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Hahnemann L, Krämer A, Fink C, Jungk C, Thomas M, Christopoulos P, Lischalk J, Meis J, Hörner-Rieber J, Eichkorn T, Deng M, Lang K, Paul A, Meixner E, Weykamp F, Debus J, König L. Fractionated stereotactic radiotherapy of intracranial postoperative cavities after resection of brain metastases - Clinical outcome and prognostic factors. Clin Transl Radiat Oncol 2024; 46:100782. [PMID: 38694237 PMCID: PMC11061678 DOI: 10.1016/j.ctro.2024.100782] [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: 10/21/2023] [Revised: 04/17/2024] [Accepted: 04/20/2024] [Indexed: 05/04/2024] Open
Abstract
Background and Purpose After surgical resection of brain metastases (BM), radiotherapy (RT) is indicated. Postoperative stereotactic radiosurgery (SRS) reduces the risk of local progression and neurocognitive decline compared to whole brain radiotherapy (WBRT). Aside from the optimal dose and fractionation, little is known about the combination of systemic therapy and postoperative fractionated stereotactic radiotherapy (fSRT), especially regarding tumour control and toxicity. Methods In this study, 105 patients receiving postoperative fSRT with 35 Gy in 7 fractions performed with Cyberknife were retrospectively reviewed. Overall survival (OS), local control (LC) and total intracranial brain control (TIBC) were analysed via Kaplan-Meier method. Cox proportional hazards models were used to identify prognostic factors. Results Median follow-up was 20.8 months. One-year TIBC was 61.6% and one-year LC was 98.6%. Median OS was 28.7 (95%-CI: 16.9-40.5) months. In total, local progression (median time not reached) occurred in 2.0% and in 20.4% radiation-induced contrast enhancements (RICE) of the cavity (after median of 14.3 months) were diagnosed. Absence of extracranial metastases was identified as an independent prognostic factor for superior OS (p = <0.001) in multivariate analyses, while a higher Karnofsky performance score (KPS) was predictive for longer OS in univariate analysis (p = 0.041). Leptomeningeal disease (LMD) developed in 13% of patients. Conclusion FSRT after surgical resection of BM is an effective and safe treatment approach with excellent local control and acceptable toxicity. Further prospective randomized trials are needed to establish standardized therapeutic guidelines.
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Affiliation(s)
- L. Hahnemann
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - A. Krämer
- Department of Radiation Oncology, University Hospital of Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - C. Fink
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - C. Jungk
- Department of Neurosurgery, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - M. Thomas
- Department of Thoracic Oncology, Thoraxklinik and National Center for Tumor Diseases at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Germany
| | - P. Christopoulos
- Department of Thoracic Oncology, Thoraxklinik and National Center for Tumor Diseases at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Germany
| | - J.W. Lischalk
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Health at Long Island, New York, NY, USA
| | - J. Meis
- Institute of Medical Biometry, University of Heidelberg, Im Neuenheimer Feld 130, 69120 Heidelberg, Germany
| | - J. Hörner-Rieber
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - T. Eichkorn
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - M. Deng
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - K. Lang
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - A. Paul
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - E. Meixner
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - F. Weykamp
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - J. Debus
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology (E050), German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - L. König
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
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2
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Hügel M, Stöhr J, Kuhnt T, Nägler F, Papsdorf K, Klagges S, Hambsch P, Güresir E, Nicolay NH, Seidel C. Long-term survival in patients with brain metastases-clinical characterization of a rare scenario. Strahlenther Onkol 2024; 200:335-345. [PMID: 37646818 DOI: 10.1007/s00066-023-02123-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 07/10/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE This study aimed to assess clinical, treatment, and prognostic features in patients with brain metastases (BM) from solid tumors achieving long-term survival (LTS). Further, the accuracy of diagnosis-specific Graded Prognostic Assessment scores (ds-GPA) to predict LTS was evaluated. METHODS Patients admitted for radiotherapy of BM between 2010 and 2020 at a large tertiary cancer center with survival of at least 3 years from diagnosis of BM were included. Patient, tumor, treatment characteristics and ds-GPA were compiled retrospectively. RESULTS From a total of 1248 patients with BM, 61 (4.9%) survived ≥ 3 years. In 40 patients, detailed patient charts were available. Among LTS patients, median survival time from diagnosis of BM was 51.5 months. Most frequent primary tumors were lung cancer (45%), melanoma (20%), and breast cancer (17.5%). At the time of diagnosis of BM, 11/40 patients (27.5%) had oligometastatic disease. Estimated mean survival time based on ds-GPA was 19.7 months (in 8 cases estimated survival < 12 months). Resection followed by focal or whole-brain radiotherapy (WBRT) was often applied (60%), followed by primary stereotactic radiotherapy (SRT) (20%) or WBRT (20%). 80% of patients received systemic treatment, appearing particularly active in specifically altered non-small lung cancer (NSCLC), melanoma, and HER2-positive breast cancer. Karnofsky performance score (KPS) and the presence of oligometastatic disease at BM diagnosis were persisting prognostic factors in LTS patients. CONCLUSION In this monocentric setting reflecting daily pattern of care, LTS with BM is heterogeneous and difficult to predict. Effective local treatment and modern systemic therapies often appear crucial for LTS. The impact of concomitant diseases and frailty is not clear.
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Affiliation(s)
- M Hügel
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - J Stöhr
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - T Kuhnt
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - F Nägler
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - K Papsdorf
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - S Klagges
- Clinical Cancer Registry, Leipzig, Germany
| | - P Hambsch
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - E Güresir
- Department of Neurosurgery, University of Leipzig Medical Center, Leipzig, Germany
| | - N H Nicolay
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - C Seidel
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany.
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3
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Samanci Y, Ali Tepebasili M, Deniz Ardor G, Haluk Duzkalir A, Orbay Askeroglu M, Peker S. Efficacy of hypofractionated Gamma Knife radiosurgery in treating surgical beds of metastatic brain tumors. J Clin Neurosci 2024; 121:105-113. [PMID: 38387112 DOI: 10.1016/j.jocn.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/01/2024] [Accepted: 02/17/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVE Surgery alone for metastatic brain tumors (METs) often results in local recurrence due to microscopic residual tumor tissue. While stereotactic radiosurgery (SRS) is commonly used post-surgery, hypofractionation may be required for large surgical beds. This study evaluated the efficacy and safety of hypofractionated Gamma Knife radiosurgery (hf-GKRS) for the first time as a post-operative adjuvant therapy. METHODS This retrospective study involved 24 patients (28 surgical beds) who underwent hf-GKRS within four weeks after surgery. The study primarily focused on local control (LC) rate and analyzed distant intracranial failure (DICF), intracranial progression-free survival (PFS), leptomeningeal disease (LMD), overall survival (OS), and radiation necrosis (RN). RESULTS During a median follow-up of 9 months, LC was achieved in 89.3 % of surgical beds. LC estimates at 6, 12, and 24 months were 96.4 %, 82.7 %, and 82.7 %, respectively. DICF was observed in 45.8 % of patients, and LMD was identified in two patients (8.3 %). At the end of the follow-up, 58.3 % of patients were alive, and the median OS was 20 months. RN occurred in only one surgical bed (3.6 %). No grade 5 toxicity was observed. The univariate analysis identified a longer interval to GKRS (HR 11.842, p = 0.042) and a larger treatment volume (HR 1.103, p = 0.037) as significant factors for local failure. CONCLUSIONS hf-GKRS shows potential as an effective and safe adjuvant treatment for surgical beds. It offers an alternative to SRS, SRT, or WBRT, particularly for larger volumes or tumors near critical structures. Further research is needed to confirm these results and optimize treatment approaches.
