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Pikis S, Mantziaris G, Protopapa M, Tos SM, Kowalchuk RO, Ross RB, Rusthoven CG, Tripathi M, Langlois AM, Mathieu D, Lee CC, Yang HC, Peker S, Samanci Y, Zhang MY, Braunstein SE, Wei Z, Niranjan A, Lunsford DL, Sheehan J. Stereotactic radiosurgery for brain metastases from human epidermal receptor 2 positive breast Cancer: an international, multi-center study. J Neurooncol 2024; 170:199-208. [PMID: 39192068 PMCID: PMC11446965 DOI: 10.1007/s11060-024-04775-3] [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: 05/26/2024] [Accepted: 07/09/2024] [Indexed: 08/29/2024]
Abstract
PURPOSE To report patient outcomes and local tumor control rates in a cohort of patients with biopsy-proven HER-2 positive breast cancer treated with stereotactic radiosurgery (SRS) for brain metastases (BM). METHODS This international, retrospective, multicenter study, included 195 female patients with 1706 SRS-treated BM. Radiologic and clinical outcomes after SRS were determined and prognostic factors identified. RESULTS At SRS, median patient age was 55 years [interquartile range (IQR) 47.6-62.0], and 156 (80%) patients had KPS ≥ 80. The median tumor volume was 0.1 cm3 (IQR 0.1-0.5) and the median prescription dose was 16 Gy (IQR 16-18). Local tumor control (LTC) rate was 98%, 94%, 93%, 90%, and 88% at six-, 12-, 24-, 36- and 60-months post-SRS, respectively. On multivariate analysis, tumor volume (p = < 0.001) and concurrent pertuzumab (p = 0.02) improved LTC. Overall survival (OS) rates at six-, 12-, 24-, 36-, 48-, and 60-months were 90%, 69%, 46%, 27%, 22%, and 18%, respectively. Concurrent pertuzumab improved OS (p = 0.032). In this patient subgroup, GPA scores ≥ 2.5 (p = 0.038 and p = 0.003) and rare primary tumor histologies (p = 0.01) were associated with increased and decreased OS, respectively. Asymptomatic adverse radiation events (ARE) occurred in 27 (14.0%) and symptomatic ARE in five (2.6%) patients. Invasive lobular carcinoma primary (p = 0.042) and concurrent pertuzumab (p < 0.001) conferred an increased risk for overall but not for symptomatic ARE. CONCLUSION SRS affords effective LTC for selected patients with BM from HER-2 positive breast cancer. Concurrent pertuzumab improved LTC and OS but at the same time increased the risk for overall, but not symptomatic, ARE.
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Affiliation(s)
- Stylianos Pikis
- Department of Radiotherapy and Stereotactic Radiosurgery, Mediterraneo Hospital, Athens, Greece
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia Health System, University of Virginia, 1215 Lee St, Charlottesville, VA, 22908, USA
| | - Maria Protopapa
- Department of Radiotherapy and Stereotactic Radiosurgery, Mediterraneo Hospital, Athens, Greece
| | - Salem M Tos
- Department of Neurological Surgery, University of Virginia Health System, University of Virginia, 1215 Lee St, Charlottesville, VA, 22908, USA
| | | | - Richard Blake Ross
- Department of Radiation Oncology, University of Colorado, Aurora, CO, USA
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Aurora, CO, USA
| | - Manjul Tripathi
- Department of Neurosurgery and Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anne-Marie Langlois
- Department of Neurosurgery, Centre de recherche du CHUS, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - David Mathieu
- Department of Neurosurgery, Centre de recherche du CHUS, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Cheng-Chia Lee
- Department of Neurosurgery School of Medicine, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery School of Medicine, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Michael Yu Zhang
- Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dade L Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia Health System, University of Virginia, 1215 Lee St, Charlottesville, VA, 22908, USA.
