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Mitchell D, Kwon HJ, Kubica PA, Huff WX, O’Regan R, Dey M. Brain metastases: An update on the multi-disciplinary approach of clinical management. Neurochirurgie 2022; 68:69-85. [PMID: 33864773 PMCID: PMC8514593 DOI: 10.1016/j.neuchi.2021.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/16/2021] [Accepted: 04/03/2021] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Brain metastasis (BM) is the most common malignant intracranial neoplasm in adults with over 100,000 new cases annually in the United States and outnumbering primary brain tumors 10:1. OBSERVATIONS The incidence of BM in adult cancer patients ranges from 10-40%, and is increasing with improved surveillance, effective systemic therapy, and an aging population. The overall prognosis of cancer patients is largely dependent on the presence or absence of brain metastasis, and therefore, a timely and accurate diagnosis is crucial for improving long-term outcomes, especially in the current era of significantly improved systemic therapy for many common cancers. BM should be suspected in any cancer patient who develops new neurological deficits or behavioral abnormalities. Gadolinium enhanced MRI is the preferred imaging technique and BM must be distinguished from other pathologies. Large, symptomatic lesion(s) in patients with good functional status are best treated with surgery and stereotactic radiosurgery (SRS). Due to neurocognitive side effects and improved overall survival of cancer patients, whole brain radiotherapy (WBRT) is reserved as salvage therapy for patients with multiple lesions or as palliation. Newer approaches including multi-lesion stereotactic surgery, targeted therapy, and immunotherapy are also being investigated to improve outcomes while preserving quality of life. CONCLUSION With the significant advancements in the systemic treatment for cancer patients, addressing BM effectively is critical for overall survival. In addition to patient's performance status, therapeutic approach should be based on the type of primary tumor and associated molecular profile as well as the size, number, and location of metastatic lesion(s).
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Affiliation(s)
- D Mitchell
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - HJ Kwon
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - PA Kubica
- Department of Neurosurgery, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA
| | - WX Huff
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - R O’Regan
- Department of Medicine/Hematology Oncology, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA
| | - M Dey
- Department of Neurosurgery, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA,Correspondence Should Be Addressed To: Mahua Dey, MD, University of Wisconsin School of Medicine & Public Health, 600 Highland Ave, Madison, WI 53792; Tel: 317-274-2601;
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Bander ED, Yuan M, Reiner AS, Panageas KS, Ballangrud ÅM, Brennan CW, Beal K, Tabar V, Moss NS. Durable 5-year local control for resected brain metastases with early adjuvant SRS: the effect of timing on intended-field control. Neurooncol Pract 2021; 8:278-289. [PMID: 34055375 DOI: 10.1093/nop/npab005] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Adjuvant stereotactic radiosurgery (SRS) improves the local control of resected brain metastases (BrM). However, the dependency of long-term outcomes on SRS timing relative to surgery remains unclear. Methods Retrospective analysis of patients treated with metastasectomy-plus-adjuvant SRS at Memorial Sloan Kettering Cancer Center (MSK) between 2013 and 2016 was conducted. Kaplan-Meier methodology was used to describe overall survival (OS) and cumulative incidence rates were estimated by type of recurrence, accounting for death as a competing event. Recursive partitioning analysis (RPA) and competing risks regression modeling assessed prognostic variables and associated events of interest. Results Two hundred and eighty-two patients with BrM had a median OS of 1.5 years (95% CI: 1.2-2.1) from adjuvant SRS with median follow-up of 49.8 months for survivors. Local surgical recurrence, other simultaneously SRS-irradiated site recurrence, and distant central nervous system (CNS) progression rates were 14.3% (95% CI: 10.1-18.5), 4.9% (95% CI: 2.3-7.5), and 47.5% (95% CI: 41.4-53.6) at 5 years, respectively. Median time-to-adjuvant SRS (TT-SRS) was 34 days (IQR: 27-39). TT-SRS was significantly associated with surgical site recurrence rate (P = 0.0008). SRS delivered within 1 month resulted in surgical site recurrence rate of 6.1% (95% CI: 1.3-10.9) at 1-year, compared to 9.2% (95% CI: 4.9-13.6) if delivered between 1 and 2 months, or 27.3% (95% CI: 0.0-55.5) if delivered >2 months after surgery. OS was significantly lower for patients with TT-SRS >~2 months. Postoperative length of stay, discharge to a rehabilitation facility, urgent care visits, and/or disease recurrence between surgery and adjuvant SRS associated with increased TT-SRS. Conclusions Adjuvant SRS provides durable local control. However, delays in initiation of postoperative SRS can decrease its efficacy.