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Affiliation(s)
- Yavuz Samanci
- Koc University School of Medicine, Department of Neurosurgery, Istanbul, Turkey
| | | | - Gokce Deniz Ardor
- Koc University Hospital, Department of Neurosurgery, Gamma Knife Center, Istanbul, Turkey
| | - Ali Haluk Duzkalir
- Koc University Hospital, Department of Neurosurgery, Gamma Knife Center, Istanbul, Turkey
| | - M Orbay Askeroglu
- Koc University Hospital, Department of Neurosurgery, Gamma Knife Center, Istanbul, Turkey
| | - Selcuk Peker
- Koc University School of Medicine, Department of Neurosurgery, Istanbul, Turkey.
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4
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Ampil F, Sin A, Toms J, Lee S, Porter C, O'Glee K. Skull base oligometastatic tumors from systemic cancer: Long-term follow-up after gamma knife radiosurgery. Oral Oncol 2024; 149:106661. [PMID: 38134701 DOI: 10.1016/j.oraloncology.2023.106661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 12/09/2023] [Indexed: 12/24/2023]
Affiliation(s)
- Federico Ampil
- Department of Radiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA.
| | - Anthony Sin
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Jamie Toms
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Sungho Lee
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Carrie Porter
- Section of Tumor Registry, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Kristie O'Glee
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
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5
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Diehl CD, Giordano FA, Grosu AL, Ille S, Kahl KH, Onken J, Rieken S, Sarria GR, Shiban E, Wagner A, Beck J, Brehmer S, Ganslandt O, Hamed M, Meyer B, Münter M, Raabe A, Rohde V, Schaller K, Schilling D, Schneider M, Sperk E, Thomé C, Vajkoczy P, Vatter H, Combs SE. Opportunities and Alternatives of Modern Radiation Oncology and Surgery for the Management of Resectable Brain Metastases. Cancers (Basel) 2023; 15:3670. [PMID: 37509330 PMCID: PMC10377800 DOI: 10.3390/cancers15143670] [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: 04/18/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Postsurgical radiotherapy (RT) has been early proven to prevent local tumor recurrence, initially performed with whole brain RT (WBRT). Subsequent to disadvantageous cognitive sequalae for the patient and the broad distribution of modern linear accelerators, focal irradiation of the tumor has omitted WBRT in most cases. In many studies, the effectiveness of local RT of the resection cavity, either as single-fraction stereotactic radiosurgery (SRS) or hypo-fractionated stereotactic RT (hFSRT), has been demonstrated to be effective and safe. However, whereas prospective high-level incidence is still lacking on which dose and fractionation scheme is the best choice for the patient, further ablative techniques have come into play. Neoadjuvant SRS (N-SRS) prior to resection combines straightforward target delineation with an accelerated post-surgical phase, allowing an earlier start of systemic treatment or rehabilitation as indicated. In addition, low-energy intraoperative RT (IORT) on the surgical bed has been introduced as another alternative to external beam RT, offering sterilization of the cavity surface with steep dose gradients towards the healthy brain. This consensus paper summarizes current local treatment strategies for resectable brain metastases regarding available data and patient-centered decision-making.
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Affiliation(s)
- Christian D Diehl
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 80336 München, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Anca-L Grosu
- Department of Radiation Oncology, University Medical Center, Medical Faculty, 79106 Freiburg, Germany
| | - Sebastian Ille
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Klaus-Henning Kahl
- Department of Radiation Oncology, University Medical Center Augsburg, 86156 Augsburg, Germany
| | - Julia Onken
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
- Berlin Institute of Health, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- German Cancer Consortium (DKTK), Partner Site Berlin, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, 37075 Göttingen, Germany
- Comprehensive Cancer Center Niedersachsen (CCC-N), 37075 Göttingen, Germany
| | - Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Ehab Shiban
- Department of Neurosurgery, University Medical Center Augsburg, 86156 Augsburg, Germany
| | - Arthur Wagner
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Jürgen Beck
- Department of Neurosurgery, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Stefanie Brehmer
- Department of Neurosurgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Oliver Ganslandt
- Neurosurgical Clinic, Klinikum Stuttgart, 70174 Stuttgart, Germany
| | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Marc Münter
- Department of Radiation Oncology, Klinikum Stuttgart Katharinenhospital, 70174 Stuttgart, Germany
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Veit Rohde
- Department of Neurosurgery, Universitätsmedizin Göttingen, 37075 Göttingen, Germany
| | - Karl Schaller
- Department of Neurosurgery, University of Geneva Medical Center & Faculty of Medicine, 1211 Geneva, Switzerland
| | - Daniela Schilling
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Elena Sperk
- Mannheim Cancer Center, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 80336 München, Germany
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6
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Cantaloube M, Boucekine M, Balossier A, Muracciole X, Meyer M, Delsanti C, Carron R, Beltaifa YM, Figarella-Branger D, Regis J, Padovani L. Stereotactic radiosurgery for post operative brain metastasic surgical cavities: a single institution experience. Radiat Oncol 2022; 17:160. [PMID: 36163026 PMCID: PMC9513906 DOI: 10.1186/s13014-022-02118-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The standard therapy for brain metastasis was surgery combined with whole brain radiotherapy (WBRT). The latter is however, associated with important neurocognitive toxicity. To reduce this toxicity, postoperative stereotactic radiosurgery (SRS) is a promising technique. We assessed the efficacy and the tolerance to postoperative Gamma Knife radiosurgery (GK) on the tumor bed after resection of brain metastases. METHODS Between February 2011 and December 2016, following macroscopic complete surgical resection, 64 patients and 65 surgical cavities were treated by GK in our institution. The indication for adjuvant radiosurgery was a multidisciplinary decision. The main assessment criteria considered in this study were local control, intracranial metastasis-free survival (ICMFS), overall survival and toxicity. RESULTS Median follow-up: 11.1 months. Median time between surgery and radiosurgery: 35 days. Median dose was 20 Gy prescribed to the 50% isodose line, for a median treated volume of 5.6 cc. Four patients (7%) suffered from local recurrence. Local recurrence-free, intracranial recurrence-free and overall survival at 1 year were 97.5%, 57.6% and 62.4% respectively. In total, 23 patients (41%) suffered from intracranial recurrence outside the tumor bed. In univariate analysis: concomitant GK treatment of multiple lesions and the tumor bed was associated with a decrease in ICMFS (HR = 1.16 [1.005-1.34] p = 0.04). In multivariate analysis: a non-lung primary tumor was significantly associated with a decrease in ICMFS (HR = 8.04 [1.82-35.4] p = 0.006). An increase in performance status (PS) and in the initial number of cerebral metastases significantly reduced overall survival (HR = 5.4 [1.11-26.3] p = 0.037, HR = 2.7 [1.004-7.36] p = 0.049, respectively) and One radiation necrosis histologically proven. CONCLUSION Our study confirmed that postoperative GK after resection of cerebral metastases is an efficient and well-tolerated technique, to treat volumes of all sizes (0.8 to 40 cc). Iterative SRS or salvage WBRT can be performed in cases of intracranial relapse, postponing WBRT with its potential side effects.
