of up to five brain metastases from HER2+ breast cancer. (TROG study 16.02). Breast 2024; 74:103675. [PMID: 38340685 PMCID: PMC10869940 DOI: 10.1016/j.breast.2024.103675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/11/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Introduction, A decade ago, stereotactic radiosurgery (SRS) without whole brain radiotherapy (WBRT) was emerging as preferred treatment for oligometastatic brain metastases. Studies of cavity SRS after neurosurgery were underway. Data specific to metastatic HER2 breast cancer (MHBC), describing intracranial, systemic and survival outcomes without WBRT, were lacking. A Phase II study was designed to address this gap. Method, Adults with MHBC, performance status 0-2, ≤ five BrM, receiving/planned to receive HER2-targeted therapy were eligible. Exclusions included leptomeningeal disease and prior WBRT. Neurosurgery allowed ≤6 weeks before registration and required for BrM >4 cm. Primary endpoint was 12-month requirement for WBRT. Secondary endpoints; freedom from (FF-) local failure (LF), distant brain failure (DBF), extracranial disease failure (ECDF), overall survival (OS), cause of death, mini-mental state examination (MMSE), adverse events (AE). Results, Twenty-five patients accrued Decembers 2016-2020. The study closed early after slow accrual. Thirty-seven BrM and four cavities received SRS. Four cavities and five BrM were observed. At 12 months: one patient required WBRT (FF-WBRT 95 %, 95 % CI 72-99), FFLF 91 % (95 % CI 69-98), FFDBF 57 % (95 % CI 34-74), FFECDF 64 % (95 % CI 45-84), OS 96 % (95 % CI 74-99). Two grade 3 AE occurred. MMSE was abnormal for 3/24 patients at baseline and 1/17 at 12 months. Conclusion, At 12 months, SRS and/or neurosurgery provided good control with low toxicity. WBRT was not required in 95 % of cases. This small study supports the practice change from WBRT to local therapies for MHBC BrM.
Collapse
Affiliation(s)
- Claire Phillips
- Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology University of Melbourne, Parkville, Australia.
| | - Mark B Pinkham
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Alisha Moore
- Trans-Tasman Radiation Oncology Group, Newcastle, Australia
| | - Joseph Sia
- Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology University of Melbourne, Parkville, Australia
| | - Rosalind L Jeffree
- Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Neurosurgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | | | - Anthony Kam
- The Alfred, Prahran, Australia; Monash University, Clayton, Australia
| | - Mathias Bressel
- Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology University of Melbourne, Parkville, Australia
| | - Annette Haworth
- Department of Physics, University of Sydney, Sydney, Australia
| |
Collapse
|
2
|
Ono T, Nemoto K. Re-Whole Brain Radiotherapy May Be One of the Treatment Choices for Symptomatic Brain Metastases Patients. Cancers (Basel) 2022; 14:cancers14215293. [PMID: 36358712 PMCID: PMC9657612 DOI: 10.3390/cancers14215293] [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: 09/07/2022] [Revised: 10/20/2022] [Accepted: 10/26/2022] [Indexed: 02/03/2023] Open
Abstract
Generally, patients with multiple brain metastases receive whole brain radiotherapy (WBRT). Although, more than 60% of patients show complete or partial responses, many experience recurrence. Therefore, some institutions consider re-WBRT administration; however, there is insufficient information regarding this. Therefore, we aimed to review re-WBRT administration among these patients. Although most patients did not live longer than 12 months, symptomatic improvement was sometimes observed, with tolerable acute toxicities. Therefore, re-WBRT may be a treatment option for patients with symptomatic recurrence of brain metastases. However, physicians should consider this treatment cautiously because there is insufficient data on late toxicity, including radiation necrosis, owing to poor prognosis. A better prognostic factor for survival following radiotherapy administration may be the time interval of > 9 months between the first WBRT and re-WBRT, but there is no evidence supporting that higher doses lead to prolonged survival, symptom improvement, and tumor control. Therefore, 20 Gy in 10 fractions or 18 Gy in five fractions may be a reasonable treatment method within the tolerable total biological effective dose 2 ≤ 150 Gy, considering the biologically effective dose for tumors and normal tissues.
Collapse
Affiliation(s)
- Takashi Ono
- Correspondence: ; Tel.: +81-23-628-5386; Fax: +81-23-628-5389
| | | |
Collapse
|
3
|
Gutierrez Torres S, Maldonado Magos F, Turcott JG, Hernandez‐Martinez J, Cacho‐Díaz B, Cardona A, Mota‐García A, Lozano Ruiz F, Ramos‐Ramirez M, Arrieta O. Re-irradiation in patients with progressive or recurrent brain metastases from extracranial solid tumors: A novel prognostic index. Cancer Med 2022; 12:146-158. [PMID: 35770957 PMCID: PMC9844632 DOI: 10.1002/cam4.4921] [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: 02/24/2022] [Revised: 05/27/2022] [Accepted: 05/28/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Most studies evaluating factors associated with the survival of patients with brain metastases (BM) have focused on patients with newly diagnosed BM. This study aimed to identify prognostic factors associated with survival after brain re-irradiation in order to develop a new prognostic index. METHODS This 5-year retrospective study included patients treated with repeat-radiotherapy for recurrent BM at the "Instituto Nacional de Cancerología" of Mexico between 2015 and 2019. Significant variables in the multivariate Cox regression analysis were used to create the brain re-irradiation index (BRI). Survival and group comparisons were performed using the Kaplan-Meier method and the log-rank test. RESULTS Fifty-seven patients receiving brain re-irradiation were identified. Most patients were women (75.4%) with a mean age at BM diagnosis of 51.4 years. Lung and breast cancer were the most prevalent neoplasms (43.9% each). Independent prognostic factors for shorter survival after re-irradiation were: Age >50 years (hazard ratio [HR]:2.5 [95% confidence interval [CI], 1.1-5.8]; p = 0.026), uncontrolled primary tumor (HR:5.5 [95% CI, 2.2-13.5]; p < 0.001), lesion size >20 mm (4.6 [95% CI, 1.7-12.2]; p = 0.002), and an interval <12 months between radiation treatments (HR:4.3 [95% CI, 1.7-10.6]; p = 0.001). Median survival (MS) after re-irradiation was 14.6 months (95% CI, 8.2-20.9).MS of patients stratified according to the BRI score was 17.38, 10.34, and 2.82 months, with significant differences between all groups. CONCLUSIONS The new BRI can be easily implemented for the prognostic classification of cancer patients with progressive or recurrent BM from extracranial solid tumors.
