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Schack A, Aunan-Diop JS, Gerhardt FA, Pedersen CB, Halle B, Kofoed MS, Markovic L, Wirenfeldt M, Poulsen FR. Evaluating the Efficacy of Perfusion MRI and Conventional MRI in Distinguishing Recurrent Cerebral Metastasis from Brain Radiation Necrosis. Brain Sci 2024; 14:321. [PMID: 38671973 PMCID: PMC11048647 DOI: 10.3390/brainsci14040321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Differentiating recurrent cerebral metastasis (CM) from brain radiation necrosis (BRN) is pivotal for guiding appropriate treatment and prognostication. Despite advances in imaging techniques, however, accurately distinguishing these conditions non-invasively is still challenging. This single-center retrospective study reviewed 32 cases (28 patients) with confirmed cerebral metastases who underwent surgical excision of lesions initially diagnosed by MRI and/or MR perfusion scans from 1 January 2015 to 30 September 2020. Diagnostic accuracy was assessed by comparing imaging findings with postoperative histopathology. Conventional MRI accurately identified recurrent CM in 75% of cases. MR perfusion scans showed significantly higher mean maximum relative cerebral blood volume (max. rCBV) in metastasis cases, indicating its potential as a discriminative biomarker. No single imaging modality could definitively distinguish CM from BRN. Survival analysis revealed gender as the only significant factor affecting overall survival, with no significant survival difference observed between patients with CM and BRN after controlling for confounding factors. This study underscores the limitations of both conventional MRI and MR perfusion scans in differentiating recurrent CM from BRN. Histopathological examination remains essential for accurate diagnosis. Further research is needed to improve the reliability of non-invasive imaging and to guide the management of patients with these post-radiation events.
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Affiliation(s)
- Anders Schack
- Department of Neurosurgery, Odense University Hospital, DK-5000 Odense, Denmark
- Department of Clinical Research, BRIDGE (Brain Research—Inter Disciplinary Guided Excellence), University of Southern Denmark, DK-5230 Odense, Denmark
| | - Jan Saip Aunan-Diop
- Department of Neurosurgery, Odense University Hospital, DK-5000 Odense, Denmark
- Department of Clinical Research, BRIDGE (Brain Research—Inter Disciplinary Guided Excellence), University of Southern Denmark, DK-5230 Odense, Denmark
| | - Frederik A. Gerhardt
- Department of Neurosurgery, Odense University Hospital, DK-5000 Odense, Denmark
- Department of Clinical Research, BRIDGE (Brain Research—Inter Disciplinary Guided Excellence), University of Southern Denmark, DK-5230 Odense, Denmark
| | - Christian Bonde Pedersen
- Department of Neurosurgery, Odense University Hospital, DK-5000 Odense, Denmark
- Department of Clinical Research, BRIDGE (Brain Research—Inter Disciplinary Guided Excellence), University of Southern Denmark, DK-5230 Odense, Denmark
| | - Bo Halle
- Department of Neurosurgery, Odense University Hospital, DK-5000 Odense, Denmark
- Department of Clinical Research, BRIDGE (Brain Research—Inter Disciplinary Guided Excellence), University of Southern Denmark, DK-5230 Odense, Denmark
| | - Mikkel S. Kofoed
- Department of Neurosurgery, Odense University Hospital, DK-5000 Odense, Denmark
- Department of Clinical Research, BRIDGE (Brain Research—Inter Disciplinary Guided Excellence), University of Southern Denmark, DK-5230 Odense, Denmark
| | - Ljubo Markovic
- Department of Radiology, Odense University Hospital, DK-5000 Odense, Denmark
| | - Martin Wirenfeldt
- Department of Pathology, University Hospital of Southern Denmark, DK-6000 Esbjerg, Denmark
- Department of Regional Health Research, BRIDGE (Brain Research—Inter Disciplinary Guided Excellence), University of Southern Denmark, DK-5230 Odense, Denmark
| | - Frantz Rom Poulsen
- Department of Neurosurgery, Odense University Hospital, DK-5000 Odense, Denmark
- Department of Clinical Research, BRIDGE (Brain Research—Inter Disciplinary Guided Excellence), University of Southern Denmark, DK-5230 Odense, Denmark
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Mayo ZS, Billena C, Suh JH, Lo SS, Chao ST. The dilemma of radiation necrosis from diagnosis to treatment in the management of brain metastases. Neuro Oncol 2024; 26:S56-S65. [PMID: 38437665 PMCID: PMC10911797 DOI: 10.1093/neuonc/noad188] [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] [Indexed: 03/06/2024] Open
Abstract
Radiation therapy with stereotactic radiosurgery (SRS) or whole brain radiation therapy is a mainstay of treatment for patients with brain metastases. The use of SRS in the management of brain metastases is becoming increasingly common and provides excellent local control. Cerebral radiation necrosis (RN) is a late complication of radiation treatment that can be seen months to years following treatment and is often indistinguishable from tumor progression on conventional imaging. In this review article, we explore risk factors associated with the development of radiation necrosis, advanced imaging modalities used to aid in diagnosis, and potential treatment strategies to manage side effects.
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Affiliation(s)
- Zachary S Mayo
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Cole Billena
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - John H Suh
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Samuel T Chao
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
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3
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Salans M, Ni L, Morin O, Ziemer B, Capaldi DPI, Raleigh DR, Vasudevan HN, Chew J, Nakamura J, Sneed PK, Boreta L, Villanueva-Meyer JE, Theodosopoulos P, Braunstein S. Adverse radiation effect versus tumor progression following stereotactic radiosurgery for brain metastases: Implications of radiologic uncertainty. J Neurooncol 2024; 166:535-546. [PMID: 38316705 PMCID: PMC10876820 DOI: 10.1007/s11060-024-04578-6] [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: 12/22/2023] [Accepted: 01/17/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Adverse radiation effect (ARE) following stereotactic radiosurgery (SRS) for brain metastases is challenging to distinguish from tumor progression. This study characterizes the clinical implications of radiologic uncertainty (RU). METHODS Cases reviewed retrospectively at a single-institutional, multi-disciplinary SRS Tumor Board between 2015-2022 for RU following SRS were identified. Treatment history, diagnostic or therapeutic interventions performed upon RU resolution, and development of neurologic deficits surrounding intervention were obtained from the medical record. Differences in lesion volume and maximum diameter at RU onset versus resolution were compared with paired t-tests. Median time from RU onset to resolution was estimated using the Kaplan-Meier method. Univariate and multivariate associations between clinical characteristics and time to RU resolution were assessed with Cox proportional-hazards regression. RESULTS Among 128 lesions with RU, 23.5% had undergone ≥ 2 courses of radiation. Median maximum diameter (20 vs. 16 mm, p < 0.001) and volume (2.7 vs. 1.5 cc, p < 0.001) were larger upon RU resolution versus onset. RU resolution took > 6 and > 12 months in 25% and 7% of cases, respectively. Higher total EQD2 prior to RU onset (HR = 0.45, p = 0.03) and use of MR perfusion (HR = 0.56, p = 0.001) correlated with shorter time to resolution; larger volume (HR = 1.05, p = 0.006) portended longer time to resolution. Most lesions (57%) were diagnosed as ARE. Most patients (58%) underwent an intervention upon RU resolution; of these, 38% developed a neurologic deficit surrounding intervention. CONCLUSIONS RU resolution took > 6 months in > 25% of cases. RU may lead to suboptimal outcomes and symptom burden. Improved characterization of post-SRS RU is needed.
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Affiliation(s)
- Mia Salans
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
| | - Lisa Ni
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
| | - Olivier Morin
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
| | - Benjamin Ziemer
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
| | - Dante P I Capaldi
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
| | - David R Raleigh
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
- Department of Neurosurgery, University of California San Francisco (DRR, JEVM, PT), San Francisco, USA
- Department of Pathology, University of California San Francisco (DRR), San Francisco, USA
| | - Harish N Vasudevan
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
- Department of Neurosurgery, University of California San Francisco (DRR, JEVM, PT), San Francisco, USA
| | - Jessica Chew
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
| | - Jean Nakamura
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
| | - Penny K Sneed
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
| | - Lauren Boreta
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
| | - Javier E Villanueva-Meyer
- Department of Neurosurgery, University of California San Francisco (DRR, JEVM, PT), San Francisco, USA
- Department of Radiology and Biomedical Imaging, University of California San Francisco (JEVM), San Francisco, USA
| | - Philip Theodosopoulos
- Department of Neurosurgery, University of California San Francisco (DRR, JEVM, PT), San Francisco, USA
| | - Steve Braunstein
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA.
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Vellayappan B, Lim-Fat MJ, Kotecha R, De Salles A, Fariselli L, Levivier M, Ma L, Paddick I, Pollock BE, Regis J, Sheehan JP, Suh JH, Yomo S, Sahgal A. A Systematic Review Informing the Management of Symptomatic Brain Radiation Necrosis After Stereotactic Radiosurgery and International Stereotactic Radiosurgery Society Recommendations. Int J Radiat Oncol Biol Phys 2024; 118:14-28. [PMID: 37482137 DOI: 10.1016/j.ijrobp.2023.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 07/02/2023] [Accepted: 07/14/2023] [Indexed: 07/25/2023]
Abstract
Radiation necrosis (RN) secondary to stereotactic radiosurgery is a significant cause of morbidity. The optimal management of corticosteroid-refractory brain RN remains unclear. Our objective was to summarize the literature specific to efficacy and toxicity of treatment paradigms for patients with symptomatic corticosteroid-refractory RN and to provide consensus guidelines for grading and management of RN on behalf of the International Stereotactic Radiosurgery Society. A systematic review of articles pertaining to treatment of RN with bevacizumab, laser interstitial thermal therapy (LITT), surgical resection, or hyperbaric oxygen therapy was performed. The primary composite outcome was clinical and/or radiologic stability/improvement (ie, proportion of patients achieving improvement or stability with the given intervention). Proportions of patients achieving the primary outcome were pooled using random weighted-effects analysis but not directly compared between interventions. Twenty-one articles were included, of which only 2 were prospective studies. Thirteen reports were relevant for bevacizumab, 5 for LITT, 5 for surgical resection and 1 for hyperbaric oxygen therapy. Weighted effects analysis revealed that bevacizumab had a pooled symptom improvement/stability rate of 86% (95% CI 77%-92%), pooled T2 imaging improvement/stability rate of 93% (95% CI 87%-98%), and pooled T1 postcontrast improvement/stability rate of 94% (95% CI 87%-98%). Subgroup analysis showed a statistically significant improvement favoring treatment with low-dose (below median, ≤7.5 mg/kg every 3 weeks) versus high-dose bevacizumab with regards to symptom improvement/stability rate (P = .02) but not for radiologic T1 or T2 changes. The pooled T1 postcontrast improvement/stability rate for LITT was 88% (95% CI 82%-93%), and pooled symptom improvement/stability rate for surgery was 89% (95% CI 81%-96%). Toxicity was inconsistently reported but was generally low for all treatment paradigms. Corticosteroid-refractory RN that does not require urgent surgical intervention, with sufficient noninvasive diagnostic testing that favors RN, can be treated medically with bevacizumab in carefully selected patients as a strong recommendation. The role of LITT is evolving as a less invasive image guided surgical modality; however, the overall evidence for each modality is of low quality. Prospective head-to-head comparisons are needed to evaluate the relative efficacy and toxicity profile among treatment approaches.
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Affiliation(s)
- Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore.
| | - Mary Jane Lim-Fat
- Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Antonio De Salles
- Department of Neurosurgery, University of California, Los Angeles, California; HCor Neuroscience, São Paulo, Brazil
| | - Laura Fariselli
- Department of Neurosurgery, Unit of Radiotherapy, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Marc Levivier
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of Southern California, Los Angeles, California
| | - Ian Paddick
- Division Physics, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jean Regis
- Department of Functional Neurosurgery, Aix Marseille University, Timone University Hospital, Marseille, France
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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5
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Kossmann MRP, Ehret F, Roohani S, Winter SF, Ghadjar P, Acker G, Senger C, Schmid S, Zips D, Kaul D. Histopathologically confirmed radiation-induced damage of the brain - an in-depth analysis of radiation parameters and spatio-temporal occurrence. Radiat Oncol 2023; 18:198. [PMID: 38087368 PMCID: PMC10717523 DOI: 10.1186/s13014-023-02385-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Radiation-induced damage (RID) after radiotherapy (RT) of primary brain tumors and metastases can be challenging to clinico-radiographically distinguish from tumor progression. RID includes pseudoprogression and radiation necrosis; the latter being irreversible and often associated with severe symptoms. While histopathology constitutes the diagnostic gold standard, biopsy-controlled clinical studies investigating RID remain limited. Whether certain brain areas are potentially more vulnerable to RID remains an area of active investigation. Here, we analyze histopathologically confirmed cases of RID in relation to the temporal and spatial dose distribution. METHODS Histopathologically confirmed cases of RID after photon-based RT for primary or secondary central nervous system malignancies were included. Demographic, clinical, and dosimetric data were collected from patient records and treatment planning systems. We calculated the equivalent dose in 2 Gy fractions (EQD22) and the biologically effective dose (BED2) for normal brain tissue (α/β ratio of 2 Gy) and analyzed the spatial and temporal distribution using frequency maps. RESULTS Thirty-three patients were identified. High-grade glioma patients (n = 18) mostly received one normofractionated RT series (median cumulative EQD22 60 Gy) to a large planning target volume (PTV) (median 203.9 ccm) before diagnosis of RID. Despite the low EQD22 and BED2, three patients with an accelerated hyperfractionated RT developed RID. In contrast, brain metastases patients (n = 15; 16 RID lesions) were often treated with two or more RT courses and with radiosurgery or fractionated stereotactic RT, resulting in a higher cumulative EQD22 (median 162.4 Gy), to a small PTV (median 6.7 ccm). All (n = 34) RID lesions occurred within the PTV of at least one of the preceding RT courses. RID in the high-grade glioma group showed a frontotemporal distribution pattern, whereas, in metastatic patients, RID was observed throughout the brain with highest density in the parietal lobe. The cumulative EQD22 was significantly lower in RID lesions that involved the subventricular zone (SVZ) than in lesions without SVZ involvement (median 60 Gy vs. 141 Gy, p = 0.01). CONCLUSIONS Accelerated hyperfractionated RT can lead to RID despite computationally low EQD22 and BED2 in high-grade glioma patients. The anatomical location of RID corresponded to the general tumor distribution of gliomas and metastases. The SVZ might be a particularly vulnerable area.
