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Kanakarajan H, De Baene W, Gehring K, Eekers DBP, Hanssens P, Sitskoorn M. Factors associated with the local control of brain metastases: a systematic search and machine learning application. BMC Med Inform Decis Mak 2024; 24:177. [PMID: 38907265 PMCID: PMC11191176 DOI: 10.1186/s12911-024-02579-z] [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: 02/06/2024] [Accepted: 06/17/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Enhancing Local Control (LC) of brain metastases is pivotal for improving overall survival, which makes the prediction of local treatment failure a crucial aspect of treatment planning. Understanding the factors that influence LC of brain metastases is imperative for optimizing treatment strategies and subsequently extending overall survival. Machine learning algorithms may help to identify factors that predict outcomes. METHODS This paper systematically reviews these factors associated with LC to select candidate predictor features for a practical application of predictive modeling. A systematic literature search was conducted to identify studies in which the LC of brain metastases is assessed for adult patients. EMBASE, PubMed, Web-of-Science, and the Cochrane Database were searched up to December 24, 2020. All studies investigating the LC of brain metastases as one of the endpoints were included, regardless of primary tumor type or treatment type. We first grouped studies based on primary tumor types resulting in lung, breast, and melanoma groups. Studies that did not focus on a specific primary cancer type were grouped based on treatment types resulting in surgery, SRT, and whole-brain radiotherapy groups. For each group, significant factors associated with LC were identified and discussed. As a second project, we assessed the practical importance of selected features in predicting LC after Stereotactic Radiotherapy (SRT) with a Random Forest machine learning model. Accuracy and Area Under the Curve (AUC) of the Random Forest model, trained with the list of factors that were found to be associated with LC for the SRT treatment group, were reported. RESULTS The systematic literature search identified 6270 unique records. After screening titles and abstracts, 410 full texts were considered, and ultimately 159 studies were included for review. Most of the studies focused on the LC of the brain metastases for a specific primary tumor type or after a specific treatment type. Higher SRT radiation dose was found to be associated with better LC in lung cancer, breast cancer, and melanoma groups. Also, a higher dose was associated with better LC in the SRT group, while higher tumor volume was associated with worse LC in this group. The Random Forest model predicted the LC of brain metastases with an accuracy of 80% and an AUC of 0.84. CONCLUSION This paper thoroughly examines factors associated with LC in brain metastases and highlights the translational value of our findings for selecting variables to predict LC in a sample of patients who underwent SRT. The prediction model holds great promise for clinicians, offering a valuable tool to predict personalized treatment outcomes and foresee the impact of changes in treatment characteristics such as radiation dose.
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Affiliation(s)
- Hemalatha Kanakarajan
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands.
| | - Wouter De Baene
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
| | - Karin Gehring
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Daniëlle B P Eekers
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Patrick Hanssens
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Margriet Sitskoorn
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands.
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Prasad S, Alzate JD, Mullen R, Bernstein K, Qu T, Silverman J, Kondziolka D. Outcomes of Gamma Knife Radiosurgery for Brain Metastases in the Motor Cortex. Neurosurgery 2024; 94:606-613. [PMID: 37823677 DOI: 10.1227/neu.0000000000002716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/14/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To study the clinical, imaging, and survival outcomes in patients with motor cortex brain metastases treated with stereotactic radiosurgery (SRS). METHODS Imaging and clinical data were obtained from our prospective patient registry. Tumor volumes were obtained from serial imaging data. RESULTS The outcomes of 208 patients with metastases involving the motor cortex who underwent SRS between 2012 and 2021 were analyzed. A total of 279 metastases (0.01 cm 3 -12.18 cm 3 , mean 0.74 cm 3 ) were irradiated. The SRS margin dose varied from 10 to 20 Gy (mean 16.9 Gy). The overall tumor control rate was 97.8%. Perilesional edema was noted in 69 (25%) tumors at presentation. Adverse radiation effects (ARE) were noted in 6% of all tumors but were symptomatic in only 1.4%. Median time to appearance of symptomatic ARE was 8 months. Edema without ARE was observed in 13%. New focal seizures were noted in 5 patients (2%) and new generalized seizures in 1 patient (0.3%). Thirty-six patients (17%) presented with motor deficits. At final follow-up, 32 (85%) were improved or unchanged, 13 (41%) had a normal examination, 10 (31%) had mild deficits, and 9 (28%) still had moderate deficits. New remote brain metastases were found in 31% of patients at a median of 8 months. After treatment, the Karnofsky performance score distribution of the population showed an overall right shift and a median survival of 10 months. Patients with incidentally found brain metastases had significantly better survival than those presenting with deficits (median 13 vs 9 months) ( P = .048). Absence of a neurological deficit, recursive partitioning analysis Class I and II, and dose >18 Gy were each associated with a significant survival advantage. CONCLUSION SRS for motor cortex metastases is safe in most patients and effective in providing tumor control. Patients treated before neurological deficits develop show better outcomes.
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Affiliation(s)
- Shefalika Prasad
- Department of Neurosurgery, NYU Grossman School of Medicine, New York , New York , USA
- Center for Advanced Radiosurgery, NYU Langone Health, New York , New York , USA
- Jacobs School of Medicine and Biomedical Sciences, Buffalo , New York , USA
| | - Juan Diego Alzate
- Department of Neurosurgery, NYU Grossman School of Medicine, New York , New York , USA
- Center for Advanced Radiosurgery, NYU Langone Health, New York , New York , USA
| | - Reed Mullen
- Department of Neurosurgery, NYU Grossman School of Medicine, New York , New York , USA
- Center for Advanced Radiosurgery, NYU Langone Health, New York , New York , USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York , New York , USA
- Center for Advanced Radiosurgery, NYU Langone Health, New York , New York , USA
| | - Tanxia Qu
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York , New York , USA
- Center for Advanced Radiosurgery, NYU Langone Health, New York , New York , USA
| | - Joshua Silverman
- Department of Neurosurgery, NYU Grossman School of Medicine, New York , New York , USA
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York , New York , USA
- Center for Advanced Radiosurgery, NYU Langone Health, New York , New York , USA
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Grossman School of Medicine, New York , New York , USA
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York , New York , USA
- Center for Advanced Radiosurgery, NYU Langone Health, New York , New York , USA
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Samanci Y, Ali Tepebasili M, Deniz Ardor G, Haluk Duzkalir A, Orbay Askeroglu M, Peker S. Efficacy of hypofractionated Gamma Knife radiosurgery in treating surgical beds of metastatic brain tumors. J Clin Neurosci 2024; 121:105-113. [PMID: 38387112 DOI: 10.1016/j.jocn.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/01/2024] [Accepted: 02/17/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVE Surgery alone for metastatic brain tumors (METs) often results in local recurrence due to microscopic residual tumor tissue. While stereotactic radiosurgery (SRS) is commonly used post-surgery, hypofractionation may be required for large surgical beds. This study evaluated the efficacy and safety of hypofractionated Gamma Knife radiosurgery (hf-GKRS) for the first time as a post-operative adjuvant therapy. METHODS This retrospective study involved 24 patients (28 surgical beds) who underwent hf-GKRS within four weeks after surgery. The study primarily focused on local control (LC) rate and analyzed distant intracranial failure (DICF), intracranial progression-free survival (PFS), leptomeningeal disease (LMD), overall survival (OS), and radiation necrosis (RN). RESULTS During a median follow-up of 9 months, LC was achieved in 89.3 % of surgical beds. LC estimates at 6, 12, and 24 months were 96.4 %, 82.7 %, and 82.7 %, respectively. DICF was observed in 45.8 % of patients, and LMD was identified in two patients (8.3 %). At the end of the follow-up, 58.3 % of patients were alive, and the median OS was 20 months. RN occurred in only one surgical bed (3.6 %). No grade 5 toxicity was observed. The univariate analysis identified a longer interval to GKRS (HR 11.842, p = 0.042) and a larger treatment volume (HR 1.103, p = 0.037) as significant factors for local failure. CONCLUSIONS hf-GKRS shows potential as an effective and safe adjuvant treatment for surgical beds. It offers an alternative to SRS, SRT, or WBRT, particularly for larger volumes or tumors near critical structures. Further research is needed to confirm these results and optimize treatment approaches.