Collapse
Affiliation(s)
| | | | - Jenny G. Turcott
- Thoracic Oncology UnitInstituto Nacional de Cancerología (INCan)Mexico CityMexico
| | - Juan‐Manuel Hernandez‐Martinez
- Thoracic Oncology UnitInstituto Nacional de Cancerología (INCan)Mexico CityMexico,Cátedras CONACYT‐Instituto Nacional de CancerologíaMexico CityMexico
| | - Bernardo Cacho‐Díaz
- Neuro‐Oncology UnitInstituto Nacional de Cancerología (INCan)Mexico CityMexico
| | - Andrés F. Cardona
- Luis Carlos Sarmiento Angulo Cancer Treatment and Research Center (CTIC)BogotáColombia,Foundation for Clinical and Applied Cancer Research (FICMAC)BogotáColombia,Molecular Oncology and Biology Systems Research Group (FOX‐G/ONCOLGroup)Universidad El BosqueBogotáColombia
| | - Aida Mota‐García
- Radiotherapy UnitInstituto Nacional de Cancerología (INCan)Mexico CityMexico
| | | | | | - Oscar Arrieta
- Thoracic Oncology UnitInstituto Nacional de Cancerología (INCan)Mexico CityMexico
| |
Collapse
|
4
|
Li M, Song Y, Li L, Qin J, Deng H, Zhang T. Reirradiation of Whole Brain for Recurrent Brain Metastases: A Case Report of Lung Cancer With 12-Year Survival. Front Oncol 2021; 11:780581. [PMID: 34900735 PMCID: PMC8660684 DOI: 10.3389/fonc.2021.780581] [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: 09/21/2021] [Accepted: 11/05/2021] [Indexed: 11/19/2022] Open
Abstract
Whole brain radiotherapy (WBRT) for brain metastases (BMs) was considered to be dose limited. Reirradiation of WBRT for recurrent BM has always been challenged. Here, we report a patient with multiple BMs of non-small-cell lung cancer (NSCLC), who received two courses of WBRT at the interval of 5 years with the cumulative administration dose for whole brain as 70 Gy and a boost for the local site as 30 Gy. Furthermore, after experiencing relapse in the brain, he underwent extra gamma knife (GK) radiotherapy for local brain metastasis for the third time after 5 years. The overall survival was 12 years since he was initially diagnosed with NSCLC with multiple brain metastases. Meanwhile, each time of radiotherapy brought a good tumor response to brain metastasis. Outstandingly, during the whole survival, he had a good quality of life (QoL) with Karnofsky Performance Score (KPS) above 80. Even after the last GK was executed, he had just a mild neurocognitive defect. In conclusion, with the cautious evaluation of a patient, we suggest that reirradiation of WBRT could be a choice, and the cumulative radiation dose of the brain may be individually modified.
Collapse
Affiliation(s)
- Minmin Li
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yanbo Song
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Longhao Li
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jian Qin
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hongbin Deng
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tao Zhang
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
5
|
Boström JP, Jetschke K, Schmieder K, Adamietz IUA. [Surgical treatment and radiation therapy of brain metastases]. Radiologe 2021; 61:767-778. [PMID: 34272570 DOI: 10.1007/s00117-021-00894-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The aim of this work is to outline the principles of interdisciplinary treatment of brain metastases. Interdisciplinary treatment is determined by the clinical situation, anatomical conditions and tumor entity and has the goal of reducing toxicity. Magnetic resonance imaging, computed tomography (CT) and positron emission tomography-CT are used to diagnose brain metastases. Neurosurgery is used for accessible, symptomatic metastases. For localized metastases, including multiple metastases, that are surgically inaccessible, radiosurgery is used. If possible, partial brain irradiation is preferred to whole-brain irradiation. Protection of the hippocampus during whole-brain radiotherapy reduces therapy toxicity. In emergency situations, steroids provide effective support and a neurosurgical intervention may be life-saving. The options for systemic drug therapy are increasing.
Collapse
Affiliation(s)
- Jan P Boström
- Klinik für Strahlentherapie und Radio-Onkologie, Marien Hospital Herne, Universitätsklinikum, Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne, Deutschland.,Gamma Knife Zentrum, Ruhr-Universität Bochum, Bochum, Deutschland
| | - Kathleen Jetschke
- Klinik für Neurochirurgie, Knappschaftskrankenhaus Langendreer, Universitätsklinikum, Ruhr-Universität Bochum, Bochum, Deutschland
| | - Kirsten Schmieder
- Klinik für Neurochirurgie, Knappschaftskrankenhaus Langendreer, Universitätsklinikum, Ruhr-Universität Bochum, Bochum, Deutschland
| | - Irenä Us A Adamietz
- Klinik für Strahlentherapie und Radio-Onkologie, Marien Hospital Herne, Universitätsklinikum, Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne, Deutschland. .,Gamma Knife Zentrum, Ruhr-Universität Bochum, Bochum, Deutschland. .,Klinik für Strahlentherapie und Radioonkologie, St. Josef-Hospital Bochum, Universitätsklinikum, Ruhr-Universität Bochum, Bochum, Deutschland.
| |
Collapse
|
6
|
Stiefel I, Schröder C, Tanadini-Lang S, Pytko I, Vu E, Klement R, Guckenberger M, Andratschke N. High-dose re-irradiation of intracranial lesions - Efficacy and safety including dosimetric analysis based on accumulated EQD2Gy dose EQD calculation. Clin Transl Radiat Oncol 2021; 27:132-138. [PMID: 33659717 PMCID: PMC7890358 DOI: 10.1016/j.ctro.2021.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 01/30/2021] [Indexed: 01/05/2023] Open
Abstract
Re-irradiation of the brain is feasible with an encouraging overall survival. Treatment related toxicity was low within the reported dose range. EQD2 cumulative dose distributions were calculated using rigid registration. Dose-Response-Modelling with logistic regression showed a correlation of the D1cc brain with any grade of acute toxicity.
Introduction The use of cranial re-irradiation is growing with improving overall survival and the advent of high-precision radiotherapy techniques. Still the value of re-irradiation needs careful evaluation regarding safety and efficacy. We analyzed dosimetric and clinical data of patients receiving cranial re-irradiation using EQD2 sum plans. Methods and material We retrospectively analyzed the data of 76 patients who received repeated cranial radiotherapy from 02/2013 to 09/2016. 34 patients suffered from recurrent primary brain tumors, 42 from brain metastases. Dosimetric analysis was performed accumulating EQD2 dose distributions based on rigid image registration. Clinical and radiological data was collected at follow-ups including toxicity, local control and overall survival. Results In total 76 patients had at least 2 courses of intracranial radiotherapy. The median accumulated prescription EQD2 dose was 96.5 Gy2 for all radiation courses combined. The median D(0.1 cc) of the brain for patients receiving more than 100 Gy2 was 114 Gy2 with a highest dose of 161.5 Gy2. 74% of patients suffered from low grade (G1–G2) acute toxicity, only two high grade (>G3) toxicities were recorded. Median overall survival from the time of first re-irradiation was 57 weeks (range 4–186 weeks). The median time to local failure for patients with a primary brain tumor was not reached and 24 weeks (range 1–77 weeks) for patients with brain metastases. Conclusion Repeated radiotherapy appears both safe and efficient in patients with recurrent primary or secondary brain tumors with doses to the brain up to 120 Gy2 EQD2, doses below 100 Gy2 for brainstem and doses below 75 Gy2 EQD2 to chiasm and optic nerves.
Collapse
Affiliation(s)
- I. Stiefel
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - C. Schröder
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
- Center for Proton Therapy, Paul Scherrer-Institut, Villigen, Switzerland
| | - S. Tanadini-Lang
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - I. Pytko
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - E. Vu
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - R.J. Klement
- Department of Radiation Oncology, Leopoldina Hospital, Schweinfurt, Germany
- University of Zurich, Zurich, Switzerland
| | - M. Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - N. Andratschke
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
- Corresponding author at: Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.