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Affiliation(s)
- Mario R P Kossmann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Augustenburger Platz 1, 13353, Berlin, Germany
- Department of Radiotherapy and Radiation Oncology, Pius-Hospital Oldenburg, Georgstr. 12, 26121, Oldenburg, Germany
| | - Felix Ehret
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Augustenburger Platz 1, 13353, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Berlin, Germany; German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Siyer Roohani
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Augustenburger Platz 1, 13353, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Berlin, Germany; German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Sebastian F Winter
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Pirus Ghadjar
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Güliz Acker
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Augustenburger Platz 1, 13353, Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurosurgery, Charitéplatz 1, 10117, Berlin, Germany
| | - Carolin Senger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Simone Schmid
- Charité - Universitätsmedizin Berlin, Berlin, Germany; German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neuropathology, Charitéplatz 1, 10117, Berlin, Germany
| | - Daniel Zips
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Augustenburger Platz 1, 13353, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Berlin, Germany; German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - David Kaul
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Augustenburger Platz 1, 13353, Berlin, Germany.
- Charité - Universitätsmedizin Berlin, Berlin, Germany; German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany.
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Ngu S, Werner C, D' Amico RS, Wernicke AG. Whole brain radiation therapy resulting in radionecrosis: a possible link with radiosensitising chemoimmunotherapy. BMJ Case Rep 2023; 16:e256758. [PMID: 38016763 PMCID: PMC10685978 DOI: 10.1136/bcr-2023-256758] [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] [Indexed: 11/30/2023] Open
Abstract
Radionecrosis describes a rare but serious complication of radiation therapy. In clinical practice, stereotactic radiosurgery (SRS) is increasingly used in combination with systemic therapy, including chemotherapy, immune checkpoint inhibitor and targeted therapy, either concurrently or sequentially. There is a paucity of literature regarding radionecrosis in patients receiving whole brain radiation therapy (WBRT) alone (without additional SRS) in combination with immunotherapy or targeted therapies. It is observed that certain combinations increase the overall radiosensitivity of the tumorous lesions. We present a rare case of symptomatic radionecrosis almost 1 year after WBRT in a patient with non-squamous non-small cell lung cancer on third-line chemoimmunotherapy. We discuss available research regarding factors that may lead to radionecrosis in these patients, including molecular and genetic profiles, specific drug therapy combinations and their timing or increased overall survival.
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Affiliation(s)
- Sam Ngu
- Department of Hematology/Oncology, Lenox Hill Hospital, New York, New York, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Cassidy Werner
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
- Department of Neurosurgery, Lenox Hill Hospital, New York, New York, USA
| | - Randy S D' Amico
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
- Department of Neurosurgery, Lenox Hill Hospital, New York, New York, USA
| | - A Gabriella Wernicke
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
- Department of Radiation Medicine, Lenox Hill Hospital, New York, New York, USA
- Northwell Health Cancer Institute, New York, New York, USA
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7
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Snyder EJ, Sarma A, Poussaint TY, Krishnasarma R, Pruthi S. Complications of Cancer Therapy in Children: A Comprehensive Review of Neuroimaging Findings. J Comput Assist Tomogr 2023; 47:820-832. [PMID: 37707414 DOI: 10.1097/rct.0000000000001481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
ABSTRACT Complications of cancer therapy in children can result in a spectrum of neurologic toxicities that may occur at the initiation of therapy or months to years after treatment. Although childhood cancer remains rare, increasing survival rates mean that more children will be living longer after cancer treatment. Therefore, complications of cancer therapy will most likely occur with increasing frequency.At times, it is very difficult to differentiate between therapeutic complications and other entities such as tumor recurrence, development of secondary malignancy, and infection (among other conditions). Radiologists often play a key role in the diagnosis and evaluation of pediatric patients with malignancies, and thus, awareness of imaging findings of cancer complications and alternative diagnoses is essential in guiding management and avoiding misdiagnosis. The aim of this review article is to illustrate the typical neuroimaging findings of cancer therapy-related toxicities, including both early and late treatment effects, highlighting pearls that may aid in making the appropriate diagnosis.
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Affiliation(s)
- Elizabeth J Snyder
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Asha Sarma
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | | | - Rekha Krishnasarma
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Sumit Pruthi
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
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8
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Cao Y, Parekh VS, Lee E, Chen X, Redmond KJ, Pillai JJ, Peng L, Jacobs MA, Kleinberg LR. A Multidimensional Connectomics- and Radiomics-Based Advanced Machine-Learning Framework to Distinguish Radiation Necrosis from True Progression in Brain Metastases. Cancers (Basel) 2023; 15:4113. [PMID: 37627141 PMCID: PMC10452423 DOI: 10.3390/cancers15164113] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
We introduce tumor connectomics, a novel MRI-based complex graph theory framework that describes the intricate network of relationships within the tumor and surrounding tissue, and combine this with multiparametric radiomics (mpRad) in a machine-learning approach to distinguish radiation necrosis (RN) from true progression (TP). Pathologically confirmed cases of RN vs. TP in brain metastases treated with SRS were included from a single institution. The region of interest was manually segmented as the single largest diameter of the T1 post-contrast (T1C) lesion plus the corresponding area of T2 FLAIR hyperintensity. There were 40 mpRad features and 6 connectomics features extracted, as well as 5 clinical and treatment factors. We developed an Integrated Radiomics Informatics System (IRIS) based on an Isomap support vector machine (IsoSVM) model to distinguish TP from RN using leave-one-out cross-validation. Class imbalance was resolved with differential misclassification weighting during model training using the IRIS. In total, 135 lesions in 110 patients were analyzed, including 43 cases (31.9%) of pathologically proven RN and 92 cases (68.1%) of TP. The top-performing connectomics features were three centrality measures of degree, betweenness, and eigenvector centralities. Combining these with the 10 top-performing mpRad features, an optimized IsoSVM model was able to produce a sensitivity of 0.87, specificity of 0.84, AUC-ROC of 0.89 (95% CI: 0.82-0.94), and AUC-PR of 0.94 (95% CI: 0.87-0.97).
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Affiliation(s)
- Yilin Cao
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
- Department of Radiation Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Harvard Medical School, Boston, MA 02115, USA
| | - Vishwa S. Parekh
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
- University of Maryland Medical Intelligent Imaging (UM2ii) Center, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD 20201, USA
| | - Emerson Lee
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Xuguang Chen
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC 27514, USA
| | - Kristin J. Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Jay J. Pillai
- Division of Neuroradiology, Mayo Clinic, Rochester, MN 55905, USA
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
| | - Luke Peng
- Department of Radiation Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Harvard Medical School, Boston, MA 02115, USA
| | - Michael A. Jacobs
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
- Department of Diagnostics and Interventional Imaging, McGovern Medical School, Houston, TX 77030, USA
| | - Lawrence R. Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
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9
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Vaios EJ, Winter SF, Shih HA, Dietrich J, Peters KB, Floyd SR, Kirkpatrick JP, Reitman ZJ. Novel Mechanisms and Future Opportunities for the Management of Radiation Necrosis in Patients Treated for Brain Metastases in the Era of Immunotherapy. Cancers (Basel) 2023; 15:2432. [PMID: 37173897 PMCID: PMC10177360 DOI: 10.3390/cancers15092432] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/12/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023] Open
Abstract
Radiation necrosis, also known as treatment-induced necrosis, has emerged as an important adverse effect following stereotactic radiotherapy (SRS) for brain metastases. The improved survival of patients with brain metastases and increased use of combined systemic therapy and SRS have contributed to a growing incidence of necrosis. The cyclic GMP-AMP (cGAMP) synthase (cGAS) and stimulator of interferon genes (STING) pathway (cGAS-STING) represents a key biological mechanism linking radiation-induced DNA damage to pro-inflammatory effects and innate immunity. By recognizing cytosolic double-stranded DNA, cGAS induces a signaling cascade that results in the upregulation of type 1 interferons and dendritic cell activation. This pathway could play a key role in the pathogenesis of necrosis and provides attractive targets for therapeutic development. Immunotherapy and other novel systemic agents may potentiate activation of cGAS-STING signaling following radiotherapy and increase necrosis risk. Advancements in dosimetric strategies, novel imaging modalities, artificial intelligence, and circulating biomarkers could improve the management of necrosis. This review provides new insights into the pathophysiology of necrosis and synthesizes our current understanding regarding the diagnosis, risk factors, and management options of necrosis while highlighting novel avenues for discovery.
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Affiliation(s)
- Eugene J. Vaios
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
| | - Sebastian F. Winter
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Helen A. Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jorg Dietrich
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Katherine B. Peters
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Scott R. Floyd
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
| | - John P. Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Zachary J. Reitman
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
- Department of Pathology, Duke University Medical Center, Durham, NC 27710, USA
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10
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Management of initial and recurrent radiation-induced contrast enhancements following radiotherapy for brain metastases: Clinical and radiological impact of bevacizumab and corticosteroids. Clin Transl Radiat Oncol 2023; 39:100600. [PMID: 36873269 PMCID: PMC9975203 DOI: 10.1016/j.ctro.2023.100600] [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: 11/16/2022] [Revised: 01/25/2023] [Accepted: 02/13/2023] [Indexed: 02/16/2023] Open
Abstract
Purpose The appearance of radiation-induced contrast enhancements (RICE) after radiotherapy for brain metastases can go along with severe neurological impairments. The aim of our analysis was to evaluate radiological changes, the course and recurrence of RICE and identify associated prognostic factors. Methods We retrospectively identified patients diagnosed with brain metastases, who were treated with radiotherapy and subsequently developed RICE. Patient demographic and clinical data, radiation-, cancer-, and RICE-treatment, radiological results, and oncological outcomes were reviewed in detail. Results A total of 95 patients with a median follow-up of 28.8 months were identified. RICE appeared after a median time of 8.0 months after first radiotherapy and 6.4 months after re-irradiation. Bevacizumab in combination with corticosteroids achieved an improvement of clinical symptoms and imaging features in 65.9% and 75.6% of cases, respectively, both significantly superior compared to treatment with corticosteroids only, and further significantly prolonged RICE-progression-free survival to a median of 5.6 months. Recurrence of RICE after initially improved or stable imaging occurred in 63.1% of cases, significantly more often in patients after re-irradiation and was associated with high mortality of 36.6% after the diagnosis of flare-up. Response of recurrence significantly depended on the applied treatment and multiple courses of bevacizumab achieved good response. Conclusion Our results suggest that bevacizumab in combination with corticosteroids is superior in achieving short-term imaging and symptom improvement of RICE and prolongs the progression-free time compared to corticosteroids alone. Long-term RICE flare-up rates after bevacizumab discontinuation are high, but repeated treatments achieved effective symptomatic control.
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11
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Mayo ZS, Halima A, Broughman JR, Smile TD, Tom MC, Murphy ES, Suh JH, Lo SS, Barnett GH, Wu G, Johnson S, Chao ST. Radiation necrosis or tumor progression? A review of the radiographic modalities used in the diagnosis of cerebral radiation necrosis. J Neurooncol 2023; 161:23-31. [PMID: 36633800 DOI: 10.1007/s11060-022-04225-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 12/20/2022] [Indexed: 01/13/2023]
Abstract
PURPOSE Cerebral radiation necrosis is a complication of radiation therapy that can be seen months to years following radiation treatment. Differentiating radiation necrosis from tumor progression on standard magnetic resonance imaging (MRI) is often difficult and advanced imaging techniques may be needed to make an accurate diagnosis. The purpose of this article is to review the imaging modalities used in differentiating radiation necrosis from tumor progression following radiation therapy for brain metastases. METHODS We performed a review of the literature addressing the radiographic modalities used in the diagnosis of radiation necrosis. RESULTS Differentiating radiation necrosis from tumor progression remains a diagnostic challenge and advanced imaging modalities are often required to make a definitive diagnosis. If diagnostic uncertainty remains following conventional imaging, a multi-modality diagnostic approach with perfusion MRI, magnetic resonance spectroscopy (MRS), positron emission tomography (PET), single photon emission spectroscopy (SPECT), and radiomics may be used to improve diagnosis. CONCLUSION Several imaging modalities exist to aid in the diagnosis of radiation necrosis. Future studies developing advanced imaging techniques are needed.
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Affiliation(s)
- Zachary S Mayo
- Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Ave CA-50, Cleveland, OH, 44195, USA
| | - Ahmed Halima
- Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Ave CA-50, Cleveland, OH, 44195, USA
| | - James R Broughman
- Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Ave CA-50, Cleveland, OH, 44195, USA
| | - Timothy D Smile
- Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Ave CA-50, Cleveland, OH, 44195, USA
| | - Martin C Tom
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Erin S Murphy
- Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Ave CA-50, Cleveland, OH, 44195, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - John H Suh
- Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Ave CA-50, Cleveland, OH, 44195, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Gene H Barnett
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.,Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
| | - Guiyun Wu
- Department of Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - Scott Johnson
- Department of Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - Samuel T Chao
- Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Ave CA-50, Cleveland, OH, 44195, USA. .,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.