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Affiliation(s)
- Yavuz Samanci
- Koc University School of Medicine, Department of Neurosurgery, Istanbul, Turkey
| | | | - Gokce Deniz Ardor
- Koc University Hospital, Department of Neurosurgery, Gamma Knife Center, Istanbul, Turkey
| | - Ali Haluk Duzkalir
- Koc University Hospital, Department of Neurosurgery, Gamma Knife Center, Istanbul, Turkey
| | - M Orbay Askeroglu
- Koc University Hospital, Department of Neurosurgery, Gamma Knife Center, Istanbul, Turkey
| | - Selcuk Peker
- Koc University School of Medicine, Department of Neurosurgery, Istanbul, Turkey.
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Bander ED, El Ahmadieh TY, Chen J, Reiner AS, Brown S, Giantini-Larsen AM, Young RJ, Beal K, Imber BS, Pike LRG, Brennan CW, Tabar V, Panageas KS, Moss NS. Outcomes Following Early Postoperative Adjuvant Radiosurgery for Brain Metastases. JAMA Netw Open 2023; 6:e2340654. [PMID: 37906192 PMCID: PMC10618851 DOI: 10.1001/jamanetworkopen.2023.40654] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/19/2023] [Indexed: 11/02/2023] Open
Abstract
Importance Adjuvant stereotactic radiosurgery (SRS) enhances the local control of resected brain metastases (BrM). However, the risks of local failure (LF) and potential for posttreatment adverse radiation effects (PTRE) after early postoperative adjuvant SRS have not yet been established. Objective To evaluate whether adjuvant SRS delivered within a median of 14 days after surgery is associated with improved LF without a concomitant increase in PTRE. Design, Setting, and Participants This prospective cohort study examines a clinical workflow (RapidRT) that was implemented from 2019 to 2022 to deliver SRS to surgical patients within a median of 14 days, ensuring all patients were treated within 30 days postoperatively. This prospective cohort was compared with a historical cohort (StanRT) of patients with BrM resected between 2013 and 2019 to assess the association of the RapidRT workflow with LF and PTRE. The 2 cohorts were combined to identify optimal SRS timing, with a median follow-up of 3.3 years for survivors. Exposure Timing of adjuvant SRS (14, 21, and 30 days postoperatively). Main Outcomes and Measures LF and PTRE, according to modified Response Assessment in Neuro-Oncology Brain Metastases criteria. Results There were 438 patients (265 [60.5%] female patients; 23 [5.3%] Asian, 27 [6.2%] Black, and 364 [83.1%] White patients) with a mean (SD) age of 62 (13) years; 377 were in the StanRT cohort and 61 in the RapidRT cohort. LF and PTRE rates at 1 year were not significantly different between RapidRT and StanRT cohorts. Timing of SRS was associated with radiographic PTRE. Patients receiving radiation within 14 days had the highest 1-year PTRE rate (18.08%; 95% CI, 8.31%-30.86%), and patients receiving radiation between 22 and 30 days had the lowest 1-year PTRE rate (4.10%; 95% CI, 1.52%-8.73%; P = .03). LF rates were highest for patients receiving radiation more than 30 days from surgery (10.65%; 95% CI, 6.90%-15.32%) but comparable for patients receiving radiation within 14 days, between 15 and 21 days, and between 22 and 30 days (≤14 days: 5.12%; 95% CI, 0.86%-15.60%; 15 to ≤21 days: 3.21%; 95% CI, 0.59%-9.99%; 22 to ≤30 days: 6.58%; 95% CI, 3.06%-11.94%; P = .20). Conclusions and Relevance In this cohort study of adjuvant SRS timing following surgical resection of BrM, the optimal timing for adjuvant SRS appears to be within 22 to 30 days following surgery. The findings of this study suggest that this timing allows for a balanced approach that minimizes the risks associated with LF and PTRE.
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Affiliation(s)
- Evan D. Bander
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical College, New York
| | - Tarek Y. El Ahmadieh
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Neurosurgery, Loma Linda University Health, Loma Linda, California
| | - Justin Chen
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne S. Reiner
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Samantha Brown
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alexandra M. Giantini-Larsen
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical College, New York
| | - Robert J. Young
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kathryn Beal
- Department of Radiation Oncology and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Brandon S. Imber
- Department of Radiation Oncology and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Luke R. G. Pike
- Department of Radiation Oncology and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cameron W. Brennan
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Viviane Tabar
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katherine S. Panageas
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nelson S. Moss
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
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Le Reun E, Granzotto A, Pêtre A, Bodgi L, Beldjoudi G, Lacornerie T, Vallet V, Bouchet A, Al-Choboq J, Bourguignon M, Thariat J, Bourhis J, Lartigau E, Foray N. Influence of the Hypersensitivity to Low Dose Phenomenon on the Tumor Response to Hypofractionated Stereotactic Body Radiation Therapy. Cancers (Basel) 2023; 15:3979. [PMID: 37568795 PMCID: PMC10416967 DOI: 10.3390/cancers15153979] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/30/2023] [Accepted: 08/03/2023] [Indexed: 08/13/2023] Open
Abstract
Stereotactic body radiation therapy (SBRT) has made the hypofractionation of high doses delivered in a few sessions more acceptable. While the benefits of hypofractionated SBRT have been attributed to additional vascular, immune effects, or specific cell deaths, a radiobiological and mechanistic model is still needed. By considering each session of SBRT, the dose is divided into hundreds of minibeams delivering some fractions of Gy. In such a dose range, the hypersensitivity to low dose (HRS) phenomenon can occur. HRS produces a biological effect equivalent to that produced by a dose 5-to-10 times higher. To examine whether HRS could contribute to enhancing radiation effects under SBRT conditions, we exposed tumor cells of different HRS statuses to SBRT. Four human HRS-positive and two HRS-negative tumor cell lines were exposed to different dose delivery modes: a single dose of 0.2 Gy, 2 Gy, 10 × 0.2 Gy, and a single dose of 2 Gy using a non-coplanar isocentric minibeams irradiation mode were delivered. Anti-γH2AX immunofluorescence, assessing DNA double-strand breaks (DSB), was applied. In the HRS-positive cells, the DSB produced by 10 × 0.2 Gy and 2 Gy, delivered by tens of minibeams, appeared to be more severe, and they provided more highly damaged cells than in the HRS-negative cells, suggesting that more severe DSB are induced in the "SBRT modes" conditions when HRS occurs in tumor. Each SBRT session can be viewed as hyperfractionated dose delivery by means of hundreds of low dose minibeams. Under current SBRT conditions (i.e., low dose per minibeam and not using ultra-high dose-rate), the response of HRS-positive tumors to SBRT may be enhanced significantly. Interestingly, similar conclusions were reached with HRS-positive and HRS-negative untransformed fibroblast cell lines, suggesting that the HRS phenomenon may also impact the risk of post-RT tissue overreactions.
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Affiliation(s)
- Eymeric Le Reun
- U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon-Bérard, Inserm, 28 Rue Laennec, 69008 Lyon, France; (E.L.R.); (A.G.); (A.P.); (A.B.); (J.A.-C.); (M.B.)