| |
Collapse
|
7
|
Outcomes From Whole-Brain Reirradiation Using Pulsed Reduced Dose Rate Radiation Therapy. Adv Radiat Oncol 2020; 5:834-839. [PMID: 33083645 PMCID: PMC7557211 DOI: 10.1016/j.adro.2020.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/23/2020] [Accepted: 06/23/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose Recurrent intracranial metastases after whole-brain irradiation pose a clinical challenge owing to the escalating morbidity associated with their treatment. Although stereotactic radiosurgery is increasingly being used, there are still situations in which whole-brain reirradiation (ReRT) continues to be appropriate. Here, we report our experience using whole-brain pulsed reduced dose rate radiation therapy (PRDR), a method that delivers radiation at a slower rate of 0.067 Gy/min to potentially increase sublethal damage repair and decrease toxicity. Methods and Materials Patients undergoing whole-brain ReRT with PRDR from January 1, 2001 to March 2019 were analyzed. The median PRDR ReRT dose was 26 Gy in 2 Gy fractions, resulting in a median total whole-brain dose of 59.5 Gy. Cox regression analysis was used for multivariate analysis. The Kaplan-Meier method was used for overall survival, progression free survival, and to evaluate the ReRT score. Binary logistic regression was employed to evaluate variables associated with rapid death. Results Seventy-five patients were treated with whole-brain PRDR radiation therapy. The median age was 54 (range, 26-72), the median Karnofsky performance status (KPS) was 80, and 86.7% had recursive partitioning analysis scores of 2. Thirty-two patients had over 10 metastases and 11 had leptomeningeal disease. The median overall survival was 4.1 months (range, 0.29-59.5 months) with a 1 year overall survival of 10.4%. Age, KPS, dexamethasone usage, and intracranial disease volume were significantly correlated with overall survival on multivariate analysis. A KPS ≤70 was associated with rapid death after radiation. The prognostic value of the ReRT score was validated. The most common acute toxicities were fatigue (23.1%) and headache (16.9%). Conclusions In this large cohort of patients with advanced intracranial metastases, PRDR achieves acceptable survival and may decrease toxicity associated with ReRT. PRDR is an easily implemented technique and is a viable treatment option for ReRT of brain metastases.
Collapse
|
8
|
El Shafie RA, Dresel T, Weber D, Schmitt D, Lang K, König L, Höne S, Forster T, von Nettelbladt B, Eichkorn T, Adeberg S, Debus J, Rieken S, Bernhardt D. Stereotactic Cavity Irradiation or Whole-Brain Radiotherapy Following Brain Metastases Resection-Outcome, Prognostic Factors, and Recurrence Patterns. Front Oncol 2020; 10:693. [PMID: 32477942 PMCID: PMC7232539 DOI: 10.3389/fonc.2020.00693] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 04/14/2020] [Indexed: 12/27/2022] Open
Abstract
Introduction: Following the resection of brain metastases (BM), whole-brain radiotherapy (WBRT) is a long-established standard of care. Its position was recently challenged by the less toxic single-session radiosurgery (SRS) or fractionated stereotactic radiotherapy (FSRT) of the resection cavity, reducing dose exposure of the healthy brain. Patients and Methods: We analyzed 101 patients treated with either SRS/FSRT (n = 50) or WBRT (n = 51) following BM resection over a 5-year period. Propensity score adjustment was done for age, total number of BM, timepoint of BM diagnosis, controlled primary and extracranial metastases. A Cox Proportional Hazards model with univariate and multivariate analysis was fitted for overall survival (OS), local control (LC) and distant brain control (DBC). Results: Median patient age was 61 (interquartile range, IQR: 56-67) years and the most common histology was non-small cell lung cancer, followed by breast cancer. 38% of the patients had additional unresected BM. Twenty-four patients received SRS, 26 patients received FSRT and 51 patients received WBRT. Median OS in the SRS/FSRT subgroup was not reached (IQR NA-16.7 months) vs. 12.6 months (IQR 21.3-4.4) in the WBRT subgroup (hazard ratio, HR 3.3, 95%-CI: [1.5; 7.2] p < 0.002). Twelve-months LC-probability was 94.9% (95%-CI: [88.3; 100.0]) in the SRS subgroup vs. 81.7% (95%-CI: [66.6; 100.0]) in the WBRT subgroup (HR 0.2, 95%-CI: [0.01; 0.9] p = 0.037). Twelve-months DBC-probabilities were 65.0% (95%-CI: [50.8; 83.0]) and 58.8% (95%-CI: [42.9; 80.7]), respectively (HR 1.4, 95%-CI: [0.7; 2.7] p = 0.401). In propensity score-adjusted multivariate analysis, incomplete resection negatively impacted OS (HR 3.9, 95%-CI: [2.0;7.4], p < 0.001) and LC (HR 5.4, 95%-CI: [1.3; 21.9], p = 0.018). Excellent clinical performance (HR 0.4, 95%-CI: [0.2; 0.9], p = 0.030) and better graded prognostic assessment (GPA) score (HR 0.4, 95%-CI: [0.2; 1.0], p = 0.040) were prognostic of superior OS. A higher number of BM was associated with a greater risk of developing new distant BM (HR 5.6, 95%-CI: [1.0; 30.4], p = 0.048). In subgroup analysis, larger cavity volume (HR 1.1, 95%-CI: [1.0; 1.3], p = 0.033) and incomplete resection (HR 12.0, 95%-CI: [1.2; 118.3], p = 0.033) were associated with inferior LC following SRS/FSRT. Conclusion: This is the first propensity score-adjusted direct comparison of SRS/FSRT and WBRT following the resection of BM. Patients receiving SRS/FSRT showed longer OS and LC compared to WBRT. Future analyses will address the optimal choice of safety margin, dose and fractionation for postoperative stereotactic RT of the resection cavity.
Collapse
Affiliation(s)
- Rami A El Shafie
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Thorsten Dresel
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Dorothea Weber
- Institute of Medical Biometry and Informatics (IMBI), Heidelberg University Hospital, Heidelberg, Germany
| | - Daniela Schmitt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Kristin Lang
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Simon Höne
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Tobias Forster
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Bastian von Nettelbladt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Tanja Eichkorn
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Sebastian Adeberg
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology (E050), German Cancer Research Center (dkfz), Heidelberg, Germany.,Deutsches Konsortium Für Translationale Krebsforschung (DKTK), Partner Site Heidelberg, German Cancer Research Center (dkfz), Heidelberg, Germany.,Heidelberger Ionenstrahltherapie-Zentrum (HIT), Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Radiation Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| |
Collapse
|
9
|
Silipigni S, Ippolito E, Matteucci P, Santo B, Gangemi E, La Cesa A, Santini D, Greco C, Ramella S. Repeated courses of radiation treatment in an HER2-positive breast cancer patient with diffuse brain metastases: A case report. Breast J 2020; 26:1370-1371. [PMID: 32279411 DOI: 10.1111/tbj.13844] [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: 12/13/2019] [Revised: 03/18/2020] [Accepted: 03/27/2020] [Indexed: 10/24/2022]
Abstract
In human epidermal growth factor receptor 2 (HER2+) expressing breast cancer subtype, the incidence of brain metastases is common and patients often die due to uncontrolled cranial disease. This is a case report of a HER2+ breast cancer woman with diffuse brain metastases that experienced long survival and clinical benefit from multiple radiotherapy treatments and combined systemic therapy, without increased toxicity.