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12
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A Multi-Disciplinary Approach to Diagnosis and Treatment of Radionecrosis in Malignant Gliomas and Cerebral Metastases. Cancers (Basel) 2022; 14:cancers14246264. [PMID: 36551750 PMCID: PMC9777318 DOI: 10.3390/cancers14246264] [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: 10/16/2022] [Revised: 12/06/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
Radiation necrosis represents a potentially devastating complication after radiation therapy in brain tumors. The establishment of the diagnosis and especially the differentiation from progression and pseudoprogression with its therapeutic implications requires interdisciplinary consent and monitoring. Herein, we want to provide an overview of the diagnostic modalities, therapeutic possibilities and an outlook on future developments to tackle this challenging topic. The aim of this report is to provide an overview of the current morphological, functional, metabolic and evolving imaging tools described in the literature in order to (I) identify the best criteria to distinguish radionecrosis from tumor recurrence after the radio-oncological treatment of malignant gliomas and cerebral metastases, (II) analyze the therapeutic possibilities and (III) give an outlook on future developments to tackle this challenging topic. Additionally, we provide the experience of a tertiary tumor center with this important issue in neuro-oncology and provide an institutional pathway dealing with this problem.
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13
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Devan SP, Jiang X, Kang H, Luo G, Xie J, Zu Z, Stokes AM, Gore JC, McKnight CD, Kirschner AN, Xu J. Towards differentiation of brain tumor from radiation necrosis using multi-parametric MRI: Preliminary results at 4.7 T using rodent models. Magn Reson Imaging 2022; 94:144-150. [PMID: 36209946 PMCID: PMC10167709 DOI: 10.1016/j.mri.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/15/2022] [Accepted: 10/01/2022] [Indexed: 02/13/2023]
Abstract
BACKGROUND It remains a clinical challenge to differentiate brain tumors from radiation-induced necrosis in the brain. Despite significant improvements, no single MRI method has been validated adequately in the clinical setting. METHODS Multi-parametric MRI (mpMRI) was performed to differentiate 9L gliosarcoma from radiation necrosis in animal models. Five types of MRI methods probed complementary information on different scales i.e., T2 (relaxation), CEST based APT (probing mobile proteins/peptides) and rNOE (mobile macromolecules), qMT (macromolecules), diffusion based ADC (cell density) and SSIFT iAUC (cell size), and perfusion based DSC (blood volume and flow). RESULTS For single MRI parameters, iAUC and ADC provide the best discrimination of radiation necrosis and brain tumor. For mpMRI, a combination of iAUC, ADC, and APT shows the best classification performance based on a two-step analysis with the Lasso and Ridge regressions. CONCLUSION A general mpMRI approach is introduced to choosing candidate multiple MRI methods, identifying the most effective parameters from all the mpMRI parameters, and finding the appropriate combination of chosen parameters to maximize the classification performance to differentiate tumors from radiation necrosis.
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Affiliation(s)
- Sean P Devan
- Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, United States; Chemical and Physical Biology Program, Vanderbilt University, Nashville, TN, United States
| | - Xiaoyu Jiang
- Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, United States; Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Hakmook Kang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Jingping Xie
- Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Zhongliang Zu
- Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, United States; Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Ashley M Stokes
- Barrow Neuroimaging Innovation Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - John C Gore
- Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, United States; Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, United States; Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, United States; Department of Physics and Astronomy, Vanderbilt University, Nashville, TN, United States
| | - Colin D McKnight
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Austin N Kirschner
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Junzhong Xu
- Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, United States; Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, United States; Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, United States; Department of Physics and Astronomy, Vanderbilt University, Nashville, TN, United States.
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14
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Teunissen WHT, Govaerts CW, Kramer MCA, Labrecque JA, Smits M, Dirven L, van der Hoorn A. Diagnostic accuracy of MRI techniques for treatment response evaluation in patients with brain metastasis: A systematic review and meta-analysis. Radiother Oncol 2022; 177:121-133. [PMID: 36377093 DOI: 10.1016/j.radonc.2022.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 10/11/2022] [Accepted: 10/21/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Treatment response assessment in patients with brain metastasis uses contrast enhanced T1-weighted MRI. Advanced MRI techniques have been studied, but the diagnostic accuracy is not well known. Therefore, we performed a metaanalysis to assess the diagnostic accuracy of the currently available MRI techniques for treatment response. METHODS A systematic literature search was done. Study selection and data extraction were done by two authors independently. Meta-analysis was performed using a bivariate random effects model. An independent cohort was used for DSC perfusion external validation of diagnostic accuracy. RESULTS Anatomical MRI (16 studies, 726 lesions) showed a pooled sensitivity of 79% and a specificity of 76%. DCE perfusion (4 studies, 114 lesions) showed a pooled sensitivity of 74% and a specificity of 92%. DSC perfusion (12 studies, 418 lesions) showed a pooled sensitivity was 83% with a specificity of 78%. Diffusion weighted imaging (7 studies, 288 lesions) showed a pooled sensitivity of 67% and a specificity of 79%. MRS (4 studies, 54 lesions) showed a pooled sensitivity of 80% and a specificity of 78%. Combined techniques (6 studies, 375 lesions) showed a pooled sensitivity of 84% and a specificity of 88%. External validation of DSC showed a lower sensitivity and a higher specificity for the reported cut-off values included in this metaanalysis. CONCLUSION A combination of techniques shows the highest diagnostic accuracy differentiating tumor progression from treatment induced abnormalities. External validation of imaging results is important to better define the reliability of imaging results with the different techniques.
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Affiliation(s)
- Wouter H T Teunissen
- Erasmus MC, department of Radiology and Nuclear Medicine, Rotterdam, the Netherlands; Brain Tumor Centre, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Medical Delta, Delft, The Netherlands
| | - Chris W Govaerts
- University Medical Center Groningen, Medical imaging center, department of Radiology, Groningen, the Netherlands
| | - Miranda C A Kramer
- University Medical Center Groningen, department of Radiotherapy, Groningen, the Netherlands
| | - Jeremy A Labrecque
- Erasmus MC, Netherlands Institute for Health Science (NIHES), Rotterdam, the Netherlands
| | - Marion Smits
- Erasmus MC, department of Radiology and Nuclear Medicine, Rotterdam, the Netherlands; Brain Tumor Centre, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Medical Delta, Delft, The Netherlands
| | - Linda Dirven
- Leiden University Medical Center, department of Neurology, Leiden, the Netherlands; Haaglanden Medical Center, department of Neurology, The Hague, the Netherlands
| | - Anouk van der Hoorn
- University Medical Center Groningen, Medical imaging center, department of Radiology, Groningen, the Netherlands.
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15
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Dashti SR, Kadner RJ, Folley BS, Sheehan JP, Han DY, Kryscio RJ, Carter MB, Shields LBE, Plato BM, La Rocca RV, Spalding AC, Yao TL, Fraser JF. Single low-dose targeted bevacizumab infusion in adult patients with steroid-refractory radiation necrosis of the brain: a phase II open-label prospective clinical trial. J Neurosurg 2022; 137:1676-1686. [DOI: 10.3171/2022.2.jns212006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 02/07/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
There is an unmet need for safe and rapidly effective therapies for refractory brain radiation necrosis (RN). The aim of this prospective single-arm phase II trial was to evaluate the safety and efficacy of a single low-dose targeted bevacizumab infusion after blood-brain barrier disruption (BBBD) in adult patients with steroid-refractory brain RN.
METHODS
Ten adults with steroid-refractory, imaging-confirmed brain RN were enrolled between November 2016 and January 2018 and followed for 12 months after treatment. Bevacizumab 2.5 mg/kg was administered as a one-time targeted intra-arterial infusion immediately after BBBD. Primary outcomes included safety and > 25% decrease in lesion volume. Images were analyzed by a board-certified neuroradiologist blinded to pretrial diagnosis and treatment status. Secondary outcomes included changes in headache, steroid use, and functional status and absence of neurocognitive sequelae. Comparisons were analyzed using the Fisher exact test, Mann-Whitney U-test, linear mixed models, Wilcoxon signed-rank test, and repeated-measures 1-way ANOVA.
RESULTS
Ten adults (mean ± SD [range] age 35 ± 15 [22–62] years) participated in this study. No patients died or exhibited serious adverse effects of systemic bevacizumab. At 3 months, 80% (95% CI 44%–98%) and 90% (95% CI 56%–100%) of patients demonstrated > 25% decrease in RN and vasogenic edema volume, respectively. At 12 months, RN volume decreased by 74% (median [range] 76% [53%–96%], p = 0.012), edema volume decreased by 50% (median [range] 70% [−11% to 83%], p = 0.086), and headache decreased by 84% (median [range] 92% [58%–100%], p = 0.022) among the 8 patients without RN recurrence. Only 1 (10%) patient was steroid dependent at the end of the trial. Scores on 12 of 16 (75%) neurocognitive indices increased, thereby supporting a pattern of cerebral white matter recovery. Two (20%) patients exhibited RN recurrence that required further treatment at 10 and 11 months, respectively, after bevacizumab infusion.
CONCLUSIONS
For the first time, to the authors’ knowledge, the authors demonstrated that a single low-dose targeted bevacizumab infusion resulted in durable clinical and imaging improvements in 80% of patients at 12 months after treatment without adverse events attributed to bevacizumab alone. These findings highlight that targeted bevacizumab may be an efficient one-time treatment for adults with brain RN. Further confirmation with a randomized controlled trial is needed to compare the intra-arterial approach with the conventional multicycle intravenous regimen.
Clinical trial registration no.: NCT02819479 (ClinicalTrials.gov)
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Affiliation(s)
- Shervin R. Dashti
- Cerebrovascular & Endovascular Neurosurgery Institute, Norton Neuroscience Institute, Norton Healthcare, Louisville, Kentucky
| | | | - Bradley S. Folley
- Norton Neuroscience Institute, Norton Healthcare, Louisville, Kentucky
- Department of Neurosurgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Dong Y. Han
- Department of Neurology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Richard J. Kryscio
- Department of Statistics, University of Kentucky, Lexington, Kentucky
- Sanders Brown Center on Aging, University of Kentucky, Lexington, Kentucky
- Center for Clinical and Translational Sciences, University of Kentucky, Lexington, Kentucky
| | | | | | - Brian M. Plato
- Headache Medicine, Norton Neuroscience Institute, Norton Healthcare, Louisville, Kentucky
| | - Renato V. La Rocca
- Precision Medicine, Norton Cancer Institute, Norton Healthcare, Louisville, Kentucky
- Kentucky Cancer Group, LLC, Louisville, Kentucky
| | - Aaron C. Spalding
- Radiation Oncology, Norton Cancer Institute, Norton Healthcare, Louisville, Kentucky; and
| | - Tom L. Yao
- Cerebrovascular & Endovascular Neurosurgery Institute, Norton Neuroscience Institute, Norton Healthcare, Louisville, Kentucky
| | - Justin F. Fraser
- Department of Neurosurgery, University of Kentucky College of Medicine, Lexington, Kentucky
- Department of Neurology, University of Kentucky College of Medicine, Lexington, Kentucky
- Departments of Radiology and
- Neuroscience, University of Kentucky College of Medicine, Lexington, Kentucky
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16
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Acquitter C, Piram L, Sabatini U, Gilhodes J, Moyal Cohen-Jonathan E, Ken S, Lemasson B. Radiomics-Based Detection of Radionecrosis Using Harmonized Multiparametric MRI. Cancers (Basel) 2022; 14:cancers14020286. [PMID: 35053450 PMCID: PMC8773614 DOI: 10.3390/cancers14020286] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/09/2021] [Accepted: 12/30/2021] [Indexed: 01/27/2023] Open
Abstract
In this study, a radiomics analysis was conducted to provide insights into the differentiation of radionecrosis and tumor progression in multiparametric MRI in the context of a multicentric clinical trial. First, the sensitivity of radiomic features to the unwanted variability caused by different protocol settings was assessed for each modality. Then, the ability of image normalization and ComBat-based harmonization to reduce the scanner-related variability was evaluated. Finally, the performances of several radiomic models dedicated to the classification of MRI examinations were measured. Our results showed that using radiomic models trained on harmonized data achieved better predictive performance for the investigated clinical outcome (balanced accuracy of 0.61 with the model based on raw data and 0.72 with ComBat harmonization). A comparison of several models based on information extracted from different MR modalities showed that the best classification accuracy was achieved with a model based on MR perfusion features in conjunction with clinical observation (balanced accuracy of 0.76 using LASSO feature selection and a Random Forest classifier). Although multimodality did not provide additional benefit in predictive power, the model based on T1-weighted MRI before injection provided an accuracy close to the performance achieved with perfusion.
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Affiliation(s)
- Clément Acquitter
- Univ. Grenoble Alpes, Inserm, U1216, Grenoble Institut Neurosciences, 38000 Grenoble, France
- Correspondence: (C.A.); (B.L.)
| | - Lucie Piram
- Radiotherapy Department, University Institute Cancer Toulouse Oncopole, 31100 Toulouse, France; (L.P.); (E.M.C.-J.)
- INSERM U1037, Team 11, Cancer Research Center of Toulouse (CRCT), 31100 Toulouse, France;
| | - Umberto Sabatini
- Institute of Neuroradiology, University Magna Graecia, 88100 Catanzaro, Italy;
| | - Julia Gilhodes
- Biostatistics Department, University Institute Cancer Toulouse Oncopole, 31100 Toulouse, France;
| | - Elizabeth Moyal Cohen-Jonathan
- Radiotherapy Department, University Institute Cancer Toulouse Oncopole, 31100 Toulouse, France; (L.P.); (E.M.C.-J.)
- INSERM U1037, Team 11, Cancer Research Center of Toulouse (CRCT), 31100 Toulouse, France;
| | - Soleakhena Ken
- INSERM U1037, Team 11, Cancer Research Center of Toulouse (CRCT), 31100 Toulouse, France;
- Engineering and Medical Physics Department, University Institute Cancer Toulouse Oncopole, 31100 Toulouse, France
| | - Benjamin Lemasson
- Univ. Grenoble Alpes, Inserm, U1216, Grenoble Institut Neurosciences, 38000 Grenoble, France
- Correspondence: (C.A.); (B.L.)