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Affiliation(s)
- Marie Cantaloube
- Radiotherapy Department, Assistance Publique Des Hôpitaux de Marseille, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Mohamed Boucekine
- Unity of Research EA3279, Aix-Marseille Université, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Anne Balossier
- Department of Functional and Stereotactic Neurosurgery and Radiosurgery, Timone University Hospital, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Xavier Muracciole
- Radiotherapy Department, Assistance Publique Des Hôpitaux de Marseille, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Mickael Meyer
- Department of Neurosurgery, Hôpital de La Timone, Assistance Publique-Hôpitaux de Marseille, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Christine Delsanti
- Department of Functional and Stereotactic Neurosurgery and Radiosurgery, Timone University Hospital, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Romain Carron
- Department of Functional and Stereotactic Neurosurgery and Radiosurgery, Timone University Hospital, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Yassine Mohamed Beltaifa
- Department of Functional and Stereotactic Neurosurgery and Radiosurgery, Timone University Hospital, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Domnique Figarella-Branger
- Neuropathology Department, Assistance Publique Des Hôpitaux de Marseille, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Jean Regis
- Department of Functional and Stereotactic Neurosurgery and Radiosurgery, Timone University Hospital, Marseille, France.,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France
| | - Laetitia Padovani
- Radiotherapy Department, Assistance Publique Des Hôpitaux de Marseille, Marseille, France. .,Neuropathology Department, Assistance Publique Des Hôpitaux de Marseille, Marseille, France. .,CRCM Inserm UMR1068, CNRS UMR7258 AMU UM105, Genome Instability and Carcinogenesis, Institut Paoli-Calmettes, Marseille, France. .,Radiotherapy Department, Assistance Publique des Hôpitaux de Marseille, marseille, France.
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7
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Wu KC, Cantalino JM, Dee EC, Hsu L, Harris TC, Rawal B, Juvekar PR, Mooney MA, Dunn IF, Aizer AA, Devlin PM, Bi WL. Salvage brachytherapy for multiply recurrent metastatic brain tumors: a matched-case analysis. Neurooncol Adv 2022; 4:vdac039. [PMID: 35571989 PMCID: PMC9092639 DOI: 10.1093/noajnl/vdac039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Patients with recurrent brain metastases who have exhausted external radiation options pose a treatment challenge in the setting of advances in systemic disease control which have improved quality of life and survival. Brachytherapy holds promise as salvage therapy given its ability to enforce surgical cytoreduction and minimize regional toxicity. This study investigates the role of salvage brachytherapy in maintaining local control for recurrent metastatic lesions. Methods We retrospectively reviewed our institution’s experience with brachytherapy in patients with multiply recurrent cerebral metastases who have exhausted external radiation treatment options (14 cases). The primary outcome of the study was freedom from local recurrence (FFLR). To capture the nuances of tumor biology, we compared FFLR achieved by brachytherapy to the preceding treatment for each patient. We further compared the response to brachytherapy in patients with lung cancer (8 cases) against a matched cohort of maximally radiated lung brain metastases (10 cases). Results Brachytherapy treatment conferred significantly longer FFLR compared to prior treatments (median 7.39 vs 5.51 months, P = .011) for multiply recurrent brain metastases. Compared to an independent matched cohort, brachytherapy demonstrated superior FFLR (median 8.49 vs 1.61 months, P = .004) and longer median overall survival (11.07 vs 5.93 months, P = .055), with comparable side effects. Conclusion Brachytherapy used as salvage treatment for select patients with a multiply recurrent oligometastatic brain metastasis in the setting of well-controlled systemic disease holds promise for improving local control in this challenging patient population.
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Affiliation(s)
- Kyle C Wu
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School
| | - Jonathan M Cantalino
- Department of Radiation Oncology, Brigham and Women’s Hospital, Harvard Medical School
| | - Edward C Dee
- Department of Radiation Oncology, Brigham and Women’s Hospital, Harvard Medical School
| | - Liangge Hsu
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School
| | - Thomas C Harris
- Department of Radiation Oncology, Brigham and Women’s Hospital, Harvard Medical School
| | - Bhupendra Rawal
- Department of Biostatistics and Computational Biology, Dana Farber Cancer Institute, Harvard Medical School
| | - Parikshit R Juvekar
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School
| | - Michael A Mooney
- Department of Neurosurgery, Barrow Neurologic Institute, Phoenix, Arizona
| | - Ian F Dunn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, University of Oklahoma College of Medicine
| | - Ayal A Aizer
- Department of Radiation Oncology, Brigham and Women’s Hospital, Harvard Medical School
| | - Phillip M Devlin
- Department of Radiation Oncology, Brigham and Women’s Hospital, Harvard Medical School
| | - Wenya Linda Bi
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School
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8
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Ganz JC. Cerebral metastases. PROGRESS IN BRAIN RESEARCH 2022; 268:229-258. [PMID: 35074082 DOI: 10.1016/bs.pbr.2021.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Brain metastases are common and deadly. Over the last 25 years GKNS has been established as an invaluable treatment. It may be used as a primary treatment or after either surgery or WBRT. Patients are assessed using one of a number of available scales. GKNS may be repeated for new metastases and for unresponsive tumors. Prescription doses are usually between 18 and 20Gy. The use of advanced MR techniques to highlight sensitive structures like the hippocampi have extended the efficacy of the treatment. More recently GKNS has been used with different target therapies with improved results. More recently frameless treatments have become more popular in this group of very sick patients. GKNS controls tumors in between 80% and over 95% of cases and may even be used for brainstem tumors.