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Affiliation(s)
- Evan D Bander
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Neurosurgery, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, New York
| | - Melissa Yuan
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne S Reiner
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katherine S Panageas
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Åse M Ballangrud
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cameron W Brennan
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Viviane Tabar
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nelson S Moss
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
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3
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Redmond KJ, Gui C, Benedict S, Milano MT, Grimm J, Vargo JA, Soltys SG, Yorke E, Jackson A, El Naqa I, Marks LB, Xue J, Heron DE, Kleinberg LR. Tumor Control Probability of Radiosurgery and Fractionated Stereotactic Radiosurgery for Brain Metastases. Int J Radiat Oncol Biol Phys 2020; 110:53-67. [PMID: 33390244 DOI: 10.1016/j.ijrobp.2020.10.034] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/25/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE As part of the American Association of Physicists in Medicine Working Group on Stereotactic Body Radiotherapy, tumor control probability (TCP) after stereotactic radiosurgery (SRS) and fractionated stereotactic radiosurgery (fSRS) for brain metastases was modeled based on pooled dosimetric and clinical data from published English-language literature. METHODS AND MATERIALS PubMed-indexed studies published between January 1995 and September 2017 were used to evaluate dosimetric and clinical predictors of TCP after SRS or fSRS for brain metastases. Eligible studies had ≥10 patients and included detailed dose-fractionation data with corresponding ≥1-year local control (LC) data, typically evaluated as a >20% increase in diameter of the targeted lesion using the pre-SRS diameter as a reference. RESULTS Of 2951 potentially eligible manuscripts, 56 included sufficient dose-volume data for analyses. Accepting that necrosis and pseudoprogression can complicate the assessment of LC, for tumors ≤20 mm, single-fraction doses of 18 and 24 Gy corresponded with >85% and 95% 1-year LC rates, respectively. For tumors 21 to 30 mm, an 18 Gy single-fraction dose was associated with 75% LC. For tumors 31 to 40 mm, a 15 Gy single-fraction dose yielded ∼69% LC. For 3- to 5-fraction fSRS using doses in the range of 27 to 35 Gy, 80% 1-year LC has been achieved for tumors of 21 to 40 mm in diameter. CONCLUSIONS TCP for SRS and fSRS are presented. For small lesions ≤20 mm, single doses of ≈18 Gy appear generally associated with excellent rates of LC; for melanoma, higher doses seem warranted. For larger lesions >20 mm, local control rates appear to be ≈ 70% to 75% with usual doses of 15 to 18 Gy, and in this setting, fSRS regimens should be considered. Greater consistency in reporting of dosimetric and LC data is needed to facilitate future pooled analyses. As systemic and biologic therapies evolve, updated analyses will be needed to further assess the necessity, efficacy, and toxicity of SRS and fSRS.
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Affiliation(s)
- Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Chengcheng Gui
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stanley Benedict
- Department of Radiation Oncology, University of California at Davis Comprehensive Cancer Center, Sacramento, California
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Jimm Grimm
- Department of Radiation Oncology, Geisinger Medical Center, Danville, Pennsylvania
| | - J Austin Vargo
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Ellen Yorke
- Medical Physics Department, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Jackson
- Medical Physics Department, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Issam El Naqa
- Department of Machine Learning and Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Lawrence B Marks
- Department of Radiation Oncology and the Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Jinyu Xue
- Department of Radiation Oncology, New York University, New York, New York
| | - Dwight E Heron
- Department of Radiation Oncology, Bon Secours Mercy Health System, Youngstown, Ohio
| | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Repeated stereotactic radiosurgery for recurrent brain metastases: An effective strategy to control intracranial oligometastatic disease. Crit Rev Oncol Hematol 2020; 153:103028. [PMID: 32622322 DOI: 10.1016/j.critrevonc.2020.103028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/07/2020] [Accepted: 06/09/2020] [Indexed: 11/21/2022] Open
Abstract
Due to improvements in systemic therapies and longer survivals, cancer patients frequently present with recurrent brain metastases (BM). The optimal therapeutic strategies for limited brain relapse remain undefined. We analyzed tumor control and survival in patients treated with salvage focal radiotherapy in our center. Thirty-three patients with 112 BM received salvage stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (FSRT) for local or regional recurrences. Local progression was observed in 11 BM (9.8 %). After 1 year, 72 % of patients were free of distant brain failure, and the 2-year overall survival (OS) was 37.7 %. No increase in toxicity or neurologically related deaths were observed. The 2- and 3-year whole brain radiation therapy free survival (WFS) rates were 92.9 % and 77.4 %, respectively. Hence, focal radiotherapy is a feasible salvage of recurrent BM in selected group of patients with limited brain disease, achieving a maintained intracranial control and less neurological toxicity.