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17
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Chen X, Parekh VS, Peng L, Chan MD, Redmond KJ, Soike M, McTyre E, Lin D, Jacobs MA, Kleinberg LR. Multiparametric radiomic tissue signature and machine learning for distinguishing radiation necrosis from tumor progression after stereotactic radiosurgery. Neurooncol Adv 2021; 3:vdab150. [PMID: 34901857 PMCID: PMC8661085 DOI: 10.1093/noajnl/vdab150] [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] [Indexed: 11/12/2022] Open
Abstract
Background Stereotactic radiosurgery (SRS) may cause radiation necrosis (RN) that is difficult to distinguish from tumor progression (TP) by conventional MRI. We hypothesize that MRI-based multiparametric radiomics (mpRad) and machine learning (ML) can differentiate TP from RN in a multi-institutional cohort. Methods Patients with growing brain metastases after SRS at 2 institutions underwent surgery, and RN or TP were confirmed by histopathology. A radiomic tissue signature (RTS) was selected from mpRad, as well as single T1 post-contrast (T1c) and T2 fluid-attenuated inversion recovery (T2-FLAIR) radiomic features. Feature selection and supervised ML were performed in a randomly selected training cohort (N = 95) and validated in the remaining cases (N = 40) using surgical pathology as the gold standard. Results One hundred and thirty-five discrete lesions (37 RN, 98 TP) from 109 patients were included. Radiographic diagnoses by an experienced neuroradiologist were concordant with histopathology in 67% of cases (sensitivity 69%, specificity 59% for TP). Radiomic analysis indicated institutional origin as a significant confounding factor for diagnosis. A random forest model incorporating 1 mpRad, 4 T1c, and 4 T2-FLAIR features had an AUC of 0.77 (95% confidence interval [CI]: 0.66–0.88), sensitivity of 67% and specificity of 86% in the training cohort, and AUC of 0.71 (95% CI: 0.51–0.91), sensitivity of 52% and specificity of 90% in the validation cohort. Conclusions MRI-based mpRad and ML can distinguish TP from RN with high specificity, which may facilitate the triage of patients with growing brain metastases after SRS for repeat radiation versus surgical intervention.
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Affiliation(s)
- Xuguang Chen
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Vishwa S Parekh
- Department of Computer Science, Johns Hopkins University, Baltimore, Maryland, USA.,Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Luke Peng
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael Soike
- Department of Radiation Oncology, University of Alabama , Birmingham, Alabama, USA
| | - Emory McTyre
- Prisma Cancer Institute, Greenville, North Carolina, USA
| | - Doris Lin
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael A Jacobs
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Sidney Kimmel Comprehensive Cancer Center, IRAT Core, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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18
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Abstract
PURPOSE OF REVIEW This review aims to cover current MRI techniques for assessing treatment response in brain tumors, with a focus on radio-induced lesions. RECENT FINDINGS Pseudoprogression and radionecrosis are common radiological entities after brain tumor irradiation and are difficult to distinguish from real progression, with major consequences on daily patient care. To date, shortcomings of conventional MRI have been largely recognized but morphological sequences are still used in official response assessment criteria. Several complementary advanced techniques have been proposed but none of them have been validated, hampering their clinical use. Among advanced MRI, brain perfusion measures increase diagnostic accuracy, especially when added with spectroscopy and susceptibility-weighted imaging. However, lack of reproducibility, because of several hard-to-control variables, is still a major limitation for their standardization in routine protocols. Amide Proton Transfer is an emerging molecular imaging technique that promises to offer new metrics by indirectly quantifying intracellular mobile proteins and peptide concentration. Preliminary studies suggest that this noncontrast sequence may add key biomarkers in tumor evaluation, especially in posttherapeutic settings. SUMMARY Benefits and pitfalls of conventional and advanced imaging on posttreatment assessment are discussed and the potential added value of APT in this clinicoradiological evolving scenario is introduced.
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Affiliation(s)
- Lucia Nichelli
- Department of Neuroradiology, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles Foix
- Sorbonne Université, INSERM, CNRS, Assistance Publique-Hôpitaux de Paris, Institut du Cerveau et de la Moelle épinière, boulevard de l’Hôpital, Paris
| | - Stefano Casagranda
- Department of Research & Innovation, Olea Medical, avenue des Sorbiers, La Ciotat, France
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Rogers S, Stauffer A, Lomax N, Alonso S, Eberle B, Gomez Ordoñez S, Lazeroms T, Kessler E, Brendel M, Schwyzer L, Riesterer O. Five fraction stereotactic radiotherapy after brain metastasectomy: a single-institution experience and literature review. J Neurooncol 2021; 155:35-43. [PMID: 34546498 DOI: 10.1007/s11060-021-03840-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The outcomes of five fraction stereotactic radiotherapy (hfSRT) following brain metastasectomy were evaluated and compared with published series. METHODS 30 Gy in 5 fractions HfSRT prescribed to the surgical cavity was reduced to 25 Gy if the volume of 'brain-GTV' receiving 20 Gy exceeded 20 cm3. Endpoints were local recurrence, nodular leptomeningeal recurrence, new brain metastases and radionecrosis. The literature was searched for reports of clinical and dosimetric outcomes following postoperative hfSRT in 3-5 fractions. RESULTS 39 patients with 40 surgical cavities were analyzed. Cavity local control rate at 1 year was 33/40 (82.5%). 3 local failures followed 30 Gy/5 fractions and 4 with 25 Gy/5 fractions. The incidence of leptomeningeal disease (LMD) was 7/40 (17.5%). No grade 3-4 toxicities, particularly no radionecrosis, were reported. The incidence of distant brain metastases was 15/40 (37.5%). The median overall survival was 15 months. Across 13 published series, the weighted mean local control was 83.1% (adjusted for sample size), the mean incidence of LMD was 14.9% (7-34%) and the mean rate of radionecrosis was 10.3% (0-20.6%). CONCLUSION Postoperative hfSRT can be delivered with 25-30 Gy in 5 fractions with efficacy in excess of 82% and no significant toxicity when the dose to 'brain-GTV' does not exceed 20 cm3.
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Affiliation(s)
- S Rogers
- Radiation Oncology Center KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland.
| | - A Stauffer
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - N Lomax
- Radiation Oncology Center KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - S Alonso
- Radiation Oncology Center KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - B Eberle
- Radiation Oncology Center KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - S Gomez Ordoñez
- Radiation Oncology Center KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - T Lazeroms
- Radiation Oncology Center KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - E Kessler
- Radiation Oncology Center KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - M Brendel
- Department of Neuroradiology, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - L Schwyzer
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - O Riesterer
- Radiation Oncology Center KSA-KSB, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland.,Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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20
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Tumor habitat analysis by magnetic resonance imaging distinguishes tumor progression from radiation necrosis in brain metastases after stereotactic radiosurgery. Eur Radiol 2021; 32:497-507. [PMID: 34357451 DOI: 10.1007/s00330-021-08204-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/22/2021] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The identification of viable tumor after stereotactic radiosurgery (SRS) is important for future targeted therapy. This study aimed to determine whether tumor habitat on structural and physiologic MRI can distinguish viable tumor from radiation necrosis of brain metastases after SRS. METHOD Multiparametric contrast-enhanced T1- and T2-weighted imaging, apparent diffusion coefficient (ADC), and cerebral blood volume (CBV) were obtained from 52 patients with 69 metastases, showing enlarging enhancing masses after SRS. Voxel-wise clustering identified three structural MRI habitats (enhancing, solid low-enhancing, and nonviable) and three physiologic MRI habitats (hypervascular cellular, hypovascular cellular, and nonviable). Habitat-based predictors for viable tumor or radiation necrosis were identified by logistic regression. Performance was validated using the area under the curve (AUC) of the receiver operating characteristics curve in an independent dataset with 24 patients. RESULTS None of the physiologic MRI habitats was indicative of viable tumor. Viable tumor was predicted by a high-volume fraction of solid low-enhancing habitat (low T2-weighted and low CE-T1-weighted values; odds ratio [OR] 1.74, p <.001) and a low-volume fraction of nonviable tissue habitat (high T2-weighted and low CE-T1-weighted values; OR 0.55, p <.001). Combined structural MRI habitats yielded good discriminatory ability in both development (AUC 0.85, 95% confidence interval [CI]: 0.77-0.94) and validation sets (AUC 0.86, 95% CI:0.70-0.99), outperforming single ADC (AUC 0.64) and CBV (AUC 0.58) values. The site of progression matched with the solid low-enhancing habitat (72%, 8/11). CONCLUSION Solid low-enhancing and nonviable tissue habitats on structural MRI can help to localize viable tumor in patients with brain metastases after SRS. KEY POINTS • Structural MRI habitats helped to differentiate viable tumor from radiation necrosis. • Solid low-enhancing habitat was most helpful to find viable tumor. • Providing spatial information, the site of progression matched with solid low-enhancing habitat.
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21
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Palmisciano P, Haider AS, Nwagwu CD, Wahood W, Aoun SG, Abdullah KG, El Ahmadieh TY. Bevacizumab vs laser interstitial thermal therapy in cerebral radiation necrosis from brain metastases: a systematic review and meta-analysis. J Neurooncol 2021; 154:13-23. [PMID: 34218396 DOI: 10.1007/s11060-021-03802-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/28/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Radiation necrosis (RN) represents a serious post-radiotherapy complication in patients with brain metastases. Bevacizumab and laser interstitial thermal therapy (LITT) are viable treatment options, but direct comparative data is scarce. We reviewed the literature to compare the two treatment strategies. METHODS PubMed, EMBASE, Scopus, and Cochrane databases were searched. All studies of patients with RN from brain metastases treated with bevacizumab or LITT were included. Treatment outcomes were analyzed using indirect meta-analysis with random-effect modeling. RESULTS Among the 18 studies included, 143 patients received bevacizumab and 148 underwent LITT. Both strategies were equally effective in providing post-treatment symptomatic improvement (P = 0.187, I2 = 54.8%), weaning off steroids (P = 0.614, I2 = 25.5%), and local lesion control (P = 0.5, I2 = 0%). Mean number of lesions per patient was not statistically significant among groups (P = 0.624). Similarly, mean T1-contrast-enhancing pre-treatment volumes were not statistically different (P = 0.582). Patterns of radiological responses differed at 6-month follow-ups, with rates of partial regression significantly higher in the bevacizumab group (P = 0.001, I2 = 88.9%), and stable disease significantly higher in the LITT group (P = 0.002, I2 = 81.9%). Survival rates were superior in the LITT cohort, and statistical significance was reached at 18 months (P = 0.038, I2 = 73.7%). Low rates of adverse events were reported in both groups (14.7% for bevacizumab and 12.2% for LITT). CONCLUSION Bevacizumab and LITT can be safe and effective treatments for RN from brain metastases. Clinical and radiological outcomes are mostly comparable, but LITT may relate with superior survival benefits in select patients. Further studies are required to identify the best patient candidates for each treatment group.
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Affiliation(s)
- Paolo Palmisciano
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Ali S Haider
- Texas A&M University College of Medicine, Houston, TX, USA
| | | | - Waseem Wahood
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, FL, USA
| | - Salah G Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Kalil G Abdullah
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Tarek Y El Ahmadieh
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA.
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Vellayappan BA, McGranahan T, Graber J, Taylor L, Venur V, Ellenbogen R, Sloan AE, Redmond KJ, Foote M, Chao ST, Suh JH, Chang EL, Sahgal A, Lo SS. Radiation Necrosis from Stereotactic Radiosurgery-How Do We Mitigate? Curr Treat Options Oncol 2021; 22:57. [PMID: 34097171 DOI: 10.1007/s11864-021-00854-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2021] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT Intracranial stereotactic radiosurgery (SRS) is an effective and convenient treatment for many brain conditions. Data regarding safety come mostly from retrospective single institutional studies and a small number of prospective studies. Variations in target delineation, treatment delivery, imaging follow-up protocols and dose prescription limit the interpretation of this data. There has been much clinical focus on radiation necrosis (RN) in particular, as it is being increasingly recognized on follow-up imaging. Symptomatic RN may be treated with medical therapy (such as corticosteroids and bevacizumab) with surgical resection being reserved for refractory patients. Nevertheless, RN remains a challenging condition to manage, and therefore upfront patient selection for SRS remains critical to provide complication-free control. Mitigation strategies need to be considered in situations where the baseline risk of RN is expected to be high-such as large target volume or re-irradiation. These may involve reduction in the prescribed dose or hypofractionated stereotactic radiation therapy (HSRT). Recently published guidelines and international meta-analysis report the benefit of HSRT in larger lesions, without compromising control rates. However, careful attention to planning parameters and SRS techniques still need to be adhered, even with HSRT. In cases where the risk is deemed to be high despite mitigation, a combination approach of surgery with or without post-operative radiation should be considered.