- Service de Radio-Oncologie, Centre Hospitalier Universitaire Vaudois (CHUV), 46 Rue du Bugnon, 1011 Lausanne, Switzerland; (V.V.); (J.B.)
| | - Adeline Granzotto
- U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon-Bérard, Inserm, 28 Rue Laennec, 69008 Lyon, France; (E.L.R.); (A.G.); (A.P.); (A.B.); (J.A.-C.); (M.B.)
| | - Adeline Pêtre
- U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon-Bérard, Inserm, 28 Rue Laennec, 69008 Lyon, France; (E.L.R.); (A.G.); (A.P.); (A.B.); (J.A.-C.); (M.B.)
- Département de Radiothérapie, Centre Léon-Bérard, 28 Rue Laennec, 69008 Lyon, France;
| | - Larry Bodgi
- Department of Radiation Oncology, American University of Beirut Medical Center, Riad El-Solh, Beirut 1107-2020, Lebanon;
| | - Guillaume Beldjoudi
- Département de Radiothérapie, Centre Léon-Bérard, 28 Rue Laennec, 69008 Lyon, France;
| | - Thomas Lacornerie
- Département de Radiothérapie, Centre Oscar-Lambret, 3 Rue Frédéric Combemale, 59000 Lille, France; (T.L.); (E.L.)
| | - Véronique Vallet
- Service de Radio-Oncologie, Centre Hospitalier Universitaire Vaudois (CHUV), 46 Rue du Bugnon, 1011 Lausanne, Switzerland; (V.V.); (J.B.)
| | - Audrey Bouchet
- U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon-Bérard, Inserm, 28 Rue Laennec, 69008 Lyon, France; (E.L.R.); (A.G.); (A.P.); (A.B.); (J.A.-C.); (M.B.)
| | - Joëlle Al-Choboq
- U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon-Bérard, Inserm, 28 Rue Laennec, 69008 Lyon, France; (E.L.R.); (A.G.); (A.P.); (A.B.); (J.A.-C.); (M.B.)
| | - Michel Bourguignon
- U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon-Bérard, Inserm, 28 Rue Laennec, 69008 Lyon, France; (E.L.R.); (A.G.); (A.P.); (A.B.); (J.A.-C.); (M.B.)
- Département de Biophysique et Médecine Nucléaire, Université Paris Saclay, Versailles St. Quentin en Yvelines, 78035 Versailles, France
| | - Juliette Thariat
- Département de Radiothérapie, Centre François-Baclesse, 3 Avenue du Général Harris, 14076 Caen, France;
| | - Jean Bourhis
- Service de Radio-Oncologie, Centre Hospitalier Universitaire Vaudois (CHUV), 46 Rue du Bugnon, 1011 Lausanne, Switzerland; (V.V.); (J.B.)
| | - Eric Lartigau
- Département de Radiothérapie, Centre Oscar-Lambret, 3 Rue Frédéric Combemale, 59000 Lille, France; (T.L.); (E.L.)
| | - Nicolas Foray
- U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon-Bérard, Inserm, 28 Rue Laennec, 69008 Lyon, France; (E.L.R.); (A.G.); (A.P.); (A.B.); (J.A.-C.); (M.B.)
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Kornhuber C, Ensminger S, Hübsch P, Janich M, Leucht CA, Vordermark D, Dietzel CT. Feasibility of a simultaneously integrated boost concept for hypofractionated stereotactic radiotherapy of unresected brain metastases. Radiat Oncol 2023; 18:88. [PMID: 37217934 DOI: 10.1186/s13014-023-02266-9] [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: 01/07/2023] [Accepted: 04/17/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND In stereotactic radiotherapy, dose is prescribed to an isodose surrounding the planning target volume (PTV). However, the desired dose inhomogeneity inside the PTV leaves the specific dose distribution to the gross tumor volume (GTV) unspecified. A simultaneously integrated boost (SIB) to the GTV could solve this shortcoming. In a retrospective planning study with 20 unresected brain metastases, a SIB approach was tested against the classical prescription. METHODS For all metastases, the GTV was isotropically enlarged by 3 mm to a PTV. Two plans were generated, one according to the classical 80% concept with 5 times 7 Gy prescribed (on D2%) to the 80% PTV surrounding isodose (with D98%(PTV) ≥ 35 Gy), and the other one following a SIB concept with 5 times 8.5 Gy average GTV dose and with D98%(PTV) ≥ 35 Gy as additional requirement. Plan pairs were compared in terms of homogeneity inside GTV, high dose in PTV rim around GTV, and dose conformity and gradients around PTV using Wilcoxon matched pairs signed rank test. RESULTS The SIB concept was superior to the classical 80% concept concerning dose homogeneity inside GTV: Heterogeneity index of GTV was in the SIB concept (median 0.0513, range 0.0397-0.0757) significantly (p = 0.001) lower than in the 80% concept (median 0.0894, range 0.0447-0.1872). Dose gradients around PTV were not inferior. The other examined measures were comparable. CONCLUSION Our stereotactic SIB concept better defines the dose distribution inside PTV and can be considered for clinical use.
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Affiliation(s)
- Christine Kornhuber
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany.
| | - Stephan Ensminger
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Patrick Hübsch
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Martin Janich
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Chris Andre Leucht
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Dirk Vordermark
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Christian T Dietzel
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
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Shiue K, Sahgal A, Lo SS. Precision Radiation for Brain Metastases With a Focus on Hypofractionated Stereotactic Radiosurgery. Semin Radiat Oncol 2023; 33:114-128. [PMID: 36990629 DOI: 10.1016/j.semradonc.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
There are multiple published randomized controlled trials supporting single-fraction stereotactic radiosurgery (SF-SRS) for patients presenting with 1 to 4 brain metastases, with the benefit of minimizing radiation-induced neurocognitive sequelae as compared to whole brain radiotherapy . More recently, the dogma of SF-SRS as the only means of delivering an SRS treatment has been challenged by hypofractionated SRS (HF-SRS). The ability to deliver 25-35 Gy in 3-5 HF-SRS fractions is a direct consequence of the evolution of radiation technologies to allow image guidance, specialized treatment planning, robotic delivery and/or patient positioning corrections in all 6 degrees-of-freedom, and frameless head immobilization. The intent is to mitigate the potentially devastating complication of radiation necrosis and improve rates of local control for larger metastases. This narrative review provides an overview of outcomes specific to HF-SRS in addition to the more recent developments of staged SRS, preoperative SRS, and hippocampal avoidance-whole brain radiotherapy with simultaneous integrated boost.
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Dosimetric Parameters in Hypofractionated Stereotactic Radiotherapy for Brain Metastases: Do Flattening Filter-Free Beams Bring Benefits? A Preliminary Study. Cancers (Basel) 2023; 15:cancers15030678. [PMID: 36765636 PMCID: PMC9913515 DOI: 10.3390/cancers15030678] [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: 12/19/2022] [Revised: 01/14/2023] [Accepted: 01/20/2023] [Indexed: 01/24/2023] Open
Abstract
PURPOSE This study aimed to compare the dosimetric results of flattening filter-free (FFF) vs. flattened (FF) treatment plans for fractionated stereotactic radiotherapy (fSRT), with the goal to highlight potential advantages of FFF beams. METHODS A group of 18 patients with brain metastases treated with fSRT (30 Gy delivered in 5 fractions) were included. The dosimetric parameters evaluated were: (1) physical dosimetric parameters (number of monitor units (MUs), conformity index (CI), dose gradient index (DGI), beam on time (BOT)); (2) clinical dosimetric parameters pertaining to target volume (PTV) and organs at risk (OARs). Two treatment plans were performed for all patients: one used 6 MV FFF beams and the other used 6 MV flattened beams. RESULTS A slight increase in MUs was observed for the FFF mode (+23.3 MUs). The CI showed a difference of -2.7% for the FF plans (p = 0.28), correlated with a poorer coverage of the PTV. DGI values reported in terms of PTV are in line with international recommendations and showed a +1.9% difference for FFF plans. An average BOT of 90.3 s was reported for FFF plans, which was 2.3 times shorter than that required for FF plans delivery (p ≤ 0.001). A slight decrease of PTV coverage (-1.26%, p = 0.036) for FF plans can be considered relevant, but no other significant differences were observed between the two optimizations. No statistically significant benefit of using FFF beams to reduce V20 for normal brain could be demonstrated. CONCLUSION These dosimetric results encourage the implementation of fSRT with standard flattened beams in centers where FFF linacs are not available.