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Affiliation(s)
- Jeremy C Ganz
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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9
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Latorzeff I, Antoni D, Josset S, Noël G, Tallet-Richard A. Radiation therapy for brain metastases. Cancer Radiother 2021; 26:129-136. [PMID: 34955413 DOI: 10.1016/j.canrad.2021.11.010] [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] [Indexed: 12/20/2022]
Abstract
We present the update of the recommendations of the French society for radiation oncology on radiation therapy for the management of brain metastases. It has evolved in recent years and has become more complex. As the life expectancy of patients has increased and retreatments have become more frequent, side effects must be absolutely avoided. Cognitive side effects must in particular be prevented, and the most modern radiation therapy techniques must be used systematically. New prognostic classifications specific to the primary tumour of patients, advances in imaging and radiation therapy technology and new systemic therapeutic strategies, are making treatment more relevant. Stereotactic radiation therapy has supplanted whole-brain radiation therapy both for patients with metastases in place and for those who underwent surgery. Hippocampus protection is possible with intensity-modulated radiation therapy. Its relevance in terms of cognitive functioning should be more clearly demonstrated but the requirement for its use is constantly increasing. New targeted cancer treatment therapies based on the nature of the primitive have complicated the notion of the place and timing of radiation therapy and the discussion during multidisciplinary care meeting to indicate the best sequences is becoming a challenging issue as data on the interaction between treatments remain to be documented. In the end, although aimed at patients in the palliative phase, the management of brain metastases is one of the locations for which technical reflection is the most challenging and treatment become increasingly personalized.
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Affiliation(s)
- I Latorzeff
- Service de radiothérapie, groupe Oncorad Garonne, clinique Pasteur, l'« Atrium », 1, rue de la Petite-Vitesse, 31300 Toulouse, France; Centre régional de radiochirurgie stéréotaxique, CHU Rangueil, avenue Jean-Poulhès, 31052 Toulouse cedex, France.
| | - D Antoni
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France
| | - S Josset
- Service de physique médicale, institut de cancérologie de l'Ouest, Unicancer, 44805 Saint-Herblain, France
| | - G Noël
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France
| | - A Tallet-Richard
- Département universitaire de radiothérapie, institut Paoli-Calmettes, Unicancer, 232, boulevard de Sainte-Marguerite, 13273 Marseille, France
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10
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Minniti G, Niyazi M, Andratschke N, Guckenberger M, Palmer JD, Shih HA, Lo SS, Soltys S, Russo I, Brown PD, Belka C. Current status and recent advances in resection cavity irradiation of brain metastases. Radiat Oncol 2021; 16:73. [PMID: 33858474 PMCID: PMC8051036 DOI: 10.1186/s13014-021-01802-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 04/07/2021] [Indexed: 12/04/2022] Open
Abstract
Despite complete surgical resection brain metastases are at significant risk of local recurrence without additional radiation therapy. Traditionally, the addition of postoperative whole brain radiotherapy (WBRT) has been considered the standard of care on the basis of randomized studies demonstrating its efficacy in reducing the risk of recurrence in the surgical bed as well as the incidence of new distant metastases. More recently, postoperative stereotactic radiosurgery (SRS) to the surgical bed has emerged as an effective and safe treatment option for resected brain metastases. Published randomized trials have demonstrated that postoperative SRS to the resection cavity provides superior local control compared to surgery alone, and significantly decreases the risk of neurocognitive decline compared to WBRT, without detrimental effects on survival. While studies support the use of postoperative SRS to the resection cavity as the standard of care after surgery, there are several issues that need to be investigated further with the aim of improving local control and reducing the risk of leptomeningeal disease and radiation necrosis, including the optimal dose prescription/fractionation, the timing of postoperative SRS treatment, and surgical cavity target delineation. We provide a clinical overview on current status and recent advances in resection cavity irradiation of brain metastases, focusing on relevant strategies that can improve local control and minimize the risk of radiation-induced toxicity.
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Affiliation(s)
- Giuseppe Minniti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Policlinico Le Scotte, 53100, Siena, Italy. .,IRCCS Neuromed, Pozzilli, IS, Italy.
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital of Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital of Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Joshua D Palmer
- Department of Radiation Oncology, Arthur G. James Cancer Hospital, The Ohio State University, Columbus, OH, USA
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Scott Soltys
- Department of Radiation Oncology, Stanford University, Stanford, CA, USA
| | - Ivana Russo
- Radiation Oncology Unit, University of Pittsburgh Medical Center Hillman Cancer Center, San Pietro Hospital FBF, Rome, and Villa Maria Hospital, Mirabella, AV, Italy
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
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11
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Roth O'Brien DA, Poppas P, Kaye SM, Mahase SS, An A, Christos PJ, Liechty B, Pisapia D, Ramakrishna R, Wernicke AG, Knisely JPS, Pannullo S, Schwartz TH. Timing of Adjuvant Fractionated Stereotactic Radiosurgery Affects Local Control of Resected Brain Metastases. Pract Radiat Oncol 2021; 11:e267-e275. [PMID: 33578001 DOI: 10.1016/j.prro.2021.01.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/05/2021] [Accepted: 01/27/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE For resected brain metastases (BMs), stereotactic radiosurgery (SRS) is often offered to minimize local recurrence (LR). Although the aim is to deliver SRS within a few weeks of surgery, a variety of socioeconomic, medical, and procedural issues can cause delays. We evaluated the relationship between timing of postoperative SRS and LR. METHODS AND MATERIALS We retrospectively identified a consecutive series of patients with BM managed with resection and SRS or fractionated SRS at our institution from 2012 to 2018. We assessed the correlation of time to SRS and other demographic, disease, and treatment variables with LR, local recurrence-free survival, distant recurrence, distant recurrence-free survival, and overall survival. RESULTS A total of 133 patients met inclusion criteria. The median age was 64.5 years. Approximately half of patients had a single BM, and median BM size was 2.9 cm. Gross total resection was achieved in 111 patients (83.5%), and more than 90% of patients received fractionated SRS. The median time to SRS was 37.0 days, and the LR rate was 16.4%. Time to SRS was predictive of LR. The median time from surgery to SRS was 34.0 days for patients without LR versus 61.0 days for those with LR (P < .01). The LR rate was 2.3% with SRS administered ≤4 weeks postoperatively, compared with 23.6% if SRS was administered >4 weeks postoperatively (P < .01). Local recurrence-free survival was also improved for patients who underwent SRS at ≤4 weeks (P = .02). Delayed SRS was also predictive of distant recurrence (P = .02) but not overall survival. CONCLUSIONS In this retrospective study, the strongest predictor of LR after postoperative SRS for BM was time to SRS, and a cutoff of 4 weeks was a reliable predictor of recurrence. These findings merit investigation in a prospective, randomized trial.