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Affiliation(s)
- Balamurugan A Vellayappan
- Department of Radiation oncology, National University Cancer Institute, 1E Kent Ridge Road, Level 7 Tower block, Singapore, 119228, Singapore.
| | - Tresa McGranahan
- Department of Neurology, Alvord Brain Tumor Center, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Jerome Graber
- Department of Neurology, Alvord Brain Tumor Center, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Lynne Taylor
- Department of Neurology, Alvord Brain Tumor Center, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Vyshak Venur
- Department of Neurology, Alvord Brain Tumor Center, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Richard Ellenbogen
- Department of Neurology, Alvord Brain Tumor Center, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Andrew E Sloan
- Department of Neurological Surgery, Seidman Cancer Center and University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH, USA
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, MD, USA
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Samuel T Chao
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John H Suh
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eric L Chang
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
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23
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Reliability of Magnetic Resonance Spectroscopy and Positron Emission Tomography Computed Tomography in Differentiating Metastatic Brain Tumor Recurrence from Radiation Necrosis. World Neurosurg 2021; 151:e1059-e1068. [PMID: 34052453 DOI: 10.1016/j.wneu.2021.05.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/16/2021] [Accepted: 05/17/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Clinical and/or neuroimaging changes after whole-brain radiation therapy (WBRT) or stereotactic radiosurgery (SRS) for metastatic brain tumor(s) present the clinical dilemma of differentiating tumor recurrence from radiation necrosis. Several imaging modalities attempt to answer this clinical question, including magnetic resonance spectroscopy (MRS) and positron emission tomography (PET) computed tomography (CT). We evaluated our experience regarding the ability of MRS and PET CT to differentiate tumor recurrence from radiation necrosis in patients who have received WBRT or SRS. METHODS We retrospectively reviewed records of 242 patients with previous WBRT or SRS to identify those who had MRS and/or PET CT to differentiate tumor recurrence from radiation necrosis. Patients were sorted into true-positive, false-positive, false-negative, and true-negative groups on the basis of imaging interpretation and clinical course combined with surgical pathology results or reaction to nonsurgical treatments including SRS, dexamethasone, or observation. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were then calculated. RESULTS Of 25 patients presenting such diagnostic questions, 19 were evaluated with MRS and 13 with PET CT. MRS sensitivity was 100%, specificity was 50%, and accuracy was 81.8%, whereas PET CT sensitivity was 36.4%, specificity was 66.7%, and accuracy was 42.9%. CONCLUSIONS MRS has better accuracy than PET CT and a high negative predictive value, therefore making it more useful in distinguishing recurrent tumor from radiation necrosis. We encourage correlation with symptoms at imaging to aid in clinical decision making.
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24
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Kaufmann TJ, Smits M, Boxerman J, Huang R, Barboriak DP, Weller M, Chung C, Tsien C, Brown PD, Shankar L, Galanis E, Gerstner E, van den Bent MJ, Burns TC, Parney IF, Dunn G, Brastianos PK, Lin NU, Wen PY, Ellingson BM. Consensus recommendations for a standardized brain tumor imaging protocol for clinical trials in brain metastases. Neuro Oncol 2021; 22:757-772. [PMID: 32048719 PMCID: PMC7283031 DOI: 10.1093/neuonc/noaa030] [Citation(s) in RCA: 120] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
A recent meeting was held on March 22, 2019, among the FDA, clinical scientists, pharmaceutical and biotech companies, clinical trials cooperative groups, and patient advocacy groups to discuss challenges and potential solutions for increasing development of therapeutics for central nervous system metastases. A key issue identified at this meeting was the need for consistent tumor measurement for reliable tumor response assessment, including the first step of standardized image acquisition with an MRI protocol that could be implemented in multicenter studies aimed at testing new therapeutics. This document builds upon previous consensus recommendations for a standardized brain tumor imaging protocol (BTIP) in high-grade gliomas and defines a protocol for brain metastases (BTIP-BM) that addresses unique challenges associated with assessment of CNS metastases. The "minimum standard" recommended pulse sequences include: (i) parameter matched pre- and post-contrast inversion recovery (IR)-prepared, isotropic 3D T1-weighted gradient echo (IR-GRE); (ii) axial 2D T2-weighted turbo spin echo acquired after injection of gadolinium-based contrast agent and before post-contrast 3D T1-weighted images; (iii) axial 2D or 3D T2-weighted fluid attenuated inversion recovery; (iv) axial 2D, 3-directional diffusion-weighted images; and (v) post-contrast 2D T1-weighted spin echo images for increased lesion conspicuity. Recommended sequence parameters are provided for both 1.5T and 3T MR systems. An "ideal" protocol is also provided, which replaces IR-GRE with 3D TSE T1-weighted imaging pre- and post-gadolinium, and is best performed at 3T, for which dynamic susceptibility contrast perfusion is included. Recommended perfusion parameters are given.
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Affiliation(s)
| | - Marion Smits
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jerrold Boxerman
- Department of Diagnostic Imaging, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Raymond Huang
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel P Barboriak
- Department of Radiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael Weller
- Department of Neurology & Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Caroline Chung
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Christina Tsien
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lalitha Shankar
- Division of Cancer Treatment and Diagnosis, National Cancer Institute (NCI), Bethesda, Maryland, USA
| | - Evanthia Galanis
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Gerstner
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Terry C Burns
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ian F Parney
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Gavin Dunn
- Department of Neurological Surgery, Washington University, St Louis, Missouri, USA
| | - Priscilla K Brastianos
- Departments of Medicine and Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Benjamin M Ellingson
- UCLA Brain Tumor Imaging Laboratory, Center for Computer Vision and Imaging Biomarkers, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.,Departments of Radiological Sciences and Psychiatry, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
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25
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Park YW, Choi D, Park JE, Ahn SS, Kim H, Chang JH, Kim SH, Kim HS, Lee SK. Differentiation of recurrent glioblastoma from radiation necrosis using diffusion radiomics with machine learning model development and external validation. Sci Rep 2021; 11:2913. [PMID: 33536499 PMCID: PMC7858615 DOI: 10.1038/s41598-021-82467-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 01/05/2021] [Indexed: 12/19/2022] Open
Abstract
The purpose of this study was to establish a high-performing radiomics strategy with machine learning from conventional and diffusion MRI to differentiate recurrent glioblastoma (GBM) from radiation necrosis (RN) after concurrent chemoradiotherapy (CCRT) or radiotherapy. Eighty-six patients with GBM were enrolled in the training set after they underwent CCRT or radiotherapy and presented with new or enlarging contrast enhancement within the radiation field on follow-up MRI. A diagnosis was established either pathologically or clinicoradiologically (63 recurrent GBM and 23 RN). Another 41 patients (23 recurrent GBM and 18 RN) from a different institution were enrolled in the test set. Conventional MRI sequences (T2-weighted and postcontrast T1-weighted images) and ADC were analyzed to extract 263 radiomic features. After feature selection, various machine learning models with oversampling methods were trained with combinations of MRI sequences and subsequently validated in the test set. In the independent test set, the model using ADC sequence showed the best diagnostic performance, with an AUC, accuracy, sensitivity, specificity of 0.80, 78%, 66.7%, and 87%, respectively. In conclusion, the radiomics models models using other MRI sequences showed AUCs ranging from 0.65 to 0.66 in the test set. The diffusion radiomics may be helpful in differentiating recurrent GBM from RN..
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Affiliation(s)
- Yae Won Park
- Department of Radiology and Research Institute of Radiological Science and Center for Clinical Image Data Science, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Dongmin Choi
- Department of Computer Science, Yonsei University, Seoul, South Korea
| | - Ji Eun Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung Soo Ahn
- Department of Radiology and Research Institute of Radiological Science and Center for Clinical Image Data Science, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Hwiyoung Kim
- Department of Radiology and Research Institute of Radiological Science and Center for Clinical Image Data Science, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Se Hoon Kim
- Department of Pathology, Yonsei University College of Medicine, Seoul, South Korea
| | - Ho Sung Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seung-Koo Lee
- Department of Radiology and Research Institute of Radiological Science and Center for Clinical Image Data Science, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
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26
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Carr CM, Benson JC, DeLone DR, Diehn FE, Kim DK, Merrell KW, Nagelschneider AA, Madhavan AA, Johnson DR. Intracranial long-term complications of radiation therapy: an image-based review. Neuroradiology 2021; 63:471-482. [PMID: 33392738 DOI: 10.1007/s00234-020-02621-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/08/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Radiation therapy is commonly utilized in the majority of solid cancers and many hematologic malignancies and other disorders. While it has an undeniably major role in improving cancer survival, radiation therapy has long been recognized to have various negative effects, ranging from mild to severe. In this manuscript, we review several intracranial manifestations of therapeutic radiation, with particular attention to those that may be encountered by radiologists. METHODS We conducted an extensive literature review of known complications of intracranial radiation therapy. Based on this review, we selected complications that had salient, recognizable imaging findings. We searched our imaging database for illustrative examples of these complications, focusing only on patients who had a history of intracranial radiation therapy. We then selected cases that best exemplified expected imaging findings in these entities. RESULTS Based on our initial literature search and imaging database review, we selected cases of radiation-induced meningioma, radiation-induced glioma, cavernous malformation, enlarging perivascular spaces, leukoencephalopathy, stroke-like migraine after radiation therapy, Moyamoya syndrome, radiation necrosis, radiation-induced labyrinthitis, optic neuropathy, and retinopathy. Although retinopathy is not typically apparent on imaging, it has been included given its clinical overlap with optic neuropathy. CONCLUSIONS We describe the clinical and imaging features of selected sequelae of intracranial radiation therapy, with a focus on those most relevant to practicing radiologists. Knowledge of these complications and their imaging findings is important, because radiologists play a key role in early detection of these entities.
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Affiliation(s)
- Carrie M Carr
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - John C Benson
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David R DeLone
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Felix E Diehn
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Dong Kun Kim
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Alex A Nagelschneider
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ajay A Madhavan
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Derek R Johnson
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Lam FCL, Kasper EM, Mahadevan A. Management and Surveillance of Short- and Long-Term Sequelae of Radiation Therapy for the Treatment of Pediatric Brain Tumors. JOURNAL OF PEDIATRIC NEUROLOGY 2020. [DOI: 10.1055/s-0040-1715501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractRadiation therapy (RT) is a mainstay for the treatment of pediatric brain tumors. As improvements in and sophistication of this modality continue to increase the survival of patients, the long-term sequelae of RT pose significant challenges in the clinical management of this patient population as they transition into adulthood. In this special edition, we review the short- and long-term effects of RT for the treatment of pediatric brain tumors and the necessary surveillance required for follow-up.
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Affiliation(s)
- Fred Chiu-Lai Lam
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Ekkehard M Kasper
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Anand Mahadevan
- Division of Radiation Oncology, Geisinger Health, Danville, Pennsylvania, United States
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28
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Peker S, Samanci Y, Aygun MS, Yavuz F, Erden ME, Nokay AE, Atasoy Aİ, Bolukbasi Y. The Use of Treatment Response Assessment Maps in Discriminating Between Radiation Effect and Persistent Tumoral Lesion in Metastatic Brain Tumors Treated with Gamma Knife Radiosurgery. World Neurosurg 2020; 146:e1134-e1146. [PMID: 33253956 DOI: 10.1016/j.wneu.2020.11.114] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Traditional imaging modalities are not useful in the follow-up of irradiated metastatic brain tumors, because radiation can change imaging characteristics. We aimed to assess the ability of treatment response assessment maps (TRAMs) calculated from delayed-contrast magnetic resonance imaging (MRI) in differentiation between radiation effect and persistent tumoral tissue. METHODS TRAMs were calculated by subtracting three-dimensional T1 MRIs acquired 5 minutes after contrast injection from the images acquired 60-105 minutes later. Red areas were regarded as radiation effect and blue areas as persistent tumoral lesion. Thirty-seven patients with 130 metastatic brain tumors who were treated with Gamma Knife radiosurgery and who underwent TRAMs perfusion-weighted MRI were enrolled in this retrospective study. RESULTS The median age was 58 years and the most common primary diagnosis was lung cancer (n = 21). The median follow-up period of patients was 12 months. The overall local control rate was 100% at 1 year and 98.9% at 2 years. The median progression-free survival was 12 months. The mean overall survival was 27.3 months. The radiologic and clinical follow-up showed a clinicoradiologic diagnosis of a persistent tumoral lesion in 3 tumors (2.3%) and radiation effect in 127 tumors (97.7%). There was a fair agreement between clinicoradiologic diagnosis and TRAMs analysis (κ = 0.380). The sensitivity and positive predictive value of TRAMs in diagnosing radiation effect were 96.06% and 99.2%, respectively. TRAMs showed comparable results to perfusion-weighted MRI, with a diagnostic odds ratio of 27.4 versus 20.7, respectively. CONCLUSIONS The presented results show the ability of TRAMs in differentiating radiation effect and persistent tumoral lesions.
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Affiliation(s)
- Selcuk Peker
- Department of Neurosurgery, School of Medicine, Koç University, Istanbul, Turkey.
| | - Yavuz Samanci
- Department of Neurosurgery, Koç University Hospital, Istanbul, Turkey
| | - Murat Serhat Aygun
- Department of Radiology, School of Medicine, Koç University, Istanbul, Turkey
| | - Furkan Yavuz
- School of Medicine, Koç University, Istanbul, Turkey
| | | | | | - Ali İhsan Atasoy
- Department of Radiation Oncology, Koç University Hospital, Istanbul, Turkey
| | - Yasemin Bolukbasi
- Department of Radiation Oncology, School of Medicine, Koç University, Istanbul, Turkey
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Winter SF, Loebel F, Loeffler J, Batchelor TT, Martinez-Lage M, Vajkoczy P, Dietrich J. Treatment-induced brain tissue necrosis: a clinical challenge in neuro-oncology. Neuro Oncol 2020; 21:1118-1130. [PMID: 30828724 DOI: 10.1093/neuonc/noz048] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 12/04/2018] [Accepted: 02/25/2019] [Indexed: 12/29/2022] Open
Abstract
Cancer therapy-induced adverse effects on the brain are a major challenge in neuro-oncology. Brain tissue necrosis (treatment necrosis [TN]) as a consequence of brain directed cancer therapy remains an insufficiently characterized condition with diagnostic and therapeutic difficulties and is frequently associated with significant patient morbidity. A better understanding of the underlying mechanisms, improvement of diagnostic tools, development of preventive strategies, and implementation of evidence-based therapeutic practices are pivotal to improve patient management. In this comprehensive review, we address existing challenges associated with current TN-related clinical and research practices and highlight unanswered questions and areas in need of further research with the ultimate goal to improve management of patients affected by this important neuro-oncological condition.