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Wei Z, Srinivasan P, Patel R, Bednarz G, Flickinger JC, Hadjipanayis CG, Niranjan A, Lunsford LD. Stereotactic Radiosurgery for Patients with Brain Metastases from Hepatopancreaticobiliary Cancers. Cancers (Basel) 2024; 16:1665. [PMID: 38730617 PMCID: PMC11083154 DOI: 10.3390/cancers16091665] [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: 04/01/2024] [Revised: 04/21/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND The role of stereotactic radiosurgery (SRS) for patients with brain metastases from hepatopancreaticobiliary (HPB) cancers has yet to be established. The authors present a single-institution experience of patients with HPB cancers who underwent SRS when their cancer spread to the brain. METHODS We surveyed our Gamma Knife SRS data base of 18,000 patients for the years 1987-2022. In total, 19 metastatic HPB cancer patients (13 male) with 76 brain metastases were identified. The median age at SRS was 61 years (range: 48-83). The primary cancer sites were hepatocellular carcinoma (HCC, 11 patients), cholangiocarcinoma (CCC, 2 patients), and pancreatic carcinoma (PCC, 6 patients). The median Karnofsky Performance Score (KPS) was 80 (range: 50-90). Two patients underwent pre-SRS whole-brain fractionated radiation therapy (WBRT) and eight patients underwent pre-SRS surgical resection. All SRS was delivered in single session. The median margin dose was 18 Gy (range: 15-20). The median cumulative tumor volume was 8.1 cc (range: 1.0-44.2). RESULTS The median patient overall survival (OS) after SRS was 7 months (range 1-79 months). Four patients had documented local tumor progression after SRS at a median time of 8.5 months (range: 2-15) between SRS and progression. Out of 76 treated tumors, 72 tumors exhibited local control. The local tumor control rate per patient was 78.9%. The local tumor control per tumor was 94.7%. Four patients developed new brain metastases at a median of 6.5 months (range: 2-17) after SRS. No patient experienced adverse radiation effects (AREs). At the last follow-up, 18 patients had died, all from systemic disease progression. CONCLUSIONS Metastatic spread to the brain from HPB cancers occurs late in the course of the primary disease. In this study, all deceased patients ultimately died from primary disease progression. SRS is a non-invasive strategy that maximally preserves quality of life, and our results reported favorable outcomes compared to the existing literature. SRS should be considered as one of the primary management strategies for patients with brain metastatic spread from HPB cancer.
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Affiliation(s)
- Zhishuo Wei
- School of Medicine, University of Pittsburgh Medical Center, 200 Lothrop Street, Pennsylvania, PA 15213, USA
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pennsylvania, PA 15213, USA (C.G.H.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pennsylvania, PA 15213, USA
| | - Priyanka Srinivasan
- School of Medicine, University of Pittsburgh Medical Center, 200 Lothrop Street, Pennsylvania, PA 15213, USA
| | - Ritam Patel
- School of Medicine, University of Pittsburgh Medical Center, 200 Lothrop Street, Pennsylvania, PA 15213, USA
| | - Greg Bednarz
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pennsylvania, PA 15213, USA (C.G.H.)
| | - John C. Flickinger
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pennsylvania, PA 15213, USA (C.G.H.)
- Department of Radiation Oncology, University of Pittsburgh Medical Center, 200 Lothrop Street, Pennsylvania, PA 15213, USA
| | - Constantinos G. Hadjipanayis
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pennsylvania, PA 15213, USA (C.G.H.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pennsylvania, PA 15213, USA
| | - Ajay Niranjan
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pennsylvania, PA 15213, USA (C.G.H.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pennsylvania, PA 15213, USA
| | - L. Dade Lunsford
- Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pennsylvania, PA 15213, USA (C.G.H.)