Collapse
Affiliation(s)
- Sonia Silipigni
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Edy Ippolito
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Paolo Matteucci
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Bianca Santo
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Emma Gangemi
- Radiology, Campus Bio-Medico University, Rome, Italy
| | | | | | - Carlo Greco
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Sara Ramella
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| |
Collapse
|
10
|
El Shafie RA, Celik A, Weber D, Schmitt D, Lang K, König L, Bernhardt D, Höne S, Forster T, von Nettelbladt B, Adeberg S, Debus J, Rieken S. A matched-pair analysis comparing stereotactic radiosurgery with whole-brain radiotherapy for patients with multiple brain metastases. J Neurooncol 2020; 147:607-618. [DOI: 10.1007/s11060-020-03447-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/28/2020] [Indexed: 11/29/2022]
|
11
|
Should Stereotactic Radiosurgery Be Considered for Salvage of Intracranial Recurrence after Prophylactic Cranial Irradiation or Whole Brain Radiotherapy in Small Cell Lung Cancer? A Population-Based Analysis and Literature Review. J Med Imaging Radiat Sci 2019; 51:75-87.e2. [PMID: 31759940 DOI: 10.1016/j.jmir.2019.10.001] [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: 05/24/2019] [Revised: 09/24/2019] [Accepted: 10/03/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Prophylactic cranial irradiation (PCI) improves survival and prevents intracranial recurrence (IR) in limited stage (LS) and extensive stage (ES) small cell lung cancer (SCLC). However, despite PCI, IR affects 12%-45%, and limited data exist regarding salvage brain reirradiation (ReRT). We performed a population-based review of IR in SCLC. METHODS Demographic, treatment, and outcome data of consecutive patients (N = 371) with SCLC assessed at a tertiary cancer centre (01/2013-12/2015) were abstracted, and summary statistics calculated. Kaplan-Meier estimates and univariate and multivariate analysis (MVA) via the Cox proportional hazard model were performed. RESULTS Median age was 66.1 years, and 59.8% were Eastern Cooperative Oncology Group (ECOG) performance status 0-2. Median survival was 24 months (95% CI 18.3-29.7 months) for LS (N = 103) and 7 months (95% CI 6.1-7.9 months) for ES (N = 268). 72 of 103 patients with LS and 97 of 214 of those with ES received PCI. 54 of 268 ES presented with brain metastases (BM) of whom 46 of 54 received whole brain RT (WBRT). 18.9% (32/169) recurred post-PCI (13 LS; 19 ES) and 30.4% (14/46) recurred after WBRT. Of those who recurred/progressed after cranial RT, 56.5% (26/46) had <5 BM, 39.1% had no extracranial disease, and 50% were ECOG 0-2. In retrospect, 17 of 46 would have been candidates for salvage stereotactic radiosurgery: 13 post-PCI and 4 post-WBRT. CONCLUSIONS This cohort challenges commonly held beliefs that IR is always diffuse, associated with clinical deterioration, and synchronous with systemic failure. Approximately 1 in 3 SCLC patients with IR after PCI or WBRT appear clinically appropriate for salvage stereotactic radiosurgery.
Collapse
|
12
|
Nguyen MN, Noel G, Antoni D. La réirradiation des métastases cérébrales : revue des cinq dernières années. Cancer Radiother 2019; 23:531-540. [DOI: 10.1016/j.canrad.2019.07.144] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 07/15/2019] [Indexed: 10/26/2022]
|
13
|
Maranzano E, Terenzi S, Anselmo P, Casale M, Arcidiacono F, Loreti F, Di Marzo A, Draghini L, Italiani M, Trippa F. A prospective phase II trial on reirradiation of brain metastases with radiosurgery. Clin Transl Radiat Oncol 2019; 17:1-6. [PMID: 31061900 PMCID: PMC6487370 DOI: 10.1016/j.ctro.2019.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/01/2019] [Accepted: 04/05/2019] [Indexed: 11/30/2022] Open
Abstract
Reirradiation with radiosurgery of brain metastases is feasible and safe. Good KPS and controlled systemic disease are most important selection criteria. An accurate patient selection is essential to avoid brain toxicity. If diameter is ≤ 2 cm and dose ≤ 20 Gy local control is high without late toxicity.
Purpose In our previous published trial on radiosurgery (SRS) of recurrent brain metastases (BM) after whole brain radiotherapy (WBRT), Karnofsky performance status (KPS) and administered dose conditioned outcome and late toxicity, respectively. Brain radionecrosis was registered in 6% of patients. With the aim to obtain similar satisfactory outcomes and limit toxicity, we started a phase II trial in which reirradiation of BM with SRS were done using a tighter patient selection. Materials and methods Patients with BM recurring after WBRT were recruited for reirradiation with SRS. Only patients with good KPS (≥70), good neurologic functional score (NFS 0-1) and lesions with a diameter ≤20 mm were considered eligible for retreatment. Dose exceeding 20 Gy was never administered. Results The 59 patients reirradiated had 109 BM with a diameter range of 6–20 mm. Median interval between prior WBRT and SRS was 15 months and median SRS administered dose was 18 Gy (range 10–20 Gy). Complete and partial response (CR, PR) was obtained in 42% of patients with 2 years of control rate of 81%. Median overall survival (OS) after reirradiation was 14 months. No radionecrosis was detected. Conclusions Analysis of our current trial compared with results of our previous data suggests that a tighter patient selection (KPS ≥ 70; NFS 0-1, BM with ≤20 mm of diameter) and SRS dose ≤20 Gy allowed a high OS rate, a good percentage of CR and PR which last for >2 years, and no brain radionecrosis.
Collapse
Affiliation(s)
| | - Sara Terenzi
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | - Paola Anselmo
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | | | | | - Fabio Loreti
- Nuclear Medicine Service, "S. Maria" Hospital, Terni, Italy
| | | | - Lorena Draghini
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | - Marco Italiani
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | - Fabio Trippa
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| |
Collapse
|
14
|
Chidambaram S, Pannullo SC, Schwartz TH, Wernicke AG. Reirradiation of Recurrent Brain Metastases: Where Do We Stand? World Neurosurg 2019; 125:156-163. [PMID: 30738931 DOI: 10.1016/j.wneu.2019.01.182] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/17/2019] [Accepted: 01/19/2019] [Indexed: 10/27/2022]
Abstract
Brain metastases occur in a large portion of patients with cancer. Although advances in radiotherapy have helped to improve survival, they have also raised questions regarding the best modality for retreatment in the context of recurrent disease. The spectrum of treatment options for recurrent intracranial metastatic disease after previous radiotherapy includes salvage stereotactic radiosurgery, whole brain radiotherapy, and brachytherapy. We have comprehensively reviewed the existing data on the efficacy and toxicity of the various reirradiation treatment modalities. We examined the key clinical considerations that guide patient selection, such as dose, tumor size, interval to retreatment, and local control and survival rates.
Collapse
Affiliation(s)
- Swathi Chidambaram
- Department of Neurosurgery, Weill Medical College of Cornell University, New York, New York, USA
| | - Susan C Pannullo
- Department of Neurosurgery, Weill Medical College of Cornell University, New York, New York, USA
| | - Theodore H Schwartz
- Department of Neurosurgery, Weill Medical College of Cornell University, New York, New York, USA
| | - A Gabriella Wernicke
- Department of Neurosurgery, Weill Medical College of Cornell University, New York, New York, USA; Department of Radiation Oncology, Weill Medical College of Cornell University, New York, New York, USA.