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Li W, Bootsma G, Shultz D, Laperriere N, Millar BA, Cho YB, Jaffray DA, Chung C, Coolens C. Assessment of intra-fraction motion during frameless image guided Gamma Knife stereotactic radiosurgery. Phys Imaging Radiat Oncol 2023; 25:100415. [PMID: 36718356 PMCID: PMC9883231 DOI: 10.1016/j.phro.2023.100415] [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: 07/26/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023] Open
Abstract
As frameless stereotactic radiosurgery increase in use, the aim of this study was to evaluate intra-fraction motion through cone-beam CT (CBCT) and high-definition motion management (HDMM) systems. Intra-fraction motion measured between localization, repeat localization and post-treatment CBCTs were correlated to intra-faction motion indicated by the HDMM files using the Pearson coefficient (r). A total of 302 plans were reviewed from 263 patients (114 male, 149 female); 216 pairs of localization-repeat localization, and 260 localization-post-treatment CBCTs were analyzed against HDMM logs. We found the magnitude of intra-fraction motion detected by the HDMM system were larger than the corresponding CBCT results.
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Affiliation(s)
- Winnie Li
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada,Corresponding author at: Radiation Medicine Program, Princess Margaret Cancer Centre, 610 University Avenue, Level 2B, Cobalt Lounge, Toronto, ON, Canada.
| | - Gregory Bootsma
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - David Shultz
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Normand Laperriere
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Barbara-Ann Millar
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Young Bin Cho
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - David A. Jaffray
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Caroline Chung
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Catherine Coolens
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
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10
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Layer JP, Layer K, Sarria GR, Röhner F, Dejonckheere CS, Friker LL, Zeyen T, Koch D, Scafa D, Leitzen C, Köksal M, Schmeel FC, Schäfer N, Landsberg J, Hölzel M, Herrlinger U, Schneider M, Giordano FA, Schmeel LC. Five-Fraction Stereotactic Radiotherapy for Brain Metastases-A Retrospective Analysis. Curr Oncol 2023; 30:1300-1313. [PMID: 36826062 PMCID: PMC9955428 DOI: 10.3390/curroncol30020101] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/10/2023] [Accepted: 01/15/2023] [Indexed: 01/18/2023] Open
Abstract
PURPOSE To determine the safety and outcome profile of five-fraction stereotactic radiotherapy (FSRT) for brain metastases (BM), either as a definitive or adjuvant treatment. METHODS We assessed clinical data of patients receiving five fractions of 7 Gy each (cumulative physical dose of 35 Gy) to BM or surgical cavities. The primary endpoints were toxicity and radiation necrosis (RN) rates. Secondary endpoints were 1-year cumulative local control rate (LCR) and estimated overall survival (OS). RESULTS A total of 36 eligible patients receiving FSRT to a total of 49 targets were identified and included. The median follow up was 9 (1.1-56.2) months. The median age was 64.5 (34-92) years, the median ECOG score was 1, and the median Diagnostic-Specific Graded Prognostic Assessment (DS-GPA) score was 2. Treatment was well tolerated and there were no grade 3 adverse events or higher. The overall RN rate was 14.3% and the median time to RN was 12.9 (1.8-23.8) months. RN occurrence was associated with immunotherapy, young age (≤45 years), and large PTV. The cumulative 1-year local control rate was 83.1% and the estimated median local progression free-survival was 18.8 months. The estimated median overall survival was 11 (1.1-56.2) months and significantly superior in those patients presenting with RN. CONCLUSIONS FSRT with 5 × 7 Gy represents a feasible, safe, and efficient fast track approach of intensified FSRT with acceptable LC and comparable RN rates for both the adjuvant and definitive RT settings.
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Affiliation(s)
- Julian P. Layer
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
- Institute of Experimental Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Katharina Layer
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Gustavo R. Sarria
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Fred Röhner
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Cas S. Dejonckheere
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Lea L. Friker
- Institute of Experimental Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
- Institute of Neuropathology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Thomas Zeyen
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany
| | - David Koch
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Davide Scafa
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Christina Leitzen
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Mümtaz Köksal
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | | | - Niklas Schäfer
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany
| | - Jennifer Landsberg
- Department of Dermatology, University Hospital Bonn, 53127 Bonn, Germany
| | - Michael Hölzel
- Institute of Experimental Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Ulrich Herrlinger
- Division of Clinical Neuro-Oncology, Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Frank A. Giordano
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, 68167 Mannheim, Germany
| | - Leonard Christopher Schmeel
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
- Correspondence:
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11
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Vetlova ER, Banov SM, Golanov AV, Pronin IN, Antipina NA, Galkin MV. [Results of hypofractionated stereotactic radiotherapy for resected and intact large brain metastases]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:67-75. [PMID: 38054229 DOI: 10.17116/neiro20238706167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
Post-resection or isolated hypofractionated stereotactic radiotherapy (HF-SRT) is a therapeutic option for large brain metastases (>2 cm, LBMs). OBJECTIVE To compare the results of post-resection or isolated HF-SRT in patients with LBMs. MATERIAL AND METHODS A prospective study included 115 patients with 129 intact LBMs and 133 patients with 149 resected LBMs who underwent HF-SRT. Median baseline focal size was 22.5 and 28 mm, median target volume - 8.3 and 23.7 cm3, respectively. RESULTS Median follow-up was 13.9 months, median overall survival - 19.1 months. After 12 months, local recurrences developed in 17 and 31% of patients, respectively (p=0.0078). Local recurrence after 12 months developed in 23% of patients with residual tumor in postoperative cavity compared to 16% of patients after total resection (p=0.0073). After 12 months, incidence of leptomeningeal progression was 27 and 11%, respectively (p=0.033), incidence of symptomatic radiation-induced necrosis - 4 and 23%, respectively (p=0.0006). CONCLUSION Post-resection HF-SRT demonstrated better local control and less severe symptomatic radiation-induced necrosis compared to patients with intact LBMs. Incidence of leptomeningeal progression is significantly higher after resection of LBMs.