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Affiliation(s)
- Sebastian F Winter
- MGH Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Charité‒Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Franziska Loebel
- Department of Neurosurgery, Charité‒Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jay Loeffler
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tracy T Batchelor
- MGH Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria Martinez-Lage
- C S Kubik Laboratory for Neuropathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité‒Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jorg Dietrich
- MGH Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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30
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Liermann J, Winkler JK, Syed M, Neuberger U, Reuss D, Harrabi S, Naumann P, Ristau J, Weykamp F, El Shafie RA, König L, Debus J, Hassel J, Rieken S. Stereotactic Radiosurgery With Concurrent Immunotherapy in Melanoma Brain Metastases Is Feasible and Effective. Front Oncol 2020; 10:592796. [PMID: 33178618 PMCID: PMC7593445 DOI: 10.3389/fonc.2020.592796] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 09/09/2020] [Indexed: 12/25/2022] Open
Abstract
Objective: Stereotactic radiosurgery (SRS) is an established treatment for brain metastases in the management of metastasized melanoma. The increasing use of checkpoint inhibitors in melanoma therapy leads to combined treatment schemes consisting of immunotherapy and SRS that need to be evaluated regarding safety and feasibility. Methods: We retrospectively analyzed 36 patients suffering from cerebral metastasized melanoma. Between November 2011 and May 2016, altogether 66 brain metastases were treated with single-fraction SRS (18-20 Gy prescribed to the 80% isodose) in combination with a checkpoint inhibitor (ipilimumab: 82%, pembrolizumab: 14% or nivolumab: 4%), administered within 3 months before or after SRS. Toxicity was evaluated with focus on the incidence of central nervous system (CNS) radiation necrosis (CRN). Overall survival (OS), freedom from local progression (FFLP), freedom from central nervous system radiation necrosis (FFCRN), and freedom from distant intracranial progression (FFDIP) were analyzed using the Kaplan-Meier method. Results: The median follow-up was 25 months (range: 2-115 months). Two patients (6%) presented with cerebral edema CTCAE °III and another two patients (6%) presented with one-sided muscle weakness CTCAE °III after SRS. One of these four symptomatic cases correlated with an observed CRN, the other three symptomatic cases were related to local tumor progression (n = 2) or related to the performance of additional whole brain radiotherapy (WBRT). No further CTCAE °III or °IV toxicity was seen. During follow-up, seven of the growing contrast-enhanced lesions were resected, revealing two cases of CRN and five cases of local tumor progression. Altogether, the observed CRN rate of the irradiated metastases was 6-17% at the time of analysis, ranging due to the radiologically challenging differentiation between CRN and local tumor progression. The observed ranges of the 1- and 2-years FFLP rates were 82-85% and 73-80%, respectively. The median FFDIP was 6.1 months, the median OS was 22.2 months. Conclusion: In the presented cohort, the combination of SRS and checkpoint inhibitors in the management of cerebral metastasized melanoma was safe and effective. Compared to historic data on SRS only, the observed CRN rate was acceptable. To gain resilient data on the incidence of CRN after combined treatment schemes, prospective trials are needed.
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Affiliation(s)
- Jakob Liermann
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
| | - Julia K Winkler
- National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Dermatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Mustafa Syed
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Ulf Neuberger
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - David Reuss
- Heidelberg University Hospital, Institute of Pathology, Heidelberg, Germany
| | - Semi Harrabi
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
| | - Patrick Naumann
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
| | - Jonas Ristau
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Fabian Weykamp
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Rami A El Shafie
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Partner Site Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jessica Hassel
- National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Dermatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
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Alemany M, Velasco R, Simó M, Bruna J. Late effects of cancer treatment: consequences for long-term brain cancer survivors. Neurooncol Pract 2020; 8:18-30. [PMID: 33664966 DOI: 10.1093/nop/npaa039] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Late adverse effects of cancer treatments represent a significant source of morbidity and also financial hardship among brain tumor patients. These effects can be produced by direct neurologic damage of the tumor and its removal, and/or by complementary treatments such as chemotherapy and radiotherapy, either alone or combined. Notably, young adults are the critical population that faces major consequences because the early onset of the disease may affect their development and socioeconomic status. The spectrum of these late adverse effects is large and involves multiple domains. In this review we classify the main long-term adverse effects into 4 sections: CNS complications, peripheral nervous system complications, secondary neoplasms, and Economic impact. In addition, CNS main complications are divided into nonfocal and focal symptoms. Owing to all the secondary effects mentioned, it is essential for physicians to have a high level of clinical suspicion to prevent and provide early intervention to minimize their impact.
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Affiliation(s)
- Montse Alemany
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L'Hospitalet (IDIBELL), Barcelona, Spain
| | - Roser Velasco
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L'Hospitalet (IDIBELL), Barcelona, Spain
| | - Marta Simó
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L'Hospitalet (IDIBELL), Barcelona, Spain
| | - Jordi Bruna
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO L'Hospitalet (IDIBELL), Barcelona, Spain
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32
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Skeie BS, Enger PØ, Knisely J, Pedersen PH, Heggdal JI, Eide GE, Skeie GO. A simple score to estimate the likelihood of pseudoprogression vs. recurrence following stereotactic radiosurgery for brain metastases: The Bergen Criteria. Neurooncol Adv 2020; 2:vdaa026. [PMID: 32642686 PMCID: PMC7212847 DOI: 10.1093/noajnl/vdaa026] [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] [Indexed: 11/13/2022] Open
Abstract
Background A major challenge in the follow-up of patients treated with stereotactic radiosurgery (SRS) for brain metastases (BM) is to distinguish pseudoprogression (PP) from tumor recurrence (TR). The aim of the study was to develop a clinical risk assessment score. Methods Follow-up images of 87 of 97 consecutive patients treated with SRS for 348 BM were analyzed. Of these, 100 (28.7%) BM in 48 (53.9%) patients responded with either TR (n = 53, 15%) or PP (n = 47, 14%). Differences between the 2 groups were analyzed and used to develop a risk assessment score (the Bergen Criteria). Results Factors associated with a higher incidence of PP vs. TR were as follows: prior radiation with whole brain radiotherapy or SRS (P = .001), target cover ratio ≥98% (P = .048), BM volume ≤2 cm3 (P = .054), and primary lung cancer vs. other cancer types (P = .084). Based on the presence (0) or absence (1) of these 5 characteristics, the Bergen Criteria was established. A total score <2 points was associated with 100% PP, 2 points with 57% PP and 43% TR, 3 points with 57% TR and 43% PP, whereas >3 points were associated with 84% TR and 16% PP, P < .001. Conclusion Based on 5 characteristics at the time of SRS the Bergen Criteria could robustly differentiate between PP vs. TR following SRS. The score is user-friendly and provides a useful tool to guide the decision making whether to retreat or observe at appropriate follow-up intervals.
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Affiliation(s)
| | - Per Øyvind Enger
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
| | - Jonathan Knisely
- Department of Radiation Oncology, Weill Cornell Medical College, New York, NY, USA
| | | | - Jan Ingeman Heggdal
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Geir Egil Eide
- Department of Global Public Health and Primary Care, University of Bergen, Norway.,Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
| | - Geir Olve Skeie
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Stereotactic Radiotherapy for Brain Metastases: Imaging Tools and Dosimetric Predictive Factors for Radionecrosis. J Pers Med 2020; 10:jpm10030059. [PMID: 32635476 PMCID: PMC7565332 DOI: 10.3390/jpm10030059] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/21/2020] [Accepted: 07/02/2020] [Indexed: 12/29/2022] Open
Abstract
Radionecrosis (RN) is the most important side effect after stereotactic radiotherapy (SRT) for brain metastases, with a reported incidence ranging from 3% to 24%. To date, there are no unanimously accepted criteria for iconographic diagnosis of RN, as well as no definitive dose-constraints correlated with the onset of this late effect. We reviewed the current literature and gave an overview report on imaging options for the diagnosis of RN and on dosimetric parameters correlated with the onset of RN. We performed a PubMed literature search according to the preferred reporting items and meta-analysis (PRISMA) guidelines, and identified articles published within the last ten years, up to 31 December 2019. When analyzing data on diagnostic tools, perfusion magnetic resonance imaging (MRI) seems to be very useful allowing evaluation of the blood flow in the lesion using the relative cerebral blood volume (rCBV) and blood vessel integrity using relative peak weight (rPH). It is necessary to combine morphological with functional imaging in order to match information about lesion morphology, metabolism and blood-flow. Eventually, serial imaging follow-up is needed. Regarding dosimetric parameters, in radiosurgery (SRS) V12 < 8 cm3 and V10 < 10.5 cm3 of normal brain are the most reliable prognostic factors, whereas in hypo-fractionated stereotactic radiotherapy (HSRT) V18 and V21 are considered the main predictive independent risk factors of RN.
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34
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Winter SF, Vaios EJ, Muzikansky A, Martinez‐Lage M, Bussière MR, Shih HA, Loeffler J, Karschnia P, Loebel F, Vajkoczy P, Dietrich J. Defining Treatment-Related Adverse Effects in Patients with Glioma: Distinctive Features of Pseudoprogression and Treatment-Induced Necrosis. Oncologist 2020; 25:e1221-e1232. [PMID: 32488924 PMCID: PMC7418360 DOI: 10.1634/theoncologist.2020-0085] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/27/2020] [Indexed: 01/24/2023] Open
Abstract
Background Pseudoprogression (PP) and treatment‐induced brain tissue necrosis (TN) are challenging cancer treatment–related effects. Both phenomena remain insufficiently defined; differentiation from recurrent disease frequently necessitates tissue biopsy. We here characterize distinctive features of PP and TN to facilitate noninvasive diagnosis and clinical management. Materials and Methods Patients with glioma and confirmed PP (defined as appearance <5 months after radiotherapy [RT] completion) or TN (>5 months after RT) were retrospectively compared using clinical, radiographic, and histopathological data. Each imaging event/lesion (region of interest [ROI]) diagnosed as PP or TN was longitudinally evaluated by serial imaging. Results We identified 64 cases of mostly (80%) biopsy‐confirmed PP (n = 27) and TN (n = 37), comprising 137 ROIs in total. Median time of onset for PP and TN was 1 and 11 months after RT, respectively. Clinically, PP occurred more frequently during active antineoplastic treatment, necessitated more steroid‐based interventions, and was associated with glioblastoma (81 vs. 40%), fewer IDH1 mutations, and shorter median overall survival. Radiographically, TN lesions often initially manifested periventricularly (n = 22/37; 60%), were more numerous (median, 2 vs. 1 ROIs), and contained fewer malignant elements upon biopsy. By contrast, PP predominantly developed around the tumor resection cavity as a non‐nodular, ring‐like enhancing structure. Both PP and TN lesions almost exclusively developed in the main prior radiation field. Presence of either condition appeared to be associated with above‐average overall survival. Conclusion PP and TN occur in clinically distinct patient populations and exhibit differences in spatial radiographic pattern. Increased familiarity with both conditions and their unique features will improve patient management and may avoid unnecessary surgical procedures. Implications for Practice Pseudoprogression (PP) and treatment‐induced brain tissue necrosis (TN) are challenging treatment‐related effects mimicking tumor progression in patients with brain cancer. Affected patients frequently require surgery to guide management. PP and TN remain arbitrarily defined and insufficiently characterized. Lack of clear diagnostic criteria compromises treatment and may adversely affect outcome interpretation in clinical trials. The present findings in a cohort of patients with glioma with PP/TN suggest that both phenomena exhibit unique clinical and imaging characteristics, manifest in different patient populations, and should be classified as distinct clinical conditions. Increased familiarity with PP and TN key features may guide clinicians toward timely noninvasive diagnosis, circumvent potentially unnecessary surgical procedures, and improve response assessment in neuro‐oncology. Cancer treatment–related adverse effects on the brain are a major diagnostic and therapeutic challenge in neuro‐oncology. This article describes the key clinical and imaging features of pseudoprogression and treatment‐induced brain tissue necrosis in patients with malignant glioma in an attempt to improve the current understanding of these conditions, facilitate the noninvasive diagnosis of treatment‐related adverse effects, and improve response assessment in neuro‐oncology.
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Affiliation(s)
- Sebastian F. Winter
- Massachusetts General Hospital Cancer Center, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Department of Neurology, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Department of Neurosurgery, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu BerlinBerlinGermany
- Berlin Institute of HealthBerlinGermany
| | - Eugene J. Vaios
- Massachusetts General Hospital Cancer Center, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Alona Muzikansky
- Biostatistics Center, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Maria Martinez‐Lage
- CS Kubik Laboratory for Neuropathology, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Marc R. Bussière
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Helen A. Shih
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Jay Loeffler
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Philipp Karschnia
- Massachusetts General Hospital Cancer Center, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Department of Neurosurgery, Ludwig Maximilians UniversityMunichGermany
| | - Franziska Loebel
- Department of Neurosurgery, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu BerlinBerlinGermany
- Berlin Institute of HealthBerlinGermany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu BerlinBerlinGermany
- Berlin Institute of HealthBerlinGermany
| | - Jorg Dietrich
- Massachusetts General Hospital Cancer Center, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Department of Neurology, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
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35
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Carminucci A, Zeller S, Danish S. Radiographic Trends for Infield Recurrence After Radiosurgery for Cerebral Metastases. Cureus 2020; 12:e8680. [PMID: 32699680 PMCID: PMC7370660 DOI: 10.7759/cureus.8680] [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] [Indexed: 11/05/2022] Open
Abstract
Objective Recurrence following stereotactic radiosurgery (SRS) for the treatment of cerebral metastases is not uncommon. Recurrence can represent recurrent tumor and/or radiation necrosis. The radiographic response to Gamma Knife (GK) treatment is variable with some remaining stable, some decreasing in size, some increasing in size, while some may show a combination of all three. For tumors that demonstrate progression on MRI, the question to intervene with additional surgical or radiation therapy and the timing of such intervention remains debatable. In this study, we retrospectively reviewed surveillance MRIs of post-GK cerebral metastases to determine if radiographic trends are a predictor of infield progression. Methods A retrospective review of cerebral metastases treated with GK radiosurgery with at least two consecutive post-GK MRI scans was performed. Infield progression was defined by new enhancement increased by at least 25% in two out of three dimensions on two consecutive scans. Primary endpoints for infield recurrence were either continued observation, therapeutic intervention, or withdrawal of care. Results A total of 579 cerebral metastases were treated with GK radiosurgery. A total of 123 metastases demonstrated radiographic progression on one follow-up MRI scan. Of those, 75% demonstrated continued progression follow-up imaging, while 25% stabilized or regressed. For post-GK metastases demonstrating progression on two consecutive MRI scans, 85% of lesions continued to progress, whereas only 15% demonstrated stabilization or regression. A total of 91% of lesions either require intervention or demonstrate continued progression with observation at this timepoint. Cumulatively 100% of metastases with radiographic progression on ≥3 consecutive MRIs went on to need further intervention. Conclusion Approximately one-fourth of infield recurrence demonstrating progression on the first surveillance MRI will stabilize or regress. Those demonstrating infield progression on two consecutive MRI scans should be considered treatment failures. Early interventions before tumor volume increases in size or patients require high-dose steroids maybe beneficial.