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pennsylvania, PA 15213, USA
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Khalaveh F, Cho A, Shaltout A, Untersteiner H, Kranawetter B, Hirschmann D, Göbl P, Marik W, Gatterbauer B, Rössler K, Dorfer C, Frischer JM. Concomitant radiosurgical and targeted oncological treatment improves the outcome of patients with brain metastases from gastrointestinal cancer. Radiat Oncol 2023; 18:197. [PMID: 38071299 PMCID: PMC10710706 DOI: 10.1186/s13014-023-02383-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/24/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND So far, only limited studies exist that evaluate patients with brain metastases (BM) from GI cancer and associated primary cancers who were treated by Gamma Knife Radiosurgery (GKRS) and concomitant immunotherapy (IT) or targeted therapy (TT). METHODS Survival after GKRS was compared to the general and specific Graded Prognostic Assessment (GPA) and Score Index for Radiosurgery (SIR). Further, the influence of age, sex, Karnofsky Performance Status Scale (KPS), extracranial metastases (ECM) status at BM diagnosis, number of BM, the Recursive Partitioning Analysis (RPA) classes, GKRS1 treatment mode and concomitant treatment with IT or TT on the survival after GKRS was analyzed. Moreover, complication rates after concomitant GKRS and mainly TT treatment are reported. RESULTS Multivariate Cox regression analysis revealed IT or TT at or after the first Gamma Knife Radiosurgery (GKRS1) treatment as the only significant predictor for overall survival after GKRS1, even after adjusting for sex, KPS group, age group, number of BM at GKRS1, RPA class, ECM status at BM diagnosis and GKRS treatment mode. Concomitant treatment with IT or TT did not increase the rate of adverse radiation effects. There was no significant difference in local BM progression after GKRS between patients who received IT or TT and patients without IT or TT. CONCLUSION Good local tumor control rates and low rates of side effects demonstrate the safety and efficacy of GKRS in patients with BM from GI cancers. The concomitant radiosurgical and targeted oncological treatment significantly improves the survival after GKRS without increasing the rate of adverse radiation effects. To provide local tumor control, radiosurgery remains of utmost importance in modern GI BM management.
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Affiliation(s)
- Farjad Khalaveh
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Anna Cho
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Abdallah Shaltout
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Helena Untersteiner
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Beate Kranawetter
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Dorian Hirschmann
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Philipp Göbl
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Wolfgang Marik
- Department of Radiology, Division of Neuro- and Musculoskeletal Radiology, Medical University of Vienna, Vienna, Austria
| | - Brigitte Gatterbauer
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Karl Rössler
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Christian Dorfer
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Josa M Frischer
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria.
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Ohtakara K, Kondo T, Obata Y, Fujii K, Suzuki K. Five-Fraction Radiosurgery Using a Biologically Equivalent Dose of a Single Fraction of 24 Gy for a 3-cm Parasagittal Para-Central Sulcus Brain Metastasis From Adenocarcinoma of the Cecum. Cureus 2023; 15:e48799. [PMID: 38098911 PMCID: PMC10720925 DOI: 10.7759/cureus.48799] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 12/17/2023] Open
Abstract
An isolated single brain metastasis (BM) is an extremely rare manifestation of failure in patients with cecal adenocarcinoma (CAC). Total en bloc resection (while preserving function) of a 3-cm BM involving both the primary motor and sensory cortexes presents a conundrum: achieving long-term local control and safety of such a BM is also challenging for stereotactic radiosurgery (SRS). We describe the case of a 3.1-cm BM from CAC in the left parasagittal para-central sulcus region, which was treated using five-fraction SRS with a biologically effective dose (BED) of 81.6 Gy. In the SRS, the gross tumor volume (GTV, 7.14 cm3) was defined based on computed tomography (CT)/T1/T2 matching (enhancing lesion 11.66 cm3), and 98.7% of the GTV (CT/T2 mass) was covered with 43.6 Gy (58% isodose) using volumetric-modulated arcs. The maximum tumor response was partial (19.7% of the prior GTV) and sustained for 15.2 months, leaving minor neurological symptoms. However, the patient developed neurological worsening at six months, attributed to adverse radiation effects with a CT/T1/T2 mismatch, for which medical management, including the addition of bevacizumab (BEV), was effective for one year. Multi-fraction SRS with a high marginal and internal BED and sequential systemic therapy, including BEV, can be a minimally invasive, efficacious, and durable treatment option for a large CAC-BM involving the central sulcus. Early co-administration of BEV following SRS, dose escalation to the GTV boundary, and more than five fractions of SRS may be considered to improve the efficacy and safety further.