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Affiliation(s)
- E R Vetlova
- Burdenko Neurosurgical Center, Moscow, Russia
| | - S M Banov
- Burdenko Neurosurgical Center, Moscow, Russia
| | - A V Golanov
- Burdenko Neurosurgical Center, Moscow, Russia
- Russian Medical Academy of Continuing Professional Education, Moscow, Russia
| | - I N Pronin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - M V Galkin
- Burdenko Neurosurgical Center, Moscow, Russia
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12
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Carpenter DJ, Fairchild AT, Adamson JD, Fecci PE, Sampson JH, Herndon JE, Torok JA, Mullikin TC, Kim GJ, Reitman ZJ, Kirkpatrick JP, Floyd SR. Outcomes in Patients with Intact and Resected Brain Metastasis Treated with 5-Fraction Stereotactic Radiosurgery. Adv Radiat Oncol 2022; 8:101166. [PMID: 36845614 PMCID: PMC9943776 DOI: 10.1016/j.adro.2022.101166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022] Open
Abstract
Purpose Hypofractionated stereotactic radiosurgery (HF-SRS) with or without surgical resection is potentially a preferred treatment for larger or symptomatic brain metastases (BMs). Herein, we report clinical outcomes and predictive factors following HF-SRS. Methods and Materials Patients undergoing HF-SRS for intact (iHF-SRS) or resected (rHF-SRS) BMs from 2008 to 2018 were retrospectively identified. Linear accelerator-based image-guided HF-SRS consisted of 5 fractions at 5, 5.5, or 6 Gy per fraction. Time to local progression (LP), time to distant brain progression (DBP), and overall survival (OS) were calculated. Cox models assessed effect of clinical factors on OS. Fine and Gray's cumulative incidence model for competing events examined effect of factors on LP and DBP. The occurrence of leptomeningeal disease (LMD) was determined. Logistic regression examined predictors of LMD. Results Among 445 patients, median age was 63.5 years; 87% had Karnofsky performance status ≥70. Fifty-three % of patients underwent surgical resection, and 75% received 5 Gy per fraction. Patients with resected BMs had higher Karnofsky performance status (90-100, 41 vs 30%), less extracranial disease (absent, 25 vs 13%), and fewer BMs (multiple, 32 vs 67%). Median diameter of the dominant BM was 3.0 cm (interquartile range, 1.8-3.6 cm) for intact BMs and 4.6 cm (interquartile range, 3.9-5.5 cm) for resected BMs. Median OS was 5.1 months (95% confidence interval [CI], 4.3-6.0) following iHF-SRS and 12.8 months (95% CI, 10.8-16.2) following rHF-SRS (P < .01). Cumulative LP incidence was 14.5% at 18 months (95% CI, 11.4-18.0%), significantly associated with greater total GTV (hazard ratio, 1.12; 95% CI, 1.05-1.20) following iFR-SRS, and with recurrent versus newly diagnosed BMs across all patients (hazard ratio, 2.28; 95% CI, 1.01-5.15). Cumulative DBP incidence was significantly greater following rHF-SRS than iHF-SRS (P = .01), with respective 24-month rates of 50.0 (95% CI, 43.3-56.3) and 35.7% (95% CI, 29.2-42.2). LMD (57 events total; 33% nodular, 67% diffuse) was observed in 17.1% of rHF-SRS and 8.1% of iHF-SRS cases (odds ratio, 2.46; 95% CI, 1.34-4.53). Any radionecrosis and grade 2+ radionecrosis events were observed in 14 and 8% of cases, respectively. Conclusions HF-SRS demonstrated favorable rates of LC and radionecrosis in postoperative and intact settings. Corresponding LMD and RN rates were comparable to those of other studies.
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Affiliation(s)
- David J. Carpenter
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina,Corresponding author: Scott Floyd, MD, PhD
| | | | - Justus D. Adamson
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Peter E. Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - John H. Sampson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - James E. Herndon
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Jordan A. Torok
- Department of Radiation Oncology, St. Clair Hospital Cancer Center, Pittsburgh, Pennsylvania
| | - Trey C. Mullikin
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Grace J. Kim
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Zachary J. Reitman
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - John P. Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina,Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Scott R. Floyd
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
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13
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Leong JC, Mary Mercado C, Bayhon M, Mae Maala J, Rehino Yanto J, Torio E, Manuel Mariano J, Vincent Opinaldo P, Martin Magsanoc J, Mariano M, Casis R, Barredo C, Marie Sih I, Allan Torcuator R. Clinical outcomes of Hypofractionated stereotactic radiotherapy (HFSRT) among patients with brain metastases in a tertiary medical center in the Philippines. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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14
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Niwa R, Ichi S, Nomura R, Sato K. Hypofractionated Stereotactic Radiotherapy with CyberKnife for Large Arteriovenous Malformations and Arteriovenous Malformations Located in Eloquent Areas. Neurol Med Chir (Tokyo) 2022; 62:445-450. [PMID: 36070959 PMCID: PMC9637402 DOI: 10.2176/jns-nmc.2022-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Literature has yet to establish an appropriate treatment strategy for large arteriovenous malformations (AVMs) and AVMs located in eloquent areas. In this study, the treatment outcomes of hypofractionated stereotactic radiotherapy (HSRT) with CyberKnife (CK) for large AVMs and AVMs in eloquent areas were evaluated. This study retrospectively evaluated 38 consecutive patients with AVMs treated with HSRT in the Japanese Red Cross Medical Center between August 2010 and July 2015. Obliteration rates and hemorrhage rates at 3- and 5-years of follow-up were calculated. Factors for hemorrhage and obliteration were analyzed with logistic regression analysis. Fourteen (36.8%) patients had a history of hemorrhage. Twenty (52.6%) AVMs were larger than 10 mL, and 34 (89.5%) AVMs were located in eloquent areas. The majority of the AVMs (84.2%) were classified into high grades (grades 3, 4, and 5) using the Spetzler-Martin grading scale. The median modified radiosurgery-based AVM score was 2.05, and the median Virginia Radiosurgery AVM Score was 3. The mean marginal dose was 24.5 ± 2.5 Gy. Twenty-three and 15 patients received three- and five-fraction stereotactic radiotherapy, respectively. At 3 and 5 years posttreatment, two (2.0%/year) and six (6.7%/year) patients had hemorrhage with obliteration rates of 15.2% and 16.7%, respectively. AVM localization in eloquent areas was a risk factor for obliteration failure. This study revealed that HSRT with CK for large AVMs and AVMs located in eloquent areas contributed to hemorrhage risk reduction and obliteration, at least in the early stages.
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Affiliation(s)
- Ryoko Niwa
- CyberKnife Center, Japanese Red Cross Medical Center.,Department of Neurosurgery, The University of Tokyo Hospital
| | - Shunsuke Ichi
- CyberKnife Center, Japanese Red Cross Medical Center
| | - Ryutaro Nomura
- CyberKnife Center, Japanese Red Cross Medical Center.,CyberKnife Center, Chigasaki Chuo Hospital
| | - Kengo Sato
- CyberKnife Center, Japanese Red Cross Medical Center
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15
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Wu J, Li XY, Liang J, Fang DL, Yang ZJ, Wei J, Chen ZJ. Network pharmacological analysis of active components of Xiaoliu decoction in the treatment of glioblastoma multiforme. Front Genet 2022; 13:940462. [PMID: 36046228 PMCID: PMC9420933 DOI: 10.3389/fgene.2022.940462] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/29/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Glioblastoma multiforme (GBM) is the most aggressive primary nervous system brain tumor. There is still a lack of effective methods to control its progression and recurrence in clinical treatment. It is clinically found that Xiaoliu Decoction (XLD) has the effect of treating brain tumors and preventing tumor recurrence. However, its mechanism is still unclear. Methods: Search the Traditional Chinese Medicine System Pharmacology Database (TCSMP) for efficient substances for the treatment of XLD in the treatment of GBM, and target the targeted genes of the effective ingredients to construct a network. At the same time, download GBM-related gene expression data from the TCGA and GTEX databases, screen differential expression bases, and establish a drug target disease network. Through bioinformatics analysis, the target genes and shared genes of the selected Chinese medicines are analyzed. Finally, molecular docking was performed to further clarify the possibility of XLD in multiple GBMs. Results: We screened 894 differentially expressed genes in GBM, 230 XLD active ingredients and 169 predicted targets of its active compounds, of which 19 target genes are related to the differential expression of GBM. Bioinformatics analysis shows that these targets are closely related to cell proliferation, cell cycle regulation, and DNA synthesis. Finally, through molecular docking, it was further confirmed that Tanshinone IIA, the active ingredient of XLD, was tightly bound to key proteins. Conclusion: To sum up, the results of this study suggest that the mechanism of XLD in the treatment of GBM involves multiple targets and signal pathways related to tumorigenesis and development. This study not only provides a new theoretical basis for the treatment of glioblastoma multiforme with traditional Chinese medicine, but also provides a new idea for the research and development of targeted drugs for the treatment of glioblastoma multiforme.