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Affiliation(s)
- Diana A Roth O'Brien
- Stich Radiation Oncology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York
| | - Phillip Poppas
- Department of Neurosurgery, Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York
| | - Sydney M Kaye
- Department of Neurosurgery, Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York
| | - Sean S Mahase
- Stich Radiation Oncology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York
| | - Anjile An
- Division of Biostatistics and Epidemiology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York
| | - Paul J Christos
- Division of Biostatistics and Epidemiology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York
| | - Benjamin Liechty
- Department of Neuropathology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York
| | - David Pisapia
- Department of Neuropathology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York
| | - Rohan Ramakrishna
- Department of Neurosurgery, Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York
| | | | - Jonathan P S Knisely
- Stich Radiation Oncology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York
| | - Susan Pannullo
- Department of Neurosurgery, Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York
| | - Theodore H Schwartz
- Department of Neurosurgery, Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York; Department of Otolaryngology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York; Department of Neuroscience, Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York.
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12
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Pasquier D, Mouttet Audouard R, Martinage G, Lacornerie T, Mirabel X, Lartigau E. [Place and modalities of postoperative radiotherapy in the management of cerebral metastases]. Cancer Radiother 2020; 24:477-481. [PMID: 32828667 DOI: 10.1016/j.canrad.2020.06.019] [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: 05/15/2020] [Revised: 06/18/2020] [Accepted: 06/20/2020] [Indexed: 11/17/2022]
Abstract
Metastases are the most common brain tumors. After surgery, stereotactic radiotherapy (SRT) of the resection cavity is the standard of care. Data from two randomized trials indicate that SRT to the surgical bed is an effective treatment in reducing local failure as compared with observation, while reducing the risk of cognitive deterioration and maintaining quality of life as compared with whole brain radiation therapy. Local control appears higher after hypofractionated SRT compared to single-fraction SRT. Several questions such as target volumes, the optimal regimen in particular for large tumor bed, strategies to reduce the risk of lepto-meningeal recurrence, and the treatment sequence still need to be answered.
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Affiliation(s)
- D Pasquier
- Département universitaire de radiothérapie, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France; Centre de recherche en informatique, signal et automatique de Lille, CRIStAL UMR 9189, université de Lille, bâtiment Esprit, avenue Henri-Poincaré, 59655 Villeneuve-d'Ascq, France.
| | - R Mouttet Audouard
- Département universitaire de radiothérapie, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France
| | - G Martinage
- Département universitaire de radiothérapie, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France
| | - T Lacornerie
- Service de physique médicale, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France
| | - X Mirabel
- Département universitaire de radiothérapie, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France
| | - E Lartigau
- Département universitaire de radiothérapie, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France; Centre de recherche en informatique, signal et automatique de Lille, CRIStAL UMR 9189, université de Lille, bâtiment Esprit, avenue Henri-Poincaré, 59655 Villeneuve-d'Ascq, France
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13
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Julie DA, Lazow SP, Vanderbilt DB, Taube S, Yondorf MZ, Sabbas A, Pannullo S, Schwartz TH, Wernicke AG. A matched-pair analysis of clinical outcomes after intracavitary cesium-131 brachytherapy versus stereotactic radiosurgery for resected brain metastases. J Neurosurg 2020; 134:1447-1454. [PMID: 32413856 DOI: 10.3171/2020.3.jns193419] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 03/10/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Adjuvant radiation therapy (RT), such as cesium-131 (Cs-131) brachytherapy or stereotactic radiosurgery (SRS), reduces local recurrence (LR) of brain metastases (BM). However, SRS is less efficacious for large cavities, and the delay between surgery and SRS may permit tumor repopulation. Cs-131 has demonstrated improved local control, with reduced radiation necrosis (RN) compared to SRS. This study represents the first comparison of outcomes between Cs-131 brachytherapy and SRS for resected BM. METHODS Patients with BM treated with Cs-131 and SRS following gross-total resection were retrospectively identified. Thirty patients who underwent Cs-131 brachytherapy were compared to 60 controls who received SRS. Controls were selected from a larger cohort to match the patients treated with Cs-131 in a 2:1 ratio according to tumor size, histology, performance status, and recursive partitioning analysis class. Overall survival (OS), LR, regional recurrence, distant recurrence (DR), and RN were compared. RESULTS With a median follow-up of 17.5 months for Cs-131-treated and 13.0 months for SRS-treated patients, the LR rate was significantly lower with brachytherapy; 10% for the Cs-131 cohort compared to 28.3% for SRS patients (OR 0.281, 95% CI 0.082-0.949; p = 0.049). Rates of regional recurrence, DR, and OS did not differ significantly between the two cohorts. Kaplan-Meier analysis with log-rank testing showed a significantly higher likelihood of freedom from LR (p = 0.027) as well as DR (p = 0.018) after Cs-131 compared to SRS treatment (p = 0.027), but no difference in likelihood of OS (p = 0.093). Six (10.0%) patients who underwent SRS experienced RN compared to 1 (3.3%) patient who received Cs-131 (p = 0.417). CONCLUSIONS Postresection patients with BM treated with Cs-131 brachytherapy were more likely to achieve local control compared to SRS-treated patients. This study provides preliminary evidence of the potential of Cs-131 to reduce LR following gross-total resection of single BM, with minimal toxicity, and suggests the need for a prospective study to address this question.