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Affiliation(s)
- Arthur Carminucci
- Neurosurgery, Rutgers Robert Wood Johnson Medical School, Piscataway, USA
| | - Sabrina Zeller
- Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
| | - Shabbar Danish
- Neurosurgery, Rutgers Robert Wood Johnson Medical School, Piscataway, USA
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36
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Stereotactic radiosurgery combined with anti-PD1 for the management of melanoma brain metastases: A retrospective study of safety and efficacy. Eur J Cancer 2020; 135:52-61. [PMID: 32535348 DOI: 10.1016/j.ejca.2020.04.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/07/2020] [Accepted: 04/07/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Brain metastases can be effectively treated with stereotactic radiosurgery (SRS). Immune checkpoint inhibitors are now pivotal in metastatic melanoma care, but some concerns have emerged regarding the safety of their combination with radiation therapy. METHODS We present a retrospective analysis of a cohort of patients treated by anti-PD1 and SRS as a sole modality of radiation therapy (no whole brain radiation therapy at any time) in a single institution. We included patients on anti-PD1 at the time of SRS or patients who started anti-PD1 within a maximum period of 3 months following SRS and were treated at least one year before the analysis. Clinical and serial imaging data were reviewed to determine the efficacy and the rate of adverse radiation effectss of the combination. RESULTS A total of 50 patients were included. SRS targeted 1, 2 to 3 and >3 brain metastases in 17, 16 and 17 patients, respectively. Two patients died before the first evaluation. Nine patients presented with an increase in peritumoral oedema, three with intracranial haemorrhage and one patient with both oedema and haemorrhage. Median follow-up was 38.89 months (interquartile range 24.43; 45.28). Median overall survival from SRS was 16.62 months with 1-, 2- and 3-year rates of 60%, 40% and 35%, respectively. Median brain-Progression Free Survival was 13.2 months with 1, 2 and 3-year rates of 62.1%, 49.7% and 49.7%, respectively. CONCLUSIONS This real-world cohort of patients treated with a homogeneous strategy combining upfront stereotactic radiosurgery and anti-PD1 shows remarkable survival rates and does not reveal unexpected toxicity.
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37
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Tripathi M, Ahuja CK, Mukherjee KK, Kumar N, Dhandapani S, Dutta P, Kaur R, Rekhapalli R, Batish A, Gurnani J, Kamboj P, Agrahari A, Kataria K. The Safety and Efficacy of Bevacizumab for Radiosurgery - Induced Steroid - Resistant Brain Edema; Not the Last Part in the Ship of Theseus. Neurol India 2020; 67:1292-1302. [PMID: 31744962 DOI: 10.4103/0028-3886.271242] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Radiation-induced brain edema (RIBE) is a serious complication of radiation therapy. It may result in dramatic clinico-radiological deterioration. At present, there are no definite guidelines for management of the complication. Corticosteroids are the usual first line of treatment, which frequently fails to provide long-term efficacy in view of its adverse complication profile. Bevacizumab has been reported to show improvement in cases of steroid-resistant radiation injury. The objective of this study is to evaluate the role of Bevacizumab in post-radiosurgery RIBE. Material and Methods Since 2012, 189 out of 1241 patients who underwent radiosurgery at our institution developed post-radiosurgery RIBE, 17 of which did not respond to high-dose corticosteroids. We systematically reviewed these 17 patients of various intracranial pathologies with clinic-radiological evidence of RIBE following gamma knife radiosurgery (GKRS). All patients received protocol-based Bevacizumab therapy. The peer-reviewed literature was evaluated. Results 82 percent of the patients showed improvement after starting Bevacizumab. The majority began to improve after the third cycle started improvement after the third cycle of Bevacizumab. Clinical improvement preceded radiological improvement by an average of eight weeks. The first dose was 5 mg/kg followed by 7.5-10 mg/kg at with two-week intervals. Bevacizumab needs to be administered for an average of seven cycles (range 5-27, median 7) for best response. Steroid therapy could be tapered in most patients by the first follow-up. One patient did not respond to Bevacizumab and needed surgical decompression for palliative care. One noncompliant patient died due to radiation injury. Conclusion Bevacizumab is a effective and safe for treatment of RIBE after GKRS. A protocol-based dose schedule in addition to frequent clinical and radiological evaluations are required. Bevacizumab should be considered as an early treatment option for RIBE.
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Affiliation(s)
- Manjul Tripathi
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Chirag K Ahuja
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kanchan K Mukherjee
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Narendra Kumar
- Department of Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sivashanmugam Dhandapani
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pinaki Dutta
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rupinder Kaur
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajashekhar Rekhapalli
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Batish
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jenil Gurnani
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Parwinder Kamboj
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Abhinav Agrahari
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ketan Kataria
- Department of Anaesthesia, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Teyateeti A, Brown PD, Mahajan A, Laack NN, Pollock BE. Brain metastases resection cavity radio—surgery based on T2-weighted MRI: technique assessment. J Neurooncol 2020; 148:89-95. [DOI: 10.1007/s11060-020-03492-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/08/2020] [Indexed: 01/29/2023]
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Abstract
Radiation necrosis (RN) is a challenging potential complication of cranial radiation therapy. Believed to result from a complex interplay of vascular, glial, and immunologic factors, the exact mechanism of RN remains unclear. Patients who develop RN typically have a history of treatment with stereotactic radiation surgery or some other form of radiation-based therapy. The time frame for its development is variable, but it most often occurs one to three years following radiation therapy. Reported treatment doses capable of inducing radiation necrosis are variable, with higher doses per fraction more likely to induce RN. Furthermore, RN remains a challenging diagnosis for clinicians to make, as its presentation is often nonspecific and imaging studies might not clearly differentiate RN from tumor recurrence or pseudoprogression. RN is initially managed with corticosteroids, followed by bevacizumab, surgical resection, or laser interstitial thermal therapy if symptoms persist. In this review, we examine the literature regarding pathophysiology, incidence, imaging characteristics, and management strategies for radiation necrosis.
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Campos B, Neumann JO, Hubert A, Adeberg S, El Shafie R, von Deimling A, Bendszus M, Debus J, Bernhardt D, Unterberg A. Analysis of a Surgical Series of 21 Cerebral Radiation Necroses. World Neurosurg 2020; 137:e462-e469. [PMID: 32058117 DOI: 10.1016/j.wneu.2020.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 01/31/2020] [Accepted: 02/01/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND There is no standard approach to differentiate cerebral radiation necrosis from tumor recurrence and no standard treatment pathway for symptomatic lesions. In addition, reports on histology-proven radiation necrosis and the underlying pathophysiology are scarce and highly relevant. METHODS Our monocentric, retrospective analysis included 21 histology-proven cerebral radiation necroses. Our study focused on 1) potential risk factors for the development of radiation necrosis, 2) radiologic and histopathologic features of individual necroses, and 3) the suitability of previously reported magnetic resonance imaging (MRI)-based methods to identify radiation necroses based on specific structural image features. RESULTS Average time between radiation treatment and development of necrosis was 4.68 years (95% confidence interval, 0.19-9.55 years). Matching available MRI data sets with those of patients with tumor lesions, we compared specificity and sensitivity of 3 previously reported methods to identify radionecrosis based on imaging criteria. In our hands, none of these methods reached a sensitivity ≥70%. Radionecrosis presented with large edema and showed increased levels of cell proliferation, as inferred by Ki-67 staining. Surgical removal of radiation necrosis proved to be a safe approach with low permanent morbidity (<5%) and no mortality. CONCLUSIONS Although the overall incidence of cerebral radiation necrosis is low, our data suggest an increasing incidence over the last 2 decades, which is likely associated with the use of stereotactic radiotherapy. There are no imaging standards to identify radiation necrosis on standard MRI with structural sequences. Surgical removal of radiation necrosis is associated with low morbidity and mortality.
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Affiliation(s)
- Benito Campos
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany.
| | - Jan-Oliver Neumann
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Alexander Hubert
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Sebastian Adeberg
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Rami El Shafie
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Andreas von Deimling
- Department of Neuropathology, University of Heidelberg, Heidelberg, Germany; Clinical Cooperation Unit Neuropathology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany; German Cancer Consortium (DKTK), Partner site Heidelberg, Heidelberg, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
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Pandey P, Ullas VA. Distinguishing radiation necrosis from tumor recurrence. CANCER RESEARCH, STATISTICS, AND TREATMENT 2020. [DOI: 10.4103/crst.crst_94_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Coregistration of Magnetic Resonance and [ 18F] Fludeoxyglucose-Positron Emission Tomography Imaging for Stereotactic Radiation Therapy Planning: Case Report in a Previously Irradiated Brain Metastasis With Recurrent Tumor and Radiation Necrosis. Pract Radiat Oncol 2019; 10:133-137. [PMID: 31790826 DOI: 10.1016/j.prro.2019.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 10/23/2019] [Accepted: 11/20/2019] [Indexed: 12/28/2022]
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Eulitz J, Lutz B, Wohlfahrt P, Dutz A, Enghardt W, Karpowitz C, Krause M, Troost EGC, Lühr A. A Monte Carlo based radiation response modelling framework to assess variability of clinical RBE in proton therapy. Phys Med Biol 2019; 64:225020. [PMID: 31374558 DOI: 10.1088/1361-6560/ab3841] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The clinical implementation of a variable relative biological effectiveness (RBE) in proton therapy is currently controversially discussed. Initial clinical evidence indicates a variable proton RBE, which needs to be verified. In this study, a radiation response modelling framework for assessing clinical RBE variability is established. It was applied to four selected glioma patients (grade III) treated with adjuvant radio(chemo)therapy and who developed late morphological image changes on T1-weighted contrast-enhanced (T1w-CE) magnetic resonance (MR) images within approximately two years of recurrence-free follow-up. The image changes were correlated voxelwise with dose and linear energy transfer (LET) values using univariable and multivariable logistic regression analysis. The regression models were evaluated by the area-under-the-curve (AUC) method performing a leave-one-out cross validation. The tolerance dose TD50 at which 50% of patient voxels experienced toxicity was interpolated from the models. A Monte Carlo (MC) model was developed to simulate dose and LET distributions, which includes variance reduction (VR) techniques to decrease computation time. Its reliability and accuracy were evaluated based on dose calculations of the clinical treatment planning system (TPS) as well as absolute dose measurements performed in the patient specific quality assurance. Morphological image changes were related to a combination of dose and LET. The multivariable models revealed cross-validated AUC values of up to 0.88. The interpolated TD50 curves decreased with increasing LET indicating an increase in biological effectiveness. The MC model reliably predicted average TPS dose within the clinical target volume as well as absolute water phantom dose measurements within 2% accuracy using dedicated VR settings. The observed correlation of dose and LET with late brain tissue damage suggests considering RBE variability for predicting chronic radiation-induced brain toxicities. The MC model simulates radiation fields in patients precisely and time-efficiently. Hence, this study encourages and enables in-depth patient evaluation to assess the variability of clinical proton RBE.
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Affiliation(s)
- J Eulitz
- Faculty of Medicine and University Hospital Carl Gustav Carus, OncoRay-National Center for Radiation Research in Oncology, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany. Faculty of Medicine and University Hospital Carl Gustav Carus, Department of Radiotherapy and Radiation Oncology, Technische Universität Dresden, Dresden, Germany. Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology-OncoRay, Dresden, Germany
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Dahl NA, Liu A, Foreman N, Widener M, Fenton L, Macy ME. Bevacizumab in the treatment of radiation injury for children with central nervous system tumors. Childs Nerv Syst 2019; 35:2043-2046. [PMID: 31367784 PMCID: PMC7251774 DOI: 10.1007/s00381-019-04304-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 07/08/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE Radiation-induced injury is a well-described toxicity in children receiving radiation therapy for tumors of the central nervous system. Standard therapy has historically consisted primarily of high-dose corticosteroids, which carry significant side effects. Preclinical models suggest that radiation necrosis may be mediated in part through vascular endothelial growth factor (VEGF) overexpression, providing the rationale for use of VEGF inhibitors in the treatment of CNS radiation necrosis. We present the first prospective experience examining the safety, feasibility, neurologic outcomes, and imaging characteristics of bevacizumab therapy for CNS radiation necrosis in children. METHODS Seven patients between 1 and 25 years of age with neurologic deterioration and MRI findings consistent with radiation injury or necrosis were enrolled on an IRB-approved pilot feasibility study. Patients received bevacizumab at a dose of 10 mg/kg intravenously every 2 weeks for up to 6 total doses. RESULTS Five patients (83%) were able to wean off corticosteroid therapy during the study period and 4 patients (57%) demonstrated improvement in serial neurologic exams. All patients demonstrated a decrease in T1-weighted post-gadolinium enhancement on MRI, while 5 (71%) showed a decrease in FLAIR signal. Four patients developed a progressive disease of their underlying tumor during bevacizumab therapy. CONCLUSIONS Our experience lends support to the safety and feasibility of bevacizumab administration for the treatment of radiation necrosis for appropriately selected patients within the pediatric population.