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5
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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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Eastman BM, Venur VA, Lo SS, Graber JJ. Stereotactic radiosurgery in the treatment of adults with metastatic brain tumors. J Neurosurg Sci 2020; 64:272-286. [PMID: 32270945 DOI: 10.23736/s0390-5616.20.04952-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Brain metastasis is the most common type of intracranial tumor affecting a significant proportion of advanced cancer patients. In recent years, stereotactic radiosurgery (SRS) has become commonly utilized. It has contributed significantly to decreased toxicity, prolonged quality of life and general improvement in outcomes of patients with brain metastases. Frequent imaging and advanced treatment techniques have allowed for the treatment of more patients with large and numerous metastases extending their overall survival. The addition of targeted therapy and immunotherapy to SRS has introduced novel treatment paradigms and has further improved our ability to effectively treat brain lesions. In this review, we examined in detail the available evidence for the use of SRS alone or in combination with surgery and systemic therapies. Given our developing understanding of the importance of primary tumor histology, the use of different treatment strategies for different metastasis is evolving. Combining SRS with immunotherapy and targeted therapy in breast cancer, lung cancer and melanoma as well as the use of preoperative SRS have shown significant promise in recent years and are investigated in multiple ongoing prospective trials. Further research is needed to guide the optimal sequence of therapies and to identify specific patient subgroups that may benefit the most from aggressive, combined treatment approaches.
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Affiliation(s)
- Boryana M Eastman
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Vyshak A Venur
- Division of Medical Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Jerome J Graber
- Department of Neurology and Neurosurgery, Alvord Brain Tumor Center, University of Washington School of Medicine, Seattle, WA, USA -
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7
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Masucci GL. Hypofractionated Radiation Therapy for Large Brain Metastases. Front Oncol 2018; 8:379. [PMID: 30333955 PMCID: PMC6176274 DOI: 10.3389/fonc.2018.00379] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 08/23/2018] [Indexed: 12/21/2022] Open
Abstract
Single fraction radiosurgery (SRS) treatment is an effective and recognized alternative to whole brain radiation for brain metastasis. However, SRS is not always possible, especially in tumors of a larger diameter where the administration of high dose in a single fraction is limited by the possibility of acute and late side effects and the dose to the surrounding organs at risk. Hypofractionated radiation therapy allows the delivery of high doses of radiation per fraction while minimizing adverse events, all the while maintaining good local control of lesions. The optimal dose fractionation has however not been established. This overwiew presents available evidence and rationale supporting usage of hypofractionated radiation therapy in the treatment of large brain metastases.
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Affiliation(s)
- Giuseppina Laura Masucci
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
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8
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Evaluation of new lesions and symptoms after gamma knife radiosurgery for brain metastases: a retrospective cohort study. Acta Neurochir (Wien) 2018; 160:1461-1471. [PMID: 29633031 DOI: 10.1007/s00701-018-3524-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 03/16/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Symptomatic new lesions that appear after gamma knife radiosurgery (GKRS) for brain metastases have not been thoroughly described. METHODS Among 238 patients who underwent a single session of GKRS without whole-brain radiotherapy or surgery for brain metastases between 2009 and 2014, a total of 165 (69.3%) patients underwent follow-up magnetic resonance imaging (MRI). Their electrical health records were reviewed retrospectively. The median age was 68 years, and 62.4% patients were men. The median number of brain metastases was 2. The most frequent primary organ site was the lung (71.5%). Then, we evaluated predictors for the symptoms of new lesions. RESULTS New lesions and leptomeningeal dissemination were observed in 101 (61.2%) and 23 (14.2%) patients, respectively. The median number of new lesions was 2; moreover, 20 of 101 patients (19.8%) with new lesions had tumours with the largest diameters of > 1 cm. Among 101 patients with new lesions, 13 were symptomatic (12.9%). Patients with larger new lesions (> 1 cm of the largest diameter) experienced symptoms more frequently (odds ratio 7.6, P < 0.01). Symptoms resolved after salvage GKRS in seven of 11 patients who abided by the recommended follow-up MRI schedule. No significant risk factors were found for symptoms of new lesions. CONCLUSIONS The incidence of symptomatic new lesions that appeared after GKRS was low, and more than half of the patients showed improvements in their symptoms after salvage GKRS. However, careful MRI-based assessments and salvage GKRS are critical for the quality of life.
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Local control after fractionated stereotactic radiation therapy for brain metastases. J Neurooncol 2014; 120:339-46. [DOI: 10.1007/s11060-014-1556-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 07/05/2014] [Indexed: 10/25/2022]
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10
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Komaki RU, Ghia AJ. Brain Metastasis from Lung Cancer. Lung Cancer 2014. [DOI: 10.1002/9781118468791.ch38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Ammirati M, Kshettry VR, Lamki T, Wei L, Grecula JC. A Prospective Phase II Trial of Fractionated Stereotactic Intensity Modulated Radiotherapy With or Without Surgery in the Treatment of Patients With 1 to 3 Newly Diagnosed Symptomatic Brain Metastases. Neurosurgery 2014; 74:586-94; discussion 594. [DOI: 10.1227/neu.0000000000000325] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
ABSTRACT
BACKGROUND:
Several studies have demonstrated that omitting the routine use of adjuvant whole-brain radiation therapy for patients with newly diagnosed brain metastases may be a reasonable first-line strategy. Retrospective evidence suggests that fractionated stereotactic radiotherapy (fSRT) may have a lower level of toxicity with equivalent efficacy in comparison with radiosurgery.