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Affiliation(s)
- Diana A Julie
- 1Stich Radiation Oncology, Weill Cornell Medical College/NewYork-Presbyterian Hospital, New York, New York
| | - Stefanie P Lazow
- 2Department of Surgery, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts; and
| | - Daniel B Vanderbilt
- 1Stich Radiation Oncology, Weill Cornell Medical College/NewYork-Presbyterian Hospital, New York, New York
| | - Shoshana Taube
- 1Stich Radiation Oncology, Weill Cornell Medical College/NewYork-Presbyterian Hospital, New York, New York
| | - Menachem Z Yondorf
- 1Stich Radiation Oncology, Weill Cornell Medical College/NewYork-Presbyterian Hospital, New York, New York
| | - Albert Sabbas
- 1Stich Radiation Oncology, Weill Cornell Medical College/NewYork-Presbyterian Hospital, New York, New York
| | - Susan Pannullo
- 3Department of Neurosurgery, Brain and Spine Center, Weill Cornell Medical College/NewYork-Presbyterian Hospital, New York, New York
| | - Theodore H Schwartz
- 3Department of Neurosurgery, Brain and Spine Center, Weill Cornell Medical College/NewYork-Presbyterian Hospital, New York, New York
| | - A Gabriella Wernicke
- 1Stich Radiation Oncology, Weill Cornell Medical College/NewYork-Presbyterian Hospital, New York, New York.,3Department of Neurosurgery, Brain and Spine Center, Weill Cornell Medical College/NewYork-Presbyterian Hospital, New York, New York
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14
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Mousli A, Bihin B, Gustin T, Koerts G, Mouchamps M, Daisne JF. Surgical bed stereotactic radiotherapy of brain metastases: Clinical outcome and predictors of local and distant brain failure. Cancer Radiother 2020; 24:298-305. [PMID: 32173270 DOI: 10.1016/j.canrad.2019.12.002] [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: 11/05/2019] [Revised: 12/16/2019] [Accepted: 12/24/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE To retrospectively analyze the outcomes of stereotactic radiotherapy (SRT) targeted at surgical bed of brain metastases (BM) and identify patterns of local/distant brain relapses (LR/DBR). PATIENTS/METHODS Seventy patients were treated with SRT between 2008-2017. Marginal dose prescription on the 70% isodose line depended on the maximal diameter of the target volume and range between 15-18Gy for single fraction radiosurgery and 23.1-26Gy in 3-5 fractions for fractionated SRT. RESULTS At 12 months, the overall survival (OS) was 69% [CI 95%=59%-81%]. At 6 and 12 months, the cumulative incidence functions (CIF) of local relapse were 4% [1%-13%] and 15% [8%-26%], respectively. According to univariate analysis, factors associated with LR were an initial volume larger than 7cc (hazard ratio: 4.6 [1.0-20.8], P=0.046) and a positive resection margin [hazard ratio: 3.6 [1.1-12.0], P=0.037. DBR occurred in 54.3% of patients with a median time of 8 months. None of the variables tested (histology, location or number of lesions) were found correlated with the DBR. Leptomeningeal disease occurred in 12.9% of cases. Salvage whole brain radiotherapy (WBRT) was required in 45.7% of patients and delayed by a median time of 9.6 months. Symptomatic radionecrosis (RN) occurred in 7.1%. CONCLUSIONS Adjuvant SRT was an effective and well-tolerated treatment to control the postoperative risk of recurrence of BM without compromising OS. Positive resection margins and large volumes were predictors factor of local relapse.
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Affiliation(s)
- A Mousli
- Radiation Oncology, université catholique de Louvain, CHU-UCL-Namur, site Sainte-Elisabeth, Namur, Belgium; Radiation Oncology Department, centre François-Baclesse, Esch-sur-Alzette, Luxembourg.
| | - B Bihin
- Biostatistics Unit, université catholique de Louvain, CHU-UCL-Namur, site Godinne, Yvoir, Belgium
| | - T Gustin
- Neurosurgery, université catholique de Louvain, CHU-UCL-Namur, site Godinne, Yvoir, Belgium
| | - G Koerts
- Neurosurgery, centre hospitalier régional Sambre-et-Meuse, Namur, Belgium
| | - M Mouchamps
- Neurosurgery, centre hospitalier régional, Liège, Belgium; Neurosurgery Department, centre hospitalier chrétien St-Joseph, Liège, Belgium
| | - J F Daisne
- Radiation Oncology, université catholique de Louvain, CHU-UCL-Namur, site Sainte-Elisabeth, Namur, Belgium; Radiation Oncology Department, Katholieke Universiteit Leuven, Universitaire Ziekehnhuis, Leuven, Belgium
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15
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Shi S, Sandhu N, Jin MC, Wang E, Jaoude JA, Schofield K, Zhang C, Liu E, Gibbs IC, Hancock SL, Chang SD, Li G, Hayden-Gephart M, Adler JR, Soltys SG, Pollom EL. Stereotactic Radiosurgery for Resected Brain Metastases: Single-Institutional Experience of Over 500 Cavities. Int J Radiat Oncol Biol Phys 2020; 106:764-771. [DOI: 10.1016/j.ijrobp.2019.11.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/22/2019] [Accepted: 11/15/2019] [Indexed: 02/05/2023]
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16
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Facchinetti F, Bozzetti F, Gnetti L, Minari R, Crafa P, Rebuzzi SE, Ferrara R, Gruppioni E, Capizzi E, Giombelli E, Crisi G, Altimari A, Tiseo M. Wide and Cystic Brain Metastases Reveal RET-Rearranged Non-Small-Cell Lung Cancers. JCO Precis Oncol 2019; 3:1-7. [PMID: 35100707 DOI: 10.1200/po.19.00073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Francesco Facchinetti
- University Hospital of Parma, Parma, Italy.,Université Paris Saclay, Villejuif, France
| | | | | | | | | | | | | | | | | | | | | | | | - Marcello Tiseo
- University Hospital of Parma, Parma, Italy.,University of Parma, Parma, Italy
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17
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Survival and prognostic factors in surgically treated brain metastases. J Neurooncol 2019; 143:359-367. [DOI: 10.1007/s11060-019-03171-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/09/2019] [Indexed: 12/26/2022]
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18
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Martinage G, Geffrelot J, Stefan D, Bogart E, Rault E, Reyns N, Emery E, Makhloufi-Martinage S, Mouttet-Audouard R, Basson L, Mirabel X, Lartigau E, Pasquier D. Efficacy and Tolerance of Post-operative Hypo-Fractionated Stereotactic Radiotherapy in a Large Series of Patients With Brain Metastases. Front Oncol 2019; 9:184. [PMID: 30984617 PMCID: PMC6448411 DOI: 10.3389/fonc.2019.00184] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 03/04/2019] [Indexed: 11/13/2022] Open
Abstract
Purpose: The aim of this study was to assess, in a large series, the efficacy and tolerance of post-operative adjuvant hypofractionated stereotactic radiation therapy (HFSRT) for brain metastases (BMs). Materials and Methods: Between July 2012 and January 2017, 160 patients from 2 centers were operated for BM and treated by HFSRT. Patients had between 1 and 3 BMs, no brainstem lesions or carcinomatous meningitis. The primary endpoint was local control. Secondary endpoints were distant brain control, overall survival (OS) and tolerance to HFSRT. Results: 73 patients (46%) presented with non-small cell lung cancer (NSCLC), 23 (14%) had melanoma and 21 (13%) breast cancer. Median age was 58 years (range, 22–83 years). BMs were synchronous in 50% of the cases. The most frequent prescription regimens were 24 Gy in 3 fractions (n = 52, 33%) and 30 Gy in 5 fractions (n = 37, 23%). Local control rates at 1 and 2 years were 88% [95%CI, 81–93%] and 81% [95%CI, 70–88%], respectively. Distant control rate at 1 year was 48% [95%CI, 81–93%]. In multivariate analysis, primary NSCLC was associated with a significant reduction in the risk of death compared to other primary sites (HR = 0.57, p = 0.007), the number of extra-cerebral metastatic sites (HR = 1.26, p = 0.003) and planning target volumes (HR = 1.15, p = 0.012) were associated with a lower OS. There was no prognostic factor of time to local progression. Median OS was 15.2 months [95%CI, 12.0–17.9 months] and the OS rate at 1 year was 58% [95% CI, 50–65%]. Salvage radiotherapy was administered to 72 patients (45%), of which 49 received new HFSRT. Ten (7%) patients presented late grade 2 and 4 (3%) patients late grade 3 toxicities. Thirteen (8.9%) patients developed radiation necrosis. Conclusions: This large multicenter retrospective study shows that HFSRT allows for good local control of metastasectomy tumor beds and that this technique is well-tolerated by patients.