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Affiliation(s)
- Ji Wu
- Department of Neurosurgery, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, China
| | - Xue-Yu Li
- Department of Neurosurgery, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, China
| | - Jing Liang
- Department of Pediatrics, The Second Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Da-Lang Fang
- Department of Breast and Thyroid Surgery, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, China
- *Correspondence: Da-Lang Fang, ; Zhao-Jian Yang, ; Jie Wei, ; Zhi-Jun Chen,
| | - Zhao-Jian Yang
- Department of Neurosurgery, Red Cross Hospital of Yulin City, Yulin, China
- *Correspondence: Da-Lang Fang, ; Zhao-Jian Yang, ; Jie Wei, ; Zhi-Jun Chen,
| | - Jie Wei
- Department of Hematology, People’s Hospital of Baise, Baise, China
- *Correspondence: Da-Lang Fang, ; Zhao-Jian Yang, ; Jie Wei, ; Zhi-Jun Chen,
| | - Zhi-Jun Chen
- Department of Neurosurgery, Red Cross Hospital of Yulin City, Yulin, China
- *Correspondence: Da-Lang Fang, ; Zhao-Jian Yang, ; Jie Wei, ; Zhi-Jun Chen,
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16
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Brachytherapy for central nervous system tumors. J Neurooncol 2022; 158:393-403. [PMID: 35546384 DOI: 10.1007/s11060-022-04026-3] [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: 03/14/2022] [Accepted: 04/28/2022] [Indexed: 10/18/2022]
Abstract
Radiation is a mainstay of treatment for central nervous system (CNS) tumors. Brachytherapy involves the placement of a localized/interstitial radiation source into a tumor or resection bed and has distinct advantages that can make it an attractive form of radiation when used in the appropriate setting. However, the data supporting use of brachytherapy is clouded by variability in radiation sources, techniques, delivered doses, and trial designs. The goal of this manuscript is to identify consistent themes, review the highest-level evidence and potential indications for brachytherapy in CNS tumors, as well as highlight avenues for future work. Improved understanding of the underlying biology, indications, complications, and evolving industry-academic collaborations, place brachytherapy on the brink of a resurgence.
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17
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Yan M, Zalay O, Kennedy T, Owen TE, Purzner J, Taslimi S, Purzner T, Alkins R, Moideen N, Fung AS, Moraes FY. Outcomes of Hypofractionated Stereotactic Radiotherapy for Small and Moderate-Sized Brain Metastases: A Single-Institution Analysis. Front Oncol 2022; 12:869572. [PMID: 35444935 PMCID: PMC9014302 DOI: 10.3389/fonc.2022.869572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/03/2022] [Indexed: 12/04/2022] Open
Abstract
Background Stereotactic radiosurgery (SRS) is the standard treatment for limited intracranial metastases. With the advent of frameless treatment delivery, fractionated stereotactic radiotherapy (FSRT) has become more commonly implemented given superior control and toxicity rates for larger lesions. We reviewed our institutional experience of FSRT to brain metastases without size restriction. Methods We performed a retrospective review of our institutional database of patients treated with FSRT for brain metastases. Clinical and dosimetric details were abstracted. All patients were treated in 3 or 5 fractions using LINAC-based FSRT, did not receive prior cranial radiotherapy, and had at least 6 months of MRI follow-up. Overall survival was estimated using the Kaplan–Meier method. Local failure and radionecrosis cumulative incidence rates were estimated using a competing risks model with death as the competing risk. Univariable and multivariable analyses using Fine and Gray’s proportional subdistribution hazards regression model were performed to determine covariates predictive of local failure and radionecrosis. Results We identified 60 patients and 133 brain metastases treated at our institution from 2016 to 2020. The most common histologies were lung (53%) and melanoma (25%). Most lesions were >1 cm in diameter (84.2%) and did not have previous surgical resection (88%). The median duration of imaging follow-up was 9.8 months. The median survival for the whole cohort was 20.5 months. The local failure at 12 months was 17.8% for all lesions, 22.1% for lesions >1 cm, and 13.7% for lesions ≤1 cm (p = 0.36). The risk of radionecrosis at 12 months was 7.1% for all lesions, 13.2% for lesions >1 cm, and 3.2% for lesions ≤1 cm (p = 0.15). Conclusions FSRT is safe and effective in the treatment of brain metastases of any size with excellent local control and toxicity outcomes. Prospective evaluation against single-fraction SRS is warranted for all lesion sizes.
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Affiliation(s)
- Michael Yan
- Department of Oncology, Division of Radiation Oncology, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Osbert Zalay
- Department of Oncology, Division of Radiation Oncology, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Thomas Kennedy
- Department of Oncology, Division of Radiation Oncology, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Timothy E Owen
- Department of Oncology, Division of Radiation Oncology, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - James Purzner
- Division of Neurosurgery, Department of Surgery, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Shervin Taslimi
- Division of Neurosurgery, Department of Surgery, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Teresa Purzner
- Division of Neurosurgery, Department of Surgery, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Ryan Alkins
- Division of Neurosurgery, Department of Surgery, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Nikitha Moideen
- Department of Oncology, Division of Radiation Oncology, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Andrea S Fung
- Department of Oncology, Division of Medical Oncology and Hematology, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
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18
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Ji T, Song Y, Zhao X, Wang Y, Li G. Comparison of Two Cyberknife Planning Approaches for Multiple Brain Metastases. Front Oncol 2022; 12:797250. [PMID: 35186738 PMCID: PMC8851316 DOI: 10.3389/fonc.2022.797250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/10/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose To compare the delivery efficiency, plan quality, and planned treatment volume (PTV) and normal brain dosimetry between different Cyberknife planning approaches for multiple brain metastases (MBM), and to evaluate the effects of the number of collimators on the related parameters. Methods The study included 18 cases of MBM. The Cyberknife treatment plans were classified as Separate or Combined. For the Separate plan, each lesion was targeted by the collimator auto-selection method (Conformality 2/3 collimators). For the Combined plan, a PTV including all PTVs was targeted by the collimators. Monitor units (MUs), number of nodes and beams, estimated fraction treatment time (EFTT), new conformity index (nCI), dose gradient index (GI), homogeneity index (HI), PTV minimum/maximum dose (Dmax/Dmin), volume doses (D2% and D98%), maximum doses to lenses, optic nerves, and brainstem as well as normal brain 3, 6, 10, and 12 Gy (V3Gy–V12Gy) were compared. Results Compared to the Combined plan, the Separate plan had fewer nodes and beams, shorter EFTT, smaller PTV Dmin, normal brain dose, and GI, and larger HI. The Separate plan with 2 collimators also had worse PTV coverage. In the Combined plan, more collimators increased beams, EFTT, GI, and normal brain dose but improved the PTV Dmin. Among treatments based on the Separate approach, there were obvious differences between plans for most of the items except the nCI. Fewer collimators resulted in significantly reduced beams, EFTT, PTV D98%, and normal brain dose with improved GI, although PTV Dmin and MUs were decreased while HI was increased. Conclusion Both approaches met the requirements for SRS/HFSRT. We found that Separate plans improved treatment efficiency and normal tissue dosimetry.