| |
Collapse
|
15
|
El Shafie RA, Böhm K, Weber D, Lang K, Schlaich F, Adeberg S, Paul A, Haefner MF, Katayama S, Sterzing F, Hörner-Rieber J, Löw S, Herfarth K, Debus J, Rieken S, Bernhardt D. Outcome and prognostic factors following palliative craniospinal irradiation for leptomeningeal carcinomatosis. Cancer Manag Res 2019; 11:789-801. [PMID: 30697071 PMCID: PMC6340499 DOI: 10.2147/cmar.s182154] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Leptomeningeal carcinomatosis (LC) is a severe complication of metastatic tumor spread to the central nervous system. Prognosis is dismal with a median overall survival (OS) of ~10–15 weeks. Treatment options include radiotherapy (RT) to involved sites, systemic chemo- or targeted therapy, intrathecal chemotherapy and best supportive care with dexamethasone. Craniospinal irradiation (CSI) is a more aggressive radiotherapeutic approach, for which very limited data exists. Here, we report on our 10-year experience with palliative CSI of selected patients with LC. Patients and methods Twenty-five patients received CSI for the treatment of LC at our institution between 2008 and 2018. Patients were selected individually for CSI based on clinical performance, presenting symptoms and estimated benefit. Median patient age was 53 years (IQR: 45–59), and breast cancer was the most common primary. Additional brain metastases were found in 18 patients (72.0%). RT was delivered at a TomoTherapy machine, using helical intensity-modulated radiotherapy (IMRT). The most commonly prescribed dose was 36 Gy in 20 fractions, corresponding to a median biologically equivalent dose of 40.8 Gy (IQR: 39.0–2.5). Clinical performance and neurologic function were assessed before and in response to therapy, and deficits were retrospectively quantified on the 5-point neurologic function scale (NFS). A Cox proportional hazards model with univariate and multivariate analyses was fitted for survival. Results Twenty-one patients died and four were alive at the time of analysis. Median OS from LC diagnosis was 19.3 weeks (IQR: 9.3–34.0, 95% CI: 11.0–32.0). In univariate analysis, a Karnofsky performance scale index (KPI) ≥70% (P=0.001), age ≤55 years at LC diagnosis (P=0.022), cerebrospinal fluid (CSF) protein <100 mg/dL (P=0.018) and no more than mild or moderate neurologic deficits (NFS ≤2; P=0.007) were predictive of longer OS. So were the neurologic response to treatment (P=0.018) and the application of systemic therapy after RT completion (P=0.029). The presence of CSF flow obstruction was predictive of shorter OS (P=0.026). In multivariate analysis, age at LC diagnosis (P=0.018), KPI (P<0.001) and neurologic response (P=0.037) remained as independent prognostic factors for longer OS. Treatment-associated toxicity was manageable and mostly grades I and II according to the Common Terminology Criteria for Adverse Events v4.0. Eight patients (32%) developed grade III myelosuppression. Neurologic symptom stabilization could be achieved in 40.0% and a sizeable improvement in 28.0% of all patients. Conclusion CSI for the treatment of LC is feasible and may have therapeutic value in carefully selected patients, alleviating symptoms or delaying neurologic deterioration. OS after CSI was comparable to the rates described in current literature for patients with LC. The use of modern irradiation techniques such as helical IMRT is warranted to limit toxicity. Patient selection should take into account prognostic factors such as age, clinical performance, neurologic function and the availability of systemic treatment options.
Collapse
Affiliation(s)
- Rami A El Shafie
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Karina Böhm
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Dorothea Weber
- Institute of Medical Biometry and Informatics (IMBI), Heidelberg University Hospital, Heidelberg 69120, Germany
| | - Kristin Lang
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Fabian Schlaich
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Sebastian Adeberg
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Angela Paul
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Heidelberg 69120, Germany
| | - Matthias F Haefner
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Sonja Katayama
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Florian Sterzing
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Department of Radiation Oncology, Klinikum Kempten, Kempten 87439, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| | - Sarah Löw
- Department of Neurology, University Hospital of Heidelberg, Heidelberg 69120, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Heidelberg 69120, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Heidelberg 69120, Germany.,German Cancer Research Center (DKFZ), Heidelberg 69120, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany, .,Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Heidelberg 69120, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany, .,National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg 69120, Germany,
| |
Collapse
|
16
|
El Shafie RA, Böhm K, Weber D, Lang K, Schlaich F, Adeberg S, Paul A, Haefner MF, Katayama S, Hörner-Rieber J, Hoegen P, Löw S, Debus J, Rieken S, Bernhardt D. Palliative Radiotherapy for Leptomeningeal Carcinomatosis-Analysis of Outcome, Prognostic Factors, and Symptom Response. Front Oncol 2019; 8:641. [PMID: 30671384 PMCID: PMC6331444 DOI: 10.3389/fonc.2018.00641] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 12/06/2018] [Indexed: 12/18/2022] Open
Abstract
Introduction: The purpose of this article is to report our institution's 10-year experience on palliative radiotherapy for the treatment of leptomeningeal carcinomatosis (LC), assessing survival, neurologic outcome, and prognostic factors. Patients and methods: We retrospectively analyzed 110 patients who received palliative radiotherapy for LC between 2008 and 2018. The most common histologies were breast cancer (n = 43, 39.1%) and non-small cell lung cancer (NSCLC) (n = 31, 28.2%). Radiotherapy was administered as whole-brain radiotherapy (WBRT) (n = 51, 46.4%), focal spinal RT (n = 11, 10.0%) or both (n = 47, 42.7%). Twenty-five patients (22.7%) were selected for craniospinal irradiation. Clinical performance and neurologic function were quantified on the neurologic function scale (NFS) before and in response to therapy. A Cox Proportional Hazards model with univariate and multivariate analysis was fitted for survival. Results: Ninety-eight patients (89.1%) died and 12 (10.9%) were alive at the time of analysis. Median OS from LC diagnosis and from the beginning of RT was 13.9 weeks (IQR: 7.1-34.0) and 9.9 weeks (IQR: 5.3-26.3), respectively. In univariate analysis, prognostic of longer OS were a Karnofsky performance scale index (KPI) of ≥70% (HR 0.20, 95%-CI: [0.13; 0.32], p < 0.001), initially moderate neurological deficits (NFS ≤2) (HR 0.32, 95% CI: [0.19; 0.52], p < 0.001), symptom response to RT (HR 0.41, 95%-CI: [0.26; 0.67], p < 0.001) and the administration of systemic therapy (HR 0.51, 95%-CI: [0.33; 0.78], p = 0.002). Prognostic of inferior OS were high-grade myelosuppression (HR 1.78, 95% CI: [1.06; 3.00], p = 0.03) and serum LDH levels >500 U/l (HR 3.62, 95% CI: [1.76; 7.44], p < 0.001). Clinical performance, symptom response and serum LDH stayed independently prognostic for survival in multivariate analysis. RT was well-tolerated and except for grade III myelosuppression in 19 cases (17.3%), no high-grade acute toxicities were observed. Neurologic symptom stabilization was achieved in 83 cases (75.5%) and a sizeable improvement in 39 cases (35.5%). Conclusion: Radiotherapy is a well-tolerated and efficacious means of providing symptom palliation for patients with LC, delaying neurologic deterioration while probably not directly influencing survival. Prognostic factors such as clinical performance, neurologic response and serum LDH can be used for patient stratification to facilitate treatment decisions.
Collapse
Affiliation(s)
- Rami A. El Shafie
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Karina Böhm
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Dorothea Weber
- Institute of Medical Biometry and Informatics, Heidelberg University Hospital, Heidelberg, Germany
| | - Kristin Lang
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Fabian Schlaich
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Sebastian Adeberg
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Angela Paul
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias F. Haefner
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Sonja Katayama
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Philipp Hoegen
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Sarah Löw
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology (E050), German Cancer Research Center (DKFZ), Heidelberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| |
Collapse
|
17
|
Suzuki R, Wei X, Allen PK, Welsh JW, Cox JD, Komaki R, Lin SH. Outcomes of re-irradiation for brain recurrence after prophylactic or therapeutic whole-brain irradiation for small cell lung Cancer: a retrospective analysis. Radiat Oncol 2018; 13:258. [PMID: 30594213 PMCID: PMC6310962 DOI: 10.1186/s13014-018-1205-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 12/18/2018] [Indexed: 12/31/2022] Open
Abstract
Background Small cell lung cancer (SCLC) can recur in the brain after whole-brain irradiation (WBI). We documented outcomes after treatment of such recurrences and sought predictors of local control and overall survival (OS). Materials and methods Eighty-five patients with SCLC and brain recurrence after prophylactic or therapeutic WBI in 1998–2015 were identified and data were extracted from the medical records. Survival was estimated with the Kaplan-Meier method, and univariate and multivariate Cox proportional hazards modeling was used to identify factors associated with OS or further brain progression. Results Brain recurrence was treated by stereotactic radiosurgery (SRS) in 33 patients (39%), repeat WBI in 14 (16%), chemotherapy-only in 16 (19%), and observation in 22 (26%). Median OS time after brain recurrence (OSrec) was 4.3 months for all patients; 6-month OSrec rates were 58% after SRS, 21% after repeat WBI, 50% after chemotherapy-only, and 5% after observation (P < 0.001). Inferior OSrec was associated with poor performance status (ECOG score ≥ 3) and uncontrolled extracranial disease. Superior OSrec was associated with receipt of ≥4 chemotherapy cycles before brain recurrence and receipt of chemotherapy, SRS, or repeat WBI afterward. Receipt of chemotherapy after brain recurrence correlated with brain progression. Conclusions Some patients with brain recurrence after WBI for SCLC can survive for extended periods with appropriate intervention, especially those with adequate performance status or controlled extracranial disease.