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Affiliation(s)
- Kazuhiro Ohtakara
- Department of Radiation Oncology, Kainan Hospital Aichi Prefectural Welfare Federation of Agricultural Cooperatives, Yatomi, JPN
- Department of Radiology, Aichi Medical University, Nagakute, JPN
| | - Takanori Kondo
- Department of Surgery, Kainan Hospital Aichi Prefectural Welfare Federation of Agricultural Cooperatives, Yatomi, JPN
| | - Yuma Obata
- Department of Surgery, Gifu Prefectural Tajimi Hospital, Tajimi, JPN
- Department of Surgery, Kainan Hospital Aichi Prefectural Welfare Federation of Agricultural Cooperatives, Yatomi, JPN
| | - Kentaro Fujii
- Department of Neurosurgery, Kainan Hospital Aichi Prefectural Welfare Federation of Agricultural Cooperatives, Yatomi, JPN
| | - Kojiro Suzuki
- Department of Radiology, Aichi Medical University, Nagakute, JPN
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Harikar MM, Venkataram T, Palmisciano P, Scalia G, Baldoncini M, Cardali SM, Umana GE, Ferini G. Comparison of Staged Stereotactic Radiosurgery and Fractionated Stereotactic Radiotherapy in Patients with Brain Metastases > 2 cm without Prior Whole Brain Radiotherapy: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 178:213-232.e6. [PMID: 37543203 DOI: 10.1016/j.wneu.2023.07.143] [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: 07/07/2023] [Accepted: 07/30/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE To compare fractionated stereotactic radiotherapy (FSRT) with staged stereotactic radiosurgery (SSRS) in patients with brain metastases >2 cm without prior whole brain radiotherapy. METHODS In this systematic review and meta-analysis, PubMed, Scopus, Web of Science, Embase, and Cochrane were searched to include studies that evaluated FSRT and/or SSRS for brain metastases >2 cm or 4 cm3 in adult patients with a known primary malignancy and no prior history of whole brain radiotherapy. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed and an indirect random-effect meta-analyses was conducted to compare treatment outcomes between the two modalities. RESULTS A total of 10 studies were included, comprising 612 (778 metastases) and 250 patients (265 metastases) in the SSRS and FSRT groups, respectively. The SSRS group had significantly older patients (66.6 ± 17.51 years vs. 62.37 ± 37.89 years; P = 0.029) with lower rate of control of primary disease (11.59% vs. 78.7%, P < 0.00001), and more patients with Karnofsky performance status ≥70 at baseline (92.81% vs. 88.56%; P = 0.045). FSRT was associated with a statistically nonsignificant but clinically important lower 12-month overall survival (44.75% [95% confidence interval [CI]: 30.48%-59.95%] vs. 53.25% [95%CI: 45.15%-61.19%], P = 0.1615) and higher rate of salvage radiotherapy (18.18% [95%CI: 8.75%-34%] vs. 12.27% [95%CI: 5.98%-23.53%], P = 0.0841). Both groups had comparable rates of local tumor control, mortality, tumor progression, recurrence, neurological death, and 6-month overall survival. CONCLUSIONS SSRS and FSRT were found to be comparable for treating brain metastases >2 cm not previously irradiated. Given the paucity of such studies, trials directly comparing the two treatment strategies are warranted to support these findings.
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Affiliation(s)
- Mandara M Harikar
- Clinical Trials Programme, Usher Institute of Molecular, Genetic and Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Tejas Venkataram
- Department of Neurosurgery, St. John's Medical College Hospital, Bangalore, India
| | - Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Gianluca Scalia
- Department of Head and Neck Surgery, Neurosurgery Unit, Garibaldi Hospital, Catania, Italy
| | - Matias Baldoncini
- Department of Neurological Surgery, San Fernando Hospital, San Fernando, Argentina
| | - Salvatore Massimiliano Cardali
- Department of Neurosurgery, Azienda Ospedaliera Papardo, University of Messina, Messina, Italy; Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
| | - Giuseppe E Umana
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy.
| | - Gianluca Ferini
- Department of Radiation Oncology, REM Radioterapia srl, Viagrande, Italy
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