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19
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Loo M, Clavier JB, Attal Khalifa J, Moyal E, Khalifa J. Dose-Response Effect and Dose-Toxicity in Stereotactic Radiotherapy for Brain Metastases: A Review. Cancers (Basel) 2021; 13:cancers13236086. [PMID: 34885193 PMCID: PMC8657210 DOI: 10.3390/cancers13236086] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 11/29/2022] Open
Abstract
Simple Summary Brain metastases are one of the most frequent complications for cancer patients. Stereotactic radiosurgery is considered a cornerstone treatment for patients with limited brain metastases and the ideal dose and fractionation schedule still remain unknown. The aim of this literature review is to discuss the dose-effect relation in brain metastases treated by stereotactic radiosurgery, accounting for fractionation and technical considerations. Abstract For more than two decades, stereotactic radiosurgery has been considered a cornerstone treatment for patients with limited brain metastases. Historically, radiosurgery in a single fraction has been the standard of care but recent technical advances have also enabled the delivery of hypofractionated stereotactic radiotherapy for dedicated situations. Only few studies have investigated the efficacy and toxicity profile of different hypofractionated schedules but, to date, the ideal dose and fractionation schedule still remains unknown. Moreover, the linear-quadratic model is being debated regarding high dose per fraction. Recent studies shown the radiation schedule is a critical factor in the immunomodulatory responses. The aim of this literature review was to discuss the dose–effect relation in brain metastases treated by stereotactic radiosurgery accounting for fractionation and technical considerations. Efficacy and toxicity data were analyzed in the light of recent published data. Only retrospective and heterogeneous data were available. We attempted to present the relevant data with caution. A BED10 of 40 to 50 Gy seems associated with a 12-month local control rate >70%. A BED10 of 50 to 60 Gy seems to achieve a 12-month local control rate at least of 80% at 12 months. In the brain metastases radiosurgery series, for single-fraction schedule, a V12 Gy < 5 to 10 cc was associated to 7.1–22.5% radionecrosis rate. For three-fractions schedule, V18 Gy < 26–30 cc, V21 Gy < 21 cc and V23 Gy < 5–7 cc were associated with about 0–14% radionecrosis rate. For five-fractions schedule, V30 Gy < 10–30 cc, V 28.8 Gy < 3–7 cc and V25 Gy < 16 cc were associated with about 2–14% symptomatic radionecrosis rate. There are still no prospective trials comparing radiosurgery to fractionated stereotactic irradiation.
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Affiliation(s)
- Maxime Loo
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
- Correspondence:
| | - Jean-Baptiste Clavier
- Radiotherapy Department, Strasbourg Europe Cancer Institute (ICANS), 67033 Strasbourg, France;
| | - Justine Attal Khalifa
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
| | - Elisabeth Moyal
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
| | - Jonathan Khalifa
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
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Volumetric Response of Limited Brain Metastatic Disease to Focal Hypofractionated Radiation Therapy. Brain Sci 2021; 11:brainsci11111457. [PMID: 34827456 PMCID: PMC8615909 DOI: 10.3390/brainsci11111457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 10/25/2021] [Accepted: 10/29/2021] [Indexed: 11/25/2022] Open
Abstract
Background: This is a retrospective study aimed at assessing the volumetric response, morbidity and failure rates of hypofractionated radiation therapy (HFRT) for definitive focal management of limited brain metastasis. Methods: Patients managed with HFRT for unresected limited metastatic (≤10 lesions) brain disease were entered into an ethics-approved database. Included patients had been deemed unsuitable for surgical resection, and lesions managed with prior radiation therapy were excluded. HFRT was delivered using IMRT or VMAT with 25 Gy or 30 Gy in five fractions. Individual lesions had volumetric assessment performed at three timepoints. The primary endpoint was the change of volume from baseline (GTV0) to one month post-HFRT (GTV1) and to seven months post-HFRT (GTV7). Secondary endpoints were local failure, survival and rates of radiation necrosis. Results: One hundred and twenty-four patients with 233 lesions were managed with HFRT. Median follow-up was 23.5 months with 32 (25.8%) patients alive at censure. Median overall survival was 7.3 months with 36.3% survival at 12 months. Superior survival was predicted by smaller GTV0 (p = 0.003) and increased percentage of volumetric response (p < 0.001). Systemic therapy was delivered to 81.5% of patients. At one month post-HFRT, 206 metastases (88.4%) were available for assessment and at seven months post-HFRT, 118 metastases (50.6%) were available. Median metastasis volume at GTV0 was 1.6 cm3 (range: 0.1–19.1). At GTV1 and GTV7, this reduced to 0.7 cm3 (p < 0.001) and 0.3 cm3 (p < 0.001), respectively, correlating to percentage reductions of 54.9% and 83.3%. No significant predictors of volumetric response following HFRT were identified. Local failure was identified in 4.3% of lesions and radiation necrosis in 3.9%. Conclusion: HFRT is an effective therapy for limited metastatic disease in the brain to maximise initial volumetric response whilst minimising toxicity.
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21
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Myrehaug S, Hudson J, Soliman H, Ruschin M, Tseng CL, Detsky J, Husain Z, Keith J, Atenafu EG, Maralani P, Heyn C, Das S, Lipsman N, Sahgal A. Hypofractionated Stereotactic Radiation Therapy for Intact Brain Metastases in 5 Daily Fractions: Effect of Dose on Treatment Response. Int J Radiat Oncol Biol Phys 2021; 112:342-350. [PMID: 34537313 DOI: 10.1016/j.ijrobp.2021.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/13/2021] [Accepted: 09/01/2021] [Indexed: 01/09/2023]
Abstract
PURPOSE Multileaf collimator (MLC) linear accelerator (Linac)-based hypofractionated stereotactic radiation therapy (HSRT) is increasingly used not only for large brain metastases or those adjacent to critical structures but also for those metastases that would otherwise be considered for single-fraction radiosurgery (SRS). However, data on outcomes in general are limited, and there is a lack of understanding regarding optimal dosing. Our aim was to report mature image-based outcomes for MLC-Linac HSRT with a focus on clinical and dosimetric factors associated with local failure (LF). METHODS AND MATERIALS A total of 220 patients with 334 brain metastases treated with HSRT were identified. All patients were treated using a 5-fraction daily regimen and were followed with clinical evaluation and volumetric magnetic resonance imaging every 2 to 3 months. Overall survival and progression-free survival were calculated using the Kaplan-Meier method, with LF determined using Fine and Gray's competing risk method. Predictive factors were identified using Cox regression multivariate analysis. RESULTS Median follow-up was 10.8 months. Median size of treated metastasis was 1.9 cm; 60% of metastases were <2 cm in size. The median total dose was 30 Gy in 5 fractions; 36% of the cohort received <30 Gy. The median time to LF and 12-month cumulative incidence of LF was 8.5 months and 23.8%, respectively. Median time to death and 12-month overall survival rates were 11.8 months and 48.2%, respectively. Fifty-two metastases (15.6%) had an adverse radiation effect, of which 32 (9.5%) were symptomatic necrosis. Multivariable analysis identified worse LF in patients who received a total dose of <30 Gy (hazard ratio, 1.62; P = .03), with LF at 6 and 12 months of 13% and 33% for patients treated with <30 Gy versus 5% and 19% for patients treated with >30 Gy. Exploratory analysis demonstrated a dose-response effect observed in all histologic types, including among breast cancer subtypes. CONCLUSION Optimal local control is achieved with HSRT of ≥30 Gy in 5 daily fractions, independent of tumor volume and histology, with an acceptable risk of radiation necrosis.