Collapse
Affiliation(s)
- Ryoko Suzuki
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA
| | - Xiong Wei
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA
| | - Pamela K Allen
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA
| | - James W Welsh
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA
| | - James D Cox
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA
| | - Ritsuko Komaki
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA
| | - Steven H Lin
- Department of Radiation Oncology, Unit 97, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA. .,Present address: Department of Radiation Oncology, Tokyo Medical and Dental University, 1 Chome-5-45 Yushima, Bunkyō, Tokyo, 113-8510, Japan.
| |
Collapse
|
18
|
Lai SF, Chen YH, Liang THK, Hsu CY, Lien HC, Lu YS, Huang CS, Kuo SH. The breast graded prognostic assessment is associated with the survival outcomes in breast cancer patients receiving whole brain re-irradiation. J Neurooncol 2018; 138:637-647. [PMID: 29557535 DOI: 10.1007/s11060-018-2833-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 02/18/2018] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Whole brain (WB) re-irradiation for breast cancer patients with progressive brain metastasis after first-course WB radiotherapy (WBRT) is controversial. In this study, we sought to investigate the association between the molecular sub-classifications and breast-specific Graded Prognostic Assessment (GPA, which includes the Karnofsky performance status, molecular subtypes, and age as its indices) and the outcomes of breast cancer patients who received WB re-irradiation. METHODS Twenty-three breast cancer patients who received WB re-irradiation for relapsed and progressive intracranial lesions after first-course WBRT between 2004 and 2016 were retrospectively reviewed. Patients were divided according to the 4 molecular subtypes of luminal A/B (hormone receptor [HR]+/human epidermal growth factor receptor 2 [HER2]-), luminal HER2 (HR+/HER2+), HER2 (HR-/HER2+), and triple negative (HR-/HER2-). The clinical and radiological responses and survival rates after WB re-irradiation were analyzed. RESULTS At 1 month after WB re-irradiation, 13 of 23 patients (56.5%) exhibited disappearance or alleviation of neurological symptoms. The median survival time after WB re-irradiation was 2.93 months (95% confidence interval [CI], 1.79-4.08). After WB re-irradiation, patients with HER2-negative tumors had poorer median survival times than those with HER2-positive tumors (2.23 vs. 3.0 months, respectively; p = 0.022). Furthermore, patients with high breast GPA scores (2.5-4.0, n = 11) had longer median survivals than those with low-scores (0-2.0, n = 12) after WB re-irradiation (4.37 vs. 1.57 months, respectively; p < 0.005). CONCLUSIONS WB re-irradiation may be a feasible treatment option for certain breast cancer patients who develop brain metastatic lesions after first-course WBRT when these lesions are ineligible for radiosurgery or surgery.
Collapse
Affiliation(s)
- Shih-Fan Lai
- Institute of Biomedical Engineering, National Taiwan University, Taipei, Taiwan.,Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Hsuan Chen
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Tony Hsiang-Kuang Liang
- Institute of Biomedical Engineering, National Taiwan University, Taipei, Taiwan.,Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Che-Yu Hsu
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Huang-Chun Lien
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Sen Lu
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,National Taiwan University Cancer Center, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chiun-Sheng Huang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Hsin Kuo
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan. .,National Taiwan University Cancer Center, College of Medicine, National Taiwan University, Taipei, Taiwan. .,Cancer Research Center, National Taiwan University College of Medicine, Taipei, Taiwan. .,Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan.
| |
Collapse
|
19
|
Schmieder K, Keilholz U, Combs S. The Interdisciplinary Management of Brain Metastases. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 113:415-21. [PMID: 27380757 DOI: 10.3238/arztebl.2016.0415] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 02/25/2016] [Accepted: 02/25/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND 20-40% of patients with malignant tumors have one or more brain metastases in the course of their illness. Brain metastases are the first manifestation of cancer in 5-10%. Manifestations such as intracranial hypertension or focal neurologic deficits are seen in over 80% of patients with brain metastases. Uncertainty surrounds the treatment of patients with intracranial metastases, as the existing data are derived from trials with low levels of evidence. METHODS This article is based on a selective literature review and on the authors' own experience of 100 consecutive patients who underwent surgery at the Department of Neurosurgery at Ruhr University Bochum (RUB), Germany. RESULTS Multimodal treatment enables successful surgery for an increasing number of patients with brain metastases. The modalities and goals of treatment are established for each patient individually by an interdisciplinary tumor board. Drug therapy is usually indicated. Surgical resection followed by stereotactic radiotherapy prolongs mean survival by 3-6 months and lowers the risk of recurrence from 40% to 12.5%. In the authors' own experience, even seriously ill patients can benefit from the resection of brain metastases. The 30-day morbidity was 29%, accounted for mainly by medical complications such as pulmonary embolism, renal failure, and sepsis. CONCLUSION Through the close interdisciplinary collaboration of neurosurgeons, radiation oncologists, and medical oncologists, the symptomatic state and the prognosis of patients with brain metastases can be improved. Longer overall survival implies that further studies will have to pay special attention to the toxicity of treatment.
Collapse
Affiliation(s)
- Kirsten Schmieder
- Department of Neurosurgery, Ruhr University Bochum, Charité Comprehensive Cancer Center, Berlin, Department of Radiation Oncology, Technical University of Munich
| | | | | |
Collapse
|
20
|
Bernhardt D, Adeberg S, Bozorgmehr F, Opfermann N, Hörner-Rieber J, König L, Kappes J, Thomas M, Unterberg A, Herth F, Heußel CP, Warth A, Debus J, Steins M, Rieken S. Outcome and prognostic factors in single brain metastases from small-cell lung cancer. Strahlenther Onkol 2017; 194:98-106. [PMID: 29085978 DOI: 10.1007/s00066-017-1228-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 10/12/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE Whole brain radiation therapy (WBRT) is historically the standard of care for patients with brain metastases (BM) from small-cell lung cancer (SCLC), although locally ablative treatments are the standard of care for patients with 1-4 BM from other solid tumors. The objective of this analysis was to find prognostic factors influencing overall survival (OS) and intracranial progression-free survival (iPFS) in SCLC patients with single BM (SBM) treated with WBRT. METHODS A total of 52 patients were identified in the authors' cancer center database with histologically confirmed SCLC and contrast-enhanced magnet resonance imaging (MRI) or computed tomography (CT), which confirmed SBM between 2006 and 2015 and were therefore treated with WBRT. A Kaplan-Meier survival analysis was performed for OS analyses. The log-rank (Mantel-Cox) test was used to compare survival curves. Univariate Cox proportional-hazards ratios (HRs) were used to assess the influence of cofactors on OS and iPFS. RESULTS The median OS after WBRT was 5 months and the median iPFS after WBRT 16 months. Patients that received surgery prior to WBRT had a significantly longer median OS of 19 months compared to 5 months in the group receiving only WBRT (p = 0.03; HR 2.24; 95% confidence interval [CI] 1.06-4.73). Patients with synchronous disease had a significantly longer OS compared to patients with metachronous BM (6 months vs. 3 months, p = 0.005; HR 0.27; 95% CI 0.11-0.68). Univariate analysis for OS revealed a statistically significant effect for metachronous disease (HR 2.25; 95% CI 1.14-4.46; p = 0.019), initial response to first-line chemotherapy (HR 0.58; 95% CI 0.35-0.97; p = 0.04), and surgical resection (HR 0.36; 95% CI 0.15-0.88; p = 0.026). OS was significantly affected by metachronous disease in multivariate analysis (HR 2.20; 95% CI 1.09-4.45; p = 0.028). CONCLUSIONS Univariate analysis revealed that surgery followed by WBRT can improve OS in patients with SBM in SCLC. Furthermore, synchronous disease and response to initial chemotherapy appeared to be major prognostic factors. Multivariate analysis revealed metachronous disease as a significantly negative prognostic factor on OS. The value of WBRT, stereotactic radiosurgery (SRS), or surgery alone or in combination for patients with a limited number of BM in SCLC should be evaluated in further prospective clinical trials.