OBJECTIVE:
To study the phase II efficacy of using a focally directed treatment strategy for symptomatic brain metastases by the use of fSRT with or without surgery and omitting the routine use of adjuvant whole-brain radiation therapy.
METHODS:
We used a Fleming single-stage design of 40 patients. Patients were eligible if they presented with 1 to 3 newly diagnosed symptomatic brain metastases, Karnofsky performance scale (KPS) greater than 60, and histological confirmation of primary disease. Patients underwent fSRT with the use of a dose of 30 Gy in 5 intensity-modulated fractions as primary or adjuvant treatment after surgical resection. The primary end point was the proportion of patients who experienced neurological death. Secondary end points were overall survival, time to KPS <70, and progression-free survival.
RESULTS:
Of 40 patients accrued, 39 were eligible for analysis. The proportion of patients dying of neurological causes was 13% (5 patients), which includes 3 patients with an unknown cause of death. Median overall survival, time to KPS <70, and progression-free survival were 16 (95% confidence interval, 9-23), 14 (95% confidence interval, 7-20), and 11 (95% confidence interval, 4-21) months, respectively.
CONCLUSION:
A focally directed treatment strategy using fSRT with or without surgery appears to be an effective initial strategy. Based on the results of this phase II clinical trial, further study is warranted.
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Affiliation(s)
- Mario Ammirati
- Department of Neurological Surgery, Ohio State University Medical Center, Columbus, Ohio
- Department of Radiation Oncology, Ohio State University Medical Center, Columbus, Ohio
| | - Varun R. Kshettry
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Tariq Lamki
- Department of Neurological Surgery, Ohio State University Medical Center, Columbus, Ohio
| | - Lai Wei
- Center for Biostatistics, Ohio State University Medical Center, Columbus, Ohio
| | - John C. Grecula
- Department of Radiation Oncology, Ohio State University Medical Center, Columbus, Ohio
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Clinical outcomes of patients treated with a second course of stereotactic radiosurgery for locally or regionally recurrent brain metastases after prior stereotactic radiosurgery. J Neurooncol 2013; 115:37-43. [DOI: 10.1007/s11060-013-1191-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 06/22/2013] [Indexed: 10/26/2022]
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13
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Morsi A, Gaziel-Sovran A, Cruz-Munoz W, Kerbel RS, Golfinos JG, Hernando E, Wadghiri YZ. Development and characterization of a clinically relevant mouse model of melanoma brain metastasis. Pigment Cell Melanoma Res 2013; 26:743-5. [PMID: 23647875 DOI: 10.1111/pcmr.12114] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Amr Morsi
- The Bernard & Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Langone Medical Center (NYULMC), New York, NY, USA
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Hardee ME, Formenti SC. Combining stereotactic radiosurgery and systemic therapy for brain metastases: a potential role for temozolomide. Front Oncol 2012; 2:99. [PMID: 22908046 PMCID: PMC3414728 DOI: 10.3389/fonc.2012.00099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 07/25/2012] [Indexed: 01/13/2023] Open
Abstract
Brain metastases are unfortunately very common in the natural history of many solid tumors and remain a life-threatening condition, associated with a dismal prognosis, despite many clinical trials aimed at improving outcomes. Radiation therapy options for brain metastases include whole brain radiotherapy (WBRT) and stereotactic radiosurgery (SRS). SRS avoids the potential toxicities of WBRT and is associated with excellent local control (LC) rates. However, distant intracranial failure following SRS remains a problem, suggesting that untreated intracranial micrometastatic disease is responsible for failure of treatment. The oral alkylating agent temozolomide (TMZ), which has demonstrated efficacy in primary malignant central nervous system tumors such as glioblastoma, has been used in early phase trials in the treatment of established brain metastases. Although results of these studies in established, macroscopic metastatic disease have been modest at best, there is clinical and preclinical data to suggest that TMZ is more efficacious at treating and controlling clinically undetectable intracranial micrometastatic disease. We review the available data for the primary management of brain metastases with SRS, as well as the use of TMZ in treating established brain metastases and undetectable micrometastatic disease, and suggest the role for a clinical trial with the aims of treating macroscopically visible brain metastases with SRS combined with TMZ to address microscopic, undetectable disease.
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Affiliation(s)
- Matthew E Hardee
- Department of Radiation Oncology, New York University Langone Medical Center New York, NY, USA
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