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Affiliation(s)
- Nathan A. Dahl
- Center for Cancer and Blood Disorders, Children’s Hospital Colorado, Denver, Colorado,Morgan Adams Foundation Pediatric Brain Tumor Research Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Arthur Liu
- Department of Radiation Oncology, University of Colorado School of Medicine, Denver, Colorado
| | - Nicholas Foreman
- Center for Cancer and Blood Disorders, Children’s Hospital Colorado, Denver, Colorado,Morgan Adams Foundation Pediatric Brain Tumor Research Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Melissa Widener
- Center for Cancer and Blood Disorders, Children’s Hospital Colorado, Denver, Colorado
| | - Laura Fenton
- Department of Radiology, Children’s Hospital Colorado, Denver, Colorado
| | - Margaret E. Macy
- Center for Cancer and Blood Disorders, Children’s Hospital Colorado, Denver, Colorado
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Lohmeier J, Bohner G, Siebert E, Brenner W, Hamm B, Makowski MR. Quantitative biparametric analysis of hybrid 18F-FET PET/MR-neuroimaging for differentiation between treatment response and recurrent glioma. Sci Rep 2019; 9:14603. [PMID: 31601829 PMCID: PMC6787240 DOI: 10.1038/s41598-019-50182-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 09/04/2019] [Indexed: 11/09/2022] Open
Abstract
We investigated the diagnostic potential of simultaneous 18F-FET PET/MR-imaging for differentiation between recurrent glioma and post-treatment related effects (PTRE) using quantitative volumetric (3D-VOI) lesion analysis. In this retrospective study, a total of 42 patients including 32 patients with histologically proven glioma relapse and 10 patients with PTRE (histopathologic follow-up, n = 4, serial imaging follow-up, n = 6) were evaluated regarding recurrence. PET/MR-imaging was semi-automatically analysed based on FET tracer uptake using conservative SUV thresholding (isocontour 80%) with emphasis on the metabolically most active regions. Mean (relative) apparent diffusion coefficient (ADCmean, rADCmean), standardised-uptake-value (SUV) including target-to-background (TBR) ratio were determined. Glioma relapse presented higher ADCmean (MD ± SE, 284 ± 91, p = 0.003) and TBRmax (MD ± SE, 1.10 ± 0.45, p = 0.02) values than treatment-related changes. Both ADCmean (AUC ± SE = 0.82 ± 0.07, p-value < 0.001) and TBRmax (AUC ± SE = 0.81 ± 0.08, p-value < 0.001) achieved reliable diagnostic performance in differentiating glioma recurrence from PTRE. Bivariate analysis based on a combination of ADCmean and TBRmax demonstrated highest diagnostic accuracy (AUC ± SE = 0.90 ± 0.05, p-value < 0.001), improving clinical (false negative and false positive) classification. In conclusion, biparametric analysis using DWI and FET PET, both providing distinct information regarding the underlying pathophysiology, presented best diagnostic accuracy and clinical benefit in differentiating recurrent glioma from treatment-related changes.
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Affiliation(s)
- Johannes Lohmeier
- Charité Universitätsmedizin Berlin, Department of Radiology, Campus Charité Mitte (CCM), Charitéplatz 1, 10117, Berlin, Germany.
| | - Georg Bohner
- Charité Universitätsmedizin Berlin, Department of Neuroradiology, Campus Charité Mitte (CCM), Charitéplatz 1, 10117, Berlin, Germany
| | - Eberhard Siebert
- Charité Universitätsmedizin Berlin, Department of Neuroradiology, Campus Charité Mitte (CCM), Charitéplatz 1, 10117, Berlin, Germany
| | - Winfried Brenner
- Charité Universitätsmedizin Berlin, Department of Nuclear Medicine, Campus Virchow-Klinikum (CVK), Augustenburger Platz 1, 13353, Berlin, Germany
| | - Bernd Hamm
- Charité Universitätsmedizin Berlin, Department of Radiology, Campus Charité Mitte (CCM), Charitéplatz 1, 10117, Berlin, Germany
| | - Marcus R Makowski
- Charité Universitätsmedizin Berlin, Department of Radiology, Campus Charité Mitte (CCM), Charitéplatz 1, 10117, Berlin, Germany
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Cerebral Radiation Necrosis: Incidence, Pathogenesis, Diagnostic Challenges, and Future Opportunities. Curr Oncol Rep 2019; 21:66. [PMID: 31218455 DOI: 10.1007/s11912-019-0818-y] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Cerebral radiation necrosis (CRN) is a major dose-limiting adverse event of radiotherapy. The incidence rate of RN varies with the radiotherapy modality, total dose, dose fractionation, and the nature of the lesion being targeted. In addition to these known and controllable features, there is a stochastic component to the occurrence of CRN-the genetic profile of the host or the lesion and their role in the development of CRN. RECENT FINDINGS Recent studies provide some insight into the genetic mechanisms underlying radiation-induced brain injury. In addition to these incompletely understood host factors, the diagnostic criteria for CRN using structural and functional imaging are also not clear, though multiple structural and functional imaging modalities exist, a combination of which may prove to be the ideal diagnostic imaging approach. As the utilization of novel molecular therapies and immunotherapy increases, the incidence of CNR is expected to increase and its diagnosis will become more challenging. Tissue biopsies can be insensitive and suffer from sampling biases and procedural risks. Liquid biopsies represent a promising, accurate, and non-invasive diagnostic strategy, though this modality is currently in its infancy. A better understanding of the pathogenesis of CRN will expand and optimize the diagnosis and management of CRN by better utilizing existing treatment options including bevacizumab, pentoxifylline, hyperbaric oxygen therapy, and laser interstitial thermal therapy.
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Donovan EK, Parpia S, Greenspoon JN. Incidence of radionecrosis in single-fraction radiosurgery compared with fractionated radiotherapy in the treatment of brain metastasis. ACTA ACUST UNITED AC 2019; 26:e328-e333. [PMID: 31285676 DOI: 10.3747/co.26.4749] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Radiation-induced brain necrosis ["radionecrosis" (rn)] is a relatively uncommon but potentially severe adverse effect of stereotactic radiosurgery (srs) for brain metastasis. Although dose, volume, and hypofractionation have been suggested to affect rn rates, patient and treatment variability in this population make it difficult to clearly delineate the risk. We set out to establish the effect of fractionation on rn rates by reviewing patients receiving simultaneous multi-fraction and single-fraction treatment at our centre. Methods Patients receiving simultaneous (within 1 month) 1-fraction (ssrs) and 3-fraction (fsrs) radiosurgery treatments during 2012-2015 were identified in our institution's database. Serial post-srs magnetic resonance imaging (mri) was reviewed to determine rn and local recurrence. The effect of maximum dose, volume, whole-brain radiotherapy (wbrt), and fractionation on rn development was assessed using logistic regression for paired data. Results are reported using odds ratios (ors) and corresponding 95% confidence intervals (cis). Results Of 90 patients identified, 22 had at least a 6-month mri follow-up. Median follow-up was 320 days. The most common primary tumour type was non-small-cell lung cancer, followed by breast and rectal cancer. Radionecrosis developed in 16 patients [21 of 62 lesions (34%), with 4 being symptomatic (20%)]. Of the 21 lesions in which rn developed, 11 received 3 fractions, and 10 received 1 fraction. The or for the association between the incidence of rn and maximum dose was 1.0 (95% ci: 0.9 to 1.1); for fractionation it was 1.0 (95% ci: 0.3 to 3.6); for previous wbrt, it was 0.4 (95% ci: 0.2 to 1.2); and for a 10-unit increase in volume, it was 3.1 (95% ci: 1.0 to 9.6). Local recurrence developed in 8 patients (12%), 6 of whom belonged to the ssrs group. Conclusions Our results indicate that patients receiving srs for multiple brain metastases experience a higher rate of rn than is reported in the literature and poorer survival despite having equivalent local control. Maximum dose did not appear to be associated with rn risk in our cohort, but volume was significantly associated with rn risk. Although fractionated treatment did not directly lower the rate of rn in this population, it might have played a role in reducing the magnitude of the rn risk in large-volume lesions. Further investigation will help to delineate optimal dose and fractionation so as to minimize rn while maintaining local control in this group.
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Affiliation(s)
- E K Donovan
- Department of Oncology, McMaster University, Juravinski Hospital and Cancer Centre, Hamilton, ON
| | - S Parpia
- Department of Statistics and Epidemiology, Juravinski Hospital, McMaster University, Hamilton, ON
| | - J N Greenspoon
- Department of Oncology, McMaster University, Juravinski Hospital and Cancer Centre, Hamilton, ON
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Kwee RM, Kwee TC. Dynamic susceptibility MR perfusion in diagnosing recurrent brain metastases after radiotherapy: A systematic review and meta-analysis. J Magn Reson Imaging 2019; 51:524-534. [PMID: 31150144 PMCID: PMC7004193 DOI: 10.1002/jmri.26812] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 05/17/2019] [Indexed: 01/18/2023] Open
Abstract
Background The diagnostic performance of dynamic susceptibility contrast (DSC) MR perfusion in discriminating treatment‐related changes from recurrence in irradiated brain metastases is currently not completely clear. Purpose To systematically review the accuracy of DSC MR perfusion in diagnosing recurrent brain metastases after radiotherapy. Study Type Systematic review and meta‐analysis. Subjects MEDLINE and Embase were searched for original studies investigating the accuracy of DSC MR perfusion in diagnosing recurrent brain metastases after radiotherapy. Ten studies, comprising a total of more than 271 metastases, were included. Field Strength/Sequence 1.5T or 3.0T, DSC MR perfusion. Assessment Quality assessment was performed according to the Quality Assessment of Diagnostic Accuracy Studies‐2 tool. Statistical Tests Sensitivity and specificity were pooled with a bivariate random‐effects model. Heterogeneity was assessed by a chi‐squared test. Potential sources for heterogeneity were explored by subgroup analyses. Results In seven studies the diagnostic criterion was not prespecified. In eight studies it was unclear whether the reference standard was interpreted blindly. In seven studies it was unclear whether DSC MR perfusion results influenced which reference standard was used. Pooled sensitivity and specificity were 81.6% (95% confidence interval [CI]: 70.6%, 89.1%) and 80.6% (95% CI: 64.2%, 90.6%), respectively. There was significant heterogeneity in both sensitivity (P = 0.005) and specificity (P < 0.001). There were no significant differences in relative diagnostic odds ratio according to publication year, country of origin, study size, and DSC MR perfusion interpretation method (visual analysis of cerebral blood volume [CBV] map vs. relative CBV measurement) (P > 0.2). Due to insufficiently detailed reporting, it was not possible to investigate the influence of primary tumor origin on accuracy. Data Conclusion Our results suggest that the accuracy of DSC MR perfusion in diagnosing recurrent brain metastases after radiotherapy is fairly high. However, these findings should be interpreted with caution because of methodological quality concerns and heterogeneity between studies. Level of Evidence: 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2020;51:524–534.
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Affiliation(s)
- Robert M Kwee
- Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, The Netherlands
| | - Thomas C Kwee
- Department of Radiology, Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, The Netherlands
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Tom MC, Cahill DP, Buckner JC, Dietrich J, Parsons MW, Yu JS. Management for Different Glioma Subtypes: Are All Low-Grade Gliomas Created Equal? Am Soc Clin Oncol Educ Book 2019; 39:133-145. [PMID: 31099638 DOI: 10.1200/edbk_238353] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Following the identification of key molecular alterations that provided superior prognostication and led to the updated 2016 World Health Organization (WHO) Central Nervous System (CNS) Tumor Classification, the understanding of glioma behavior has rapidly evolved. Mutations in isocitrate dehydrogenase (IDH) 1 and 2 are present in the majority of adult grade 2 and 3 gliomas, and when used in conjunction with 1p/19q codeletion for classification, the prognostic distinction between grade 2 versus grade 3 is diminished. As such, the previously often used term of "low-grade glioma," which referred to grade 2 gliomas, has now been replaced by the phrase "lower-grade glioma" to encompass both grade 2 and 3 tumors. Additional molecular characterization is ongoing to even further classify this heterogeneous group of tumors. With such a colossal shift in the understanding of lower-grade gliomas, management of disease is being redefined in the setting of emerging molecular-genetic biomarkers. In this article, we review recent progress and future directions regarding the surgical, radiotherapeutic, chemotherapeutic, and long-term management of adult lower-grade gliomas.
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Affiliation(s)
- Martin C Tom
- 1 Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Daniel P Cahill
- 2 Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jan C Buckner
- 3 Department of Oncology, Mayo Clinic, Rochester, MN
| | - Jörg Dietrich
- 4 Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Michael W Parsons
- 4 Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Jennifer S Yu
- 1 Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.,5 Department of Cancer Biology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
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What Neuroradiologists Need to Know About Radiation Treatment for Neural Tumors. Top Magn Reson Imaging 2019; 28:37-47. [PMID: 31022047 DOI: 10.1097/rmr.0000000000000196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Radiation oncologists and radiologists have a unique and mutually dependent relationship. Radiation oncologists rely on diagnostic imaging to locate the tumor and define the treatment target volume, evaluation of response to therapy, and follow-up. Accurate interpretation of post-treatment imaging requires diagnostic radiologists to have a basic understanding of radiation treatment planning and delivery. There are various radiation treatment modalities such as 3D conformal radiation therapy, intensity modulated radiation therapy and stereotactic radiosurgery as well as different radiation modalities such as photons and protons that can be used for treatment. All of these have subtle differences in how the treatment is planned and how the imaging findings might be affected. This paper provides an overview of the basic principles of radiation oncology, different radiation treatment modalities, how radiation therapy is planned and delivered, how knowledge of this process can help interpretation of images, and how the radiologist can contribute to this process.
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