Collapse
Affiliation(s)
- Denise Bernhardt
- Department of Radiation Oncology, INF 400, University Hospital Heidelberg, 69120, Heidelberg, Germany. .,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany. .,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany.
| | - Sebastian Adeberg
- Department of Radiation Oncology, INF 400, University Hospital Heidelberg, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany
| | - Farastuk Bozorgmehr
- Department of Thoracic Oncology, Thoraxklinik, Translational Lung Research Centre Heidelberg (TLRC-H), Heidelberg University, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Nils Opfermann
- Department of Radiation Oncology, INF 400, University Hospital Heidelberg, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, INF 400, University Hospital Heidelberg, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, INF 400, University Hospital Heidelberg, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany
| | - Jutta Kappes
- Department of Pneumology, Thoraxklinik, Heidelberg University, Heidelberg, Germany
| | - Michael Thomas
- Department of Thoracic Oncology, Thoraxklinik, Translational Lung Research Centre Heidelberg (TLRC-H), Heidelberg University, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, INF 400, University Hospital Heidelberg, 69120, Heidelberg, Germany
| | - Felix Herth
- Department of Pneumology, Thoraxklinik, Heidelberg University, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Claus Peter Heußel
- Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany.,Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.,Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany
| | - Arne Warth
- Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany.,Institute of Pathology, Heidelberg University, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, INF 400, University Hospital Heidelberg, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany
| | - Martin Steins
- Department of Thoracic Oncology, Thoraxklinik, Translational Lung Research Centre Heidelberg (TLRC-H), Heidelberg University, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, INF 400, University Hospital Heidelberg, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| |
Collapse
|
21
|
Logie N, Jimenez RB, Pulenzas N, Linden K, Ciafone D, Ghosh S, Xu Y, Lefresne S, Wong E, Son CH, Shih HA, Wong WW, Tyldesley S, Dennis K, Chow E, Fairchild AM. Estimating prognosis at the time of repeat whole brain radiation therapy for multiple brain metastases: The reirradiation score. Adv Radiat Oncol 2017; 2:381-390. [PMID: 29114606 PMCID: PMC5605302 DOI: 10.1016/j.adro.2017.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/07/2017] [Accepted: 05/31/2017] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Whole brain radiation therapy (WBRT) remains the standard of care for patients with multiple brain metastases, but more than half of treated patients will develop intracranial progression. Because there is no clear consensus on the optimal therapeutic approach, a prognostic index would be helpful to guide treatment options at progression. We explored whether the recursive partitioning analysis (RPA) score prior to repeat WBRT is predictive of survival. METHODS AND MATERIALS This multi-institutional pooled analysis included patients with 2 or more brain metastases from any solid primary tumor that was treated with 2 courses of WBRT. Information on demographics, disease characteristics, and intervals between courses was collected. RPA class was abstracted or retrospectively assigned, and descriptive statistics calculated. Median survival (MS) was determined using the Kaplan-Meier method and compared using log rank tests. Univariate and multivariate analyses were performed via Cox regression analysis. RESULTS For 205 patients, the median age was 55 years (range, 25-83 years), 68% were female, 40.5% had non-small cell lung cancer, and 31.2% had small cell lung cancer. Prior to the second WBRT, 4.9% of patients were RPA class 1, 36.6% were RPA2, and 58.5% were RPA3, with an MS of 7.5 months (95% confidence interval [CI], 4.7-10.3), 5.2 months (95% CI, 3.7-6.7 months), and 2.9 months (95% CI, 2.2-2.9 months), respectively (P = .001). On univariate and multivariate analyses, a Karnofsky Performance Status of <80, extracranial metastases, interval between courses <9 months, small cell lung cancer histology, and uncontrolled primary significantly correlated with shorter MS. By assigning a score of 1 to each of these factors, a new prognostic index was created, the reirradiation (ReRT) score. Survival on the basis of ReRT score grouping ranged from 2.2 to 7.2 months and demonstrated significant differences in MS. CONCLUSIONS In the largest reported cohort to receive repeat WBRT, application of the RPA score was not predictive of MS. The new ReRT score is a simple tool based on readily available clinical information.
Collapse
Affiliation(s)
- Natalie Logie
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Rachel B. Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Natalie Pulenzas
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kelly Linden
- Division of Radiation Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada
| | - Denise Ciafone
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Sunita Ghosh
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Yuhui Xu
- Division of Radiation Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada
| | - Shilo Lefresne
- Department of Radiation Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Erin Wong
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Christina H. Son
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Helen A. Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - William W. Wong
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Scott Tyldesley
- Department of Radiation Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Kristopher Dennis
- Division of Radiation Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada
| | - Edward Chow
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alysa M. Fairchild
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| |
Collapse
|
22
|
Outcome and prognostic factors in patients with brain metastases from small-cell lung cancer treated with whole brain radiotherapy. J Neurooncol 2017; 134:205-212. [PMID: 28560661 DOI: 10.1007/s11060-017-2510-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 05/20/2017] [Indexed: 12/20/2022]
Abstract
The purpose of this study was to evaluate prognostic factors associated with overall survival (OS) and neurological progression free survival (nPFS) in small-cell lung cancer (SCLC) patients with brain metastases who received whole-brain radiotherapy (WBRT). From 2003 to 2015, 229 SCLC patients diagnosed with brain metastases who received WBRT were analyzed retrospectively. In this cohort 219 patients (95%) received a total photon dose of 30 Gy in 10 fractions. The prognostic factors evaluated for OS and nPFS were: age, Karnofsky Performance Status (KPS), number of brain metastases, synchronous versus metachronous disease, initial response to chemotherapy, the Radiation Therapy Oncology Group recursive partitioning analysis (RPA) class and thoracic radiation. Median OS after WBRT was 6 months and the median nPFS after WBRT was 11 months. Patients with synchronous cerebral metastases had a significantly better median OS with 8 months compared to patients with metachronous metastases with a median survival of 3 months (p < 0.0001; HR 0.46; 95% CI 0.31-0.67). Based on RPA classification median survival after WBRT was 17 months in RPA class I, 7 months in class II and 3 months in class III (p < 0.0001). Karnofsky performance status scale (KPS < 70%) was significantly associated with OS in both univariate (HR 2.84; p < 0.001) and multivariate analyses (HR 2.56; p = 0.011). Further, metachronous brain metastases (HR 1.8; p < 0.001), initial response to first-line chemotherapy (HR 0.51, p < 0.001) and RPA class III (HR 2.74; p < 0.001) were significantly associated with OS in univariate analysis. In multivariate analysis metachronous disease (HR 1.89; p < 0.001) and initial response to chemotherapy (HR 0.61; p < 0.001) were further identified as significant prognostic factors. NPFS was negatively significantly influenced by poor KPS (HR 2.56; p = 0.011), higher number of brain metastases (HR 1.97; p = 0.02), and higher RPA class (HR 2.26; p = 0.03) in univariate analysis. In this series, the main prognostic factors associated with OS were performance status, time of appearance of intracranial disease (synchronous vs. metachronous), initial response to chemotherapy and higher RPA class. NPFS was negatively influenced by poor KPS, multiplicity of brain metastases, and higher RPA class in univariate analysis. For patients with low performance status, metachronous disease or RPA class III, WBRT should be weighed against supportive therapy with steroids alone or palliative chemotherapy.