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Affiliation(s)
- Geoffrey Martinage
- Academic Department of Radiation Oncology, Centre Oscar Lambret, University Lille II, Lille, France
| | - Julien Geffrelot
- Department of Radiation Oncology, Centre François Baclesse, Caen, France
| | - Dinu Stefan
- Department of Radiation Oncology, Centre François Baclesse, Caen, France
| | - Emilie Bogart
- Department of Biostatistics, Centre Oscar Lambret, Lille, France
| | - Erwan Rault
- Department of Medical Physics, Centre Oscar Lambret, Lille, France
| | - Nicolas Reyns
- Department of Neurosurgery, CHRU Lille, Lille, France
| | - Evelyne Emery
- Neurosurgical Department, Universitary Hospital Caen, Caen, France
| | | | | | - Laurent Basson
- Academic Department of Radiation Oncology, Centre Oscar Lambret, University Lille II, Lille, France
| | - Xavier Mirabel
- Academic Department of Radiation Oncology, Centre Oscar Lambret, University Lille II, Lille, France
| | - Eric Lartigau
- Academic Department of Radiation Oncology, Centre Oscar Lambret, University Lille II, Lille, France.,CRIStAL UMR CNRS 9189, Lille University, Lille, France
| | - David Pasquier
- Academic Department of Radiation Oncology, Centre Oscar Lambret, University Lille II, Lille, France.,CRIStAL UMR CNRS 9189, Lille University, Lille, France
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19
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Bachmann N, Leiser D, Ermis E, Vulcu S, Schucht P, Raabe A, Aebersold DM, Herrmann E. Impact of regular magnetic resonance imaging follow-up after stereotactic radiotherapy to the surgical cavity in patients with one to three brain metastases. Radiat Oncol 2019; 14:45. [PMID: 30871597 PMCID: PMC6417038 DOI: 10.1186/s13014-019-1252-x] [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: 11/21/2018] [Accepted: 03/05/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Administering stereotactic radiotherapy to the surgical cavity and thus omitting postoperative whole brain radiotherapy (WBRT) is a favored strategy in limited metastatic brain disease. Little is known about the impact of regular magnetic resonance imaging follow-up (MRI FU) in such patient cohorts. The aim of this study is to examine the impact of regular MRI FU and to report the oncological outcomes of patients with one to three brain metastases (BMs) treated with stereotactic radiosurgery (SRS) or hypo-fractionated stereotactic radiotherapy (HFSRT) to the surgical cavity. METHODS We retrospectively analyzed patients who received SRS or HFSRT to the surgical cavity after resection of one to two BMs. Additional, non-resected BMs were managed with SRS alone. Survival was estimated by the Kaplan-Meier method. Prognostic factors were examined with the log-rank test and Cox proportional hazards model. Regular MRI FU was defined as performing a brain MRI 3 months after radiotherapy (RT) and/or performing ≥1 brain MRI per 180 days. Primary endpoint was local control (LC). Secondary endpoints were distant brain control (DBC), overall survival (OS) and the correlation between regular MRI FU and overall survival (OS), symptom-free survival (SFS), deferment of WBRT and WBRT-free survival (WFS). RESULTS Overall, 75 patients were enrolled. One, 2 and 3 BMs were seen in 63 (84%), 11 (15%) and 1 (1%) patients, respectively. Forty (53%) patients underwent MRI FU 3 months after RT and 38 (51%) patients received ≥1 brain MRI per 180 days. Median OS was 19.4 months (95% CI: 13.2-25.6 months). Actuarial LC, DBC and OS at 1 year were 72% (95% CI: 60-83%), 60% (95% CI: 48-72%) and 66% (95% CI: 53-76%), respectively. A planning target volume > 15 cm3 (p = 0.01), Graded Prognostic Assessment (GPA) score (p = 0.001) and residual tumor after surgery (p = 0.008) were prognostic for decreased OS in multivariate analysis. No significant correlation between MRI FU at 3 months and OS (p = 0.462), SFS (p = 0.536), WFS (p = 0.407) or deferment of WBRT (p = 0.955) was seen. Likewise, performing ≥1 MRI per 180 days had no significant impact on OS (p = 0.954), SFS (p = 0.196), WFS (p = 0.308) or deferment of WBRT (p = 0.268). CONCLUSION Our results regarding oncological outcomes consist with the current data from the literature. Surprisingly, regular MRI FU did not result in increased OS, SFS, WFS or deferment of WBRT in our cohort consisting mainly of patients with a single and resected BM. Therefore, the impact of regular MRI FU needs prospective evaluation. TRIAL REGISTRATION Project ID: 2017-00033, retrospectively registered.
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Affiliation(s)
- N Bachmann
- Department of Radiation Oncology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse 18, CH-3010, Bern, Switzerland
| | - D Leiser
- Department of Radiation Oncology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse 18, CH-3010, Bern, Switzerland
| | - E Ermis
- Department of Radiation Oncology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse 18, CH-3010, Bern, Switzerland
| | - S Vulcu
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - P Schucht
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - A Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - D M Aebersold
- Department of Radiation Oncology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse 18, CH-3010, Bern, Switzerland
| | - E Herrmann
- Department of Radiation Oncology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse 18, CH-3010, Bern, Switzerland.
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20
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Huff WX, Agrawal N, Shapiro S, Miller J, Kulwin C, Shah M, Savage JJ, Payner T, Vortmeyer A, Watson G, Dey M. Efficacy of pre-operative stereotactic radiosurgery followed by surgical resection and correlative radiobiological analysis for patients with 1-4 brain metastases: study protocol for a phase II trial. Radiat Oncol 2018; 13:252. [PMID: 30572923 PMCID: PMC6302493 DOI: 10.1186/s13014-018-1178-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 11/09/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) has emerged as a common adjuvant modality used with surgery for resectable brain metastases (BMs). However, the optimal sequence of the multi-modality therapy has not been established. The goal of the study is to evaluate 6-month local control utilizing pre-operative SRS followed by surgical resection for patients with 1-4 brain metastases. METHODS This prospective, single arm, phase II trial will recruit patients with up to 4 brain metastases and at least one resectable lesion. All lesions will be treated with SRS and symptomatic lesions will be resected within 1-4 days after SRS. Patients will be monitored for 6-month local control, in-brain progression free survival, distant in-brain failure, rate of leptomeningeal spread, radiation necrosis and overall survival. Additionally, we will also perform correlative radiobiological molecular studies to assess the effect of radiation dosing on the tumor tissue and clinical outcomes. We expect that pre-operative SRS to the gross tumor prior to surgical resection will improve local control and decrease leptomeningeal failure. DISCUSSION Our study is the second prospective trial to investigate the efficacy of pre-operative SRS in the treatment of multiple BMs. In addition, the correlative molecular studies will be the first to investigate early response of BMs at a cellular and genetic level in response to radiation doses and potentially provide molecular prognostic markers for local control and overall survival. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT03398694 (registration date: January 12, 2018).