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Affiliation(s)
- Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada.
| | - John Hudson
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Mark Ruschin
- Department of Medical Physics, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Julia Keith
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, Ontario, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Chris Heyn
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Sunit Das
- Department of Neurosurgery, St. Michaels Hospital, Ontario, Canada
| | - Nir Lipsman
- Department of Neurosurgery, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
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22
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Hartgerink D, Bruynzeel A, Eekers D, Swinnen A, Hurkmans C, Wiggenraad R, Swaak-Kragten A, Dieleman E, van der Toorn PP, Oei B, van Veelen L, Verhoeff J, Lagerwaard F, de Ruysscher D, Lambin P, Zindler J. A Dutch phase III randomized multicenter trial: whole brain radiotherapy versus stereotactic radiotherapy for 4-10 brain metastases. Neurooncol Adv 2021; 3:vdab021. [PMID: 33738451 PMCID: PMC7954103 DOI: 10.1093/noajnl/vdab021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background The clinical value of whole brain radiotherapy (WBRT) for brain metastases (BM) is a matter of debate due to the significant side effects involved. Stereotactic radiosurgery (SRS) is an attractive alternative treatment option that may avoid these side effects and improve local tumor control. We initiated a randomized trial (NCT02353000) to investigate whether quality of life is better preserved after SRS compared with WBRT in patients with multiple brain metastases. Methods Patients with 4-10 BM were randomized between the standard arm WBRT (total dose 20 Gy in 5 fractions) or SRS (single fraction or 3 fractions). The primary endpoint was the difference in quality of life (QOL) at 3 months post-treatment. Results The study was prematurely closed due to poor accrual. A total of 29 patients (13%) were randomized, of which 15 patients have been treated with SRS and 14 patients with WBRT. The median number of lesions were 6 (range: 4-9) and the median total treatment volume was 13.0 cc3 (range: 1.8-25.9 cc3). QOL at 3 months decreased in the SRS group by 0.1 (SD = 0.2), compared to 0.2 (SD = 0.2) in the WBRT group (P = .23). The actuarial 1-year survival rates were 57% (SRS) and 31% (WBRT) (P = .52). The actuarial 1-year brain salvage-free survival rates were 50% (SRS) and 78% (WBRT) (P = .22). Conclusion In patients with 4-10 BM, SRS alone resulted in 1-year survival for 57% of patients while maintaining quality of life. Due to the premature closure of the trial, no statistically significant differences could be determined.
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Affiliation(s)
- Dianne Hartgerink
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Anna Bruynzeel
- Department of Radiation Oncology, Amsterdam University Medical Centers, the Netherlands
| | - Danielle Eekers
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Ans Swinnen
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Coen Hurkmans
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Ruud Wiggenraad
- Department of Radiation Oncology, Haaglanden Medical Center, the Netherlands
| | | | - Edith Dieleman
- Department of Radiation Oncology, Amsterdam University Medical Centers, the Netherlands
| | | | - Bing Oei
- Department of Radiation Oncology, Verbeeten Institute Tilburg, the Netherlands
| | - Lieneke van Veelen
- Department of Radiation Oncology, Zuid-West Radiotherapy Institute Vlissingen, the Netherlands
| | - Joost Verhoeff
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Frank Lagerwaard
- Department of Radiation Oncology, Amsterdam University Medical Centers, the Netherlands
| | - Dirk de Ruysscher
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Philippe Lambin
- Department of Precision Medicine, The M-Lab, GROW - School for Oncology and Developmental Biology, Maastricht Comprehensive Cancer Centre, Maastricht University, Maastricht, the Netherlands
| | - Jaap Zindler
- Department of Radiation Oncology, Haaglanden MC, Den Haag, the Netherlands.,Holland Proton Therapy Center, Delft, the Netherlands
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Cyberknife ® hypofractionated stereotactic radiosurgery (CK-hSRS) as salvage treatment for brain metastases. J Cancer Res Clin Oncol 2021; 147:2765-2773. [PMID: 33638006 PMCID: PMC8310836 DOI: 10.1007/s00432-021-03564-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 02/10/2021] [Indexed: 11/16/2022]
Abstract
Purpose The introduction of hypofractionated stereotactic radiosurgery (hSRS) extended the treatment modalities beyond the well-established single-fraction stereotactic radiosurgery and fractionated radiotherapy. Here, we report the efficacy and side effects of hSRS using Cyberknife® (CK-hSRS) for the treatment of patients with critical brain metastases (BM) and a very poor prognosis. We discuss our experience in light of current literature. Methods All patients who underwent CK-hSRS over 3 years were retrospectively included. We applied a surface dose of 27 Gy in 3 fractions. Rates of local control (LC), systemic progression-free survival (PFS), and overall survival (OS) were estimated using Kaplan–Meier method. Treatment-related complications were rated using the Common Terminology Criteria for Adverse Events (CTCAE). Results We analyzed 34 patients with 75 BM. 53% of the patients had a large tumor, tumor location was eloquent in 32%, and deep seated in 15%. 36% of tumors were recurrent after previous irradiation. The median Karnofsky Performance Status was 65%. The actuarial rates of LC at 3, 6, and 12 months were 98%, 98%, and 78.6%, respectively. Three, 6, and 12 months PFS was 38%, 32%, and 15%, and OS was 65%, 47%, and 28%, respectively. Median OS was significantly associated with higher KPS, which was the only significant factor for survival. Complications CTCAE grade 1–3 were observed in 12%. Conclusion Our radiation schedule showed a reasonable treatment effectiveness and tolerance. Representing an optimal salvage treatment for critical BM in patients with a very poor prognosis and clinical performance state, CK-hSRS may close the gap between surgery, stereotactic radiosurgery, conventional radiotherapy, and palliative care.
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Bander ED, Yuan M, Reiner AS, Panageas KS, Ballangrud ÅM, Brennan CW, Beal K, Tabar V, Moss NS. Durable 5-year local control for resected brain metastases with early adjuvant SRS: the effect of timing on intended-field control. Neurooncol Pract 2021; 8:278-289. [PMID: 34055375 DOI: 10.1093/nop/npab005] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Adjuvant stereotactic radiosurgery (SRS) improves the local control of resected brain metastases (BrM). However, the dependency of long-term outcomes on SRS timing relative to surgery remains unclear. Methods Retrospective analysis of patients treated with metastasectomy-plus-adjuvant SRS at Memorial Sloan Kettering Cancer Center (MSK) between 2013 and 2016 was conducted. Kaplan-Meier methodology was used to describe overall survival (OS) and cumulative incidence rates were estimated by type of recurrence, accounting for death as a competing event. Recursive partitioning analysis (RPA) and competing risks regression modeling assessed prognostic variables and associated events of interest. Results Two hundred and eighty-two patients with BrM had a median OS of 1.5 years (95% CI: 1.2-2.1) from adjuvant SRS with median follow-up of 49.8 months for survivors. Local surgical recurrence, other simultaneously SRS-irradiated site recurrence, and distant central nervous system (CNS) progression rates were 14.3% (95% CI: 10.1-18.5), 4.9% (95% CI: 2.3-7.5), and 47.5% (95% CI: 41.4-53.6) at 5 years, respectively. Median time-to-adjuvant SRS (TT-SRS) was 34 days (IQR: 27-39). TT-SRS was significantly associated with surgical site recurrence rate (P = 0.0008). SRS delivered within 1 month resulted in surgical site recurrence rate of 6.1% (95% CI: 1.3-10.9) at 1-year, compared to 9.2% (95% CI: 4.9-13.6) if delivered between 1 and 2 months, or 27.3% (95% CI: 0.0-55.5) if delivered >2 months after surgery. OS was significantly lower for patients with TT-SRS >~2 months. Postoperative length of stay, discharge to a rehabilitation facility, urgent care visits, and/or disease recurrence between surgery and adjuvant SRS associated with increased TT-SRS. Conclusions Adjuvant SRS provides durable local control. However, delays in initiation of postoperative SRS can decrease its efficacy.
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Affiliation(s)
- Evan D Bander
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Neurosurgery, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, New York
| | - Melissa Yuan
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne S Reiner
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katherine S Panageas
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Åse M Ballangrud
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cameron W Brennan
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Viviane Tabar
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nelson S Moss
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
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