Collapse
|
23
|
Phillips C, Jeffree R, Khasraw M. Management of breast cancer brain metastases: A practical review. Breast 2017; 31:90-98. [DOI: 10.1016/j.breast.2016.10.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 10/07/2016] [Accepted: 10/10/2016] [Indexed: 11/26/2022] Open
|
24
|
Bernhardt D, Bozorgmehr F, Adeberg S, Opfermann N, von Eiff D, Rieber J, Kappes J, Foerster R, König L, Thomas M, Debus J, Steins M, Rieken S. Outcome in patients with small cell lung cancer re-irradiated for brain metastases after prior prophylactic cranial irradiation. Lung Cancer 2016; 101:76-81. [DOI: 10.1016/j.lungcan.2016.09.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 09/09/2016] [Accepted: 09/13/2016] [Indexed: 11/29/2022]
|
25
|
Specht HM, Kessel KA, Oechsner M, Meyer B, Zimmer C, Combs SE. HFSRT of the resection cavity in patients with brain metastases. Strahlenther Onkol 2016; 192:368-76. [PMID: 26964777 DOI: 10.1007/s00066-016-0955-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 02/03/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE Aim of this single center, retrospective study was to assess the efficacy and safety of linear accelerator-based hypofractionated stereotactic radiotherapy (HFSRT) to the resection cavity of brain metastases after surgical resection. Local control (LC), locoregional control (LRC = new brain metastases outside of the treatment volume), overall survival (OS) as well as acute and late toxicity were evaluated. PATIENTS AND METHODS 46 patients with large (> 3 cm) or symptomatic brain metastases were treated with HFSRT. Median resection cavity volume was 14.16 cm(3) (range 1.44-38.68 cm(3)) and median planning target volume (PTV) was 26.19 cm(3) (range 3.45-63.97 cm(3)). Patients were treated with 35 Gy in 7 fractions prescribed to the 95-100 % isodose line in a stereotactic treatment setup. LC and LRC were assessed by follow-up magnetic resonance imaging. RESULTS The 1-year LC rate was 88 % and LRC was 48 %; 57% of all patients showed cranial progression after HFSRT (4% local, 44% locoregional, 9% local and locoregional). The median follow-up was 19 months; median OS for the whole cohort was 25 months. Tumor histology and recursive partitioning analysis score were significant predictors for OS. HFSRT was tolerated well without any severe acute side effects > grade 2 according to CTCAE criteria. CONCLUSION HFSRT after surgical resection of brain metastases was tolerated well without any severe acute side effects and led to excellent LC and a favorable OS. Since more than half of the patients showed cranial progression after local irradiation of the resection cavity, close patient follow-up is warranted. A prospective evaluation in clinical trials is currently being performed.
Collapse
Affiliation(s)
- Hanno M Specht
- Klinik für RadioOnkologie und Strahlentherapie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany
| | - Kerstin A Kessel
- Klinik für RadioOnkologie und Strahlentherapie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany.,Institut für Innovative Radiotherapie, Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Oberschleißheim, Germany
| | - Markus Oechsner
- Klinik für RadioOnkologie und Strahlentherapie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, 81675, Munich, Germany
| | - Claus Zimmer
- Abteilung Neuroradiologie, Klinikum rechts der Isar, Technische Universität München, 81675, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung, Technische Universität München, 81675, Munich, Germany
| | - Stephanie E Combs
- Klinik für RadioOnkologie und Strahlentherapie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany. .,Institut für Innovative Radiotherapie, Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Oberschleißheim, Germany. .,Deutsches Konsortium für Translationale Krebsforschung, Technische Universität München, 81675, Munich, Germany.
| |
Collapse
|
26
|
Aktan M, Koc M, Kanyilmaz G, Tezcan Y. Outcomes of reirradiation in the treatment of patients with multiple brain metastases of solid tumors: a retrospective analysis. ANNALS OF TRANSLATIONAL MEDICINE 2016; 3:325. [PMID: 26734635 DOI: 10.3978/j.issn.2305-5839.2015.12.21] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Patients with multiple brain metastases are often treated with whole brain radiation therapy (WBRT). Second course of WBRT is an important treatment option for patients with clinical or radiological intracranial disease progression. This study examines the outcomes in patients with multiple brain metastases who underwent reirradiation. METHODS We examined the medical records of 34 patients with multiple brain metastases who were treated WBRT. The median dose for the first course of WBRT was 30 Gy (range, 25-30 Gy) and for the second course 25 Gy (range, 20-30 Gy). Statistical analyses were performed with using Cox regression analyses, log-rank test and Kaplan-Meier method. RESULTS The median Karnofsky performance status (KPS) was 80 (range, 50-100) before reirradiation. Patients with KPS of >70 had a median survival of 11.4 months, compared to 2.2 months with KPS of ≤70 (P=0.012) and patients who have severe symptoms at the time of reirradiation with median survival 2.2 months while those with mild symptoms had a median of 4.8 months survival (P=0.08). The median overall survival for all patients after diagnosis of metastases was 24.7 months, after the re-irradiation WBRT (re-WBRT) it was 5.3 months (95% CI, 4.08-6.62) and from the diagnosis of primary tumor was 27.1 months (95% CI, 17.75-37.04). CONCLUSIONS In select patients who have good performance status and who do not have severe symptoms might benefit from re-WBRT and re-WBRT seems to be associated with minimal toxicity in patients treated with lower palliation doses.
Collapse
Affiliation(s)
- Meryem Aktan
- Department of Radiation Oncology, Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Mehmet Koc
- Department of Radiation Oncology, Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Gul Kanyilmaz
- Department of Radiation Oncology, Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Yilmaz Tezcan
- Department of Radiation Oncology, Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| |
Collapse
|
27
|
De Ruysscher D, Faivre-Finn C, Le Pechoux C, Peeters S, Belderbos J. High-dose re-irradiation following radical radiotherapy for non-small-cell lung cancer. Lancet Oncol 2014; 15:e620-e624. [PMID: 25456380 DOI: 10.1016/s1470-2045(14)70345-6] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
As the prognosis of lung cancer patients improves, more patients are at risk of developing local recurrence or a new primary tumour in previously irradiated areas. Technological advances in radiotherapy and imaging have made treatment of patients with high-dose re-irradiation possible, with the aim of long-term disease-free survival and even cure. However, high-dose re-irradiation with overlapping volumes of previously irradiated tissues is not without risks. Late, irreversible, and potentially serious normal tissue damage may occur because of injury to surrounding thoracic structures and organs at risk. In this Review, we aimed to report the efficacy and toxic effects of high-dose re-irradiation for locoregional recurrent non-small-cell lung cancer. Our findings indicate that high-dose re-irradiation might be beneficial in selected patients; however, patients and physicians should be aware of the scarcity of high-quality data when considering this treatment.
Collapse
Affiliation(s)
- Dirk De Ruysscher
- Radiation Oncology, University Hospitals Leuven/KU Leuven, Leuven, Belgium.
| | - Corinne Faivre-Finn
- Radiation Related Research, The Christie NHS Foundation Trust and University of Manchester, Manchester, UK
| | - Cecile Le Pechoux
- Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Stéphanie Peeters
- Radiation Oncology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - José Belderbos
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| |
Collapse
|