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Affiliation(s)
- Wei X. Huff
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, Neuroscience Research Building, 320 W 15th Street, NB 400A, Indiana, IN 46202 USA
| | - Namita Agrawal
- Department of Radiation Oncology, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, Indiana, USA
| | - Scott Shapiro
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, Neuroscience Research Building, 320 W 15th Street, NB 400A, Indiana, IN 46202 USA
| | - James Miller
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, Neuroscience Research Building, 320 W 15th Street, NB 400A, Indiana, IN 46202 USA
| | - Charles Kulwin
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, Neuroscience Research Building, 320 W 15th Street, NB 400A, Indiana, IN 46202 USA
| | - Mitesh Shah
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, Neuroscience Research Building, 320 W 15th Street, NB 400A, Indiana, IN 46202 USA
| | - Jesse J. Savage
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, Neuroscience Research Building, 320 W 15th Street, NB 400A, Indiana, IN 46202 USA
| | - Troy Payner
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, Neuroscience Research Building, 320 W 15th Street, NB 400A, Indiana, IN 46202 USA
| | - Alexander Vortmeyer
- Department of Pathology, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, Indiana, USA
| | - Gordon Watson
- Department of Radiation Oncology, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, Indiana, USA
| | - Mahua Dey
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, Neuroscience Research Building, 320 W 15th Street, NB 400A, Indiana, IN 46202 USA
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21
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Ayas AW, Grau S, Jablonska K, Ruess D, Ruge M, Marnitz S, Goldbrunner R, Kocher M. Postoperative local fractionated radiotherapy for resected single brain metastases. Strahlenther Onkol 2018; 194:1163-1170. [PMID: 30218137 DOI: 10.1007/s00066-018-1368-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 08/28/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Evaluation of postoperative fractionated local 3D-conformal radiotherapy (3DRT) of the resection cavity in brain metastases. PATIENTS AND METHODS Between 2011 and 2016, 57 patients underwent resection of a single, previously untreated (37/57, 65%) or recurrent (20/57, 35%) brain metastasis (median maximal diameter 3.5 cm [1.1-6.5 cm]) followed by 3DRT. For definition of the gross tumor volume (GTV), the resection cavity was used and for the clinical target volume (CTV), margins of 1.0-1.5 cm were added. Median dose was 48.0 Gy (30.0-50.4 Gy) in 25 (10-28) fractions; most patients had 36.0-42.0 Gy in 3.0 Gy fractions (n = 16, EQD210Gy 39.0-45.5 Gy) or 40.0-50.4 Gy in 1.8-2.0 Gy fractions (n = 37, EQD210Gy 39.3-50.0 Gy). RESULTS Median follow-up was 18 months. Local control rates were 83% at 1 year and 78% at 2 years and were significantly influenced by histology (breast cancer 100%, non-small lung cancer 87%, melanoma 80%, colorectal cancer 26% at 2 years, p = 0.006) and resection status (p < 0.0001), but not by EQD210Gy or size of the planning target volume (median 96.7 ml [16.7-282.8 ml]). At 1 and 2 years, 74% and 52% of the patients were free from distant brain metastases. Salvage procedures were applied in 25/27 (93%) of recurrent patients. Survival was 68% at 1 year and 41% at 2 years and was significantly improved in younger patients (p = 0.006) with higher Karnofsky performance score (p < 0.0001) and without prior radiotherapy (54% vs. 9% at 2 years, p = 0.006). No cases of radiographic or symptomatic radionecrosis were observed. CONCLUSION Adjuvant fractionated local 3DRT is highly effective in radiosensitive, completely resected metastases and should be considered for treating large resection cavities as an alternative to postoperative stereotactic single dose or hypofractionated radiosurgery.
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Affiliation(s)
- Ahmad Walid Ayas
- Department of Radiation Oncology, Center for Integrated Oncology, University Hospital Cologne, Cologne, Germany
| | - Stefan Grau
- Department of Neurosurgery, Center for Integrated Oncology, University Hospital Cologne, Cologne, Germany
| | - Karolina Jablonska
- Department of Radiation Oncology, Center for Integrated Oncology, University Hospital Cologne, Cologne, Germany
| | - Daniel Ruess
- Department of Stereotactic and Functional Neurosurgery, Center for Integrated Oncology, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Maximilian Ruge
- Department of Stereotactic and Functional Neurosurgery, Center for Integrated Oncology, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Simone Marnitz
- Department of Radiation Oncology, Center for Integrated Oncology, University Hospital Cologne, Cologne, Germany
| | - Roland Goldbrunner
- Department of Neurosurgery, Center for Integrated Oncology, University Hospital Cologne, Cologne, Germany
| | - Martin Kocher
- Department of Radiation Oncology, Center for Integrated Oncology, University Hospital Cologne, Cologne, Germany.
- Department of Stereotactic and Functional Neurosurgery, Center for Integrated Oncology, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
- Institute of Neuroscience and Medicine (INM-4), Forschungszentrum Juelich, Juelich, Germany.
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22
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Xia Y, Mashouf LA, Maxwell R, Peng LC, Lipson EJ, Sharfman WH, Bettegowda C, Redmond KJ, Kleinberg LR, Lim M. Adjuvant radiotherapy and outcomes of presumed hemorrhagic melanoma brain metastases without malignant cells. Surg Neurol Int 2018; 9:146. [PMID: 30105140 PMCID: PMC6080145 DOI: 10.4103/sni.sni_140_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 06/14/2018] [Indexed: 12/28/2022] Open
Abstract
Background Patients with melanoma can present with a hemorrhagic intracranial lesion. Upon resection, pathology reports may not detect any malignant cells. However, the hemorrhage may obscure their presence and so physicians may still decide whether adjuvant radiotherapy should be applied. Here, we report on the outcomes of a series of patients with melanoma with hemorrhagic brain lesions that returned with no tumor cells. Methods All melanoma patients who had craniotomies from 2008 to 2017 at a single institution for hemorrhagic brain lesions were identified through retrospective chart review. Those who had pathology reports with no malignant cells were analyzed. Recurrence at the former site of hemorrhage and resection was the primary outcome. Results Ten patients met inclusion criteria, and the median follow-up time was 8.5 (1.8-27.3) months. At the time of craniotomy, the median number of brain lesions was 3 (1-25). Two patients had prior craniotomies, eight had prior radiation, and six had prior immunotherapy to the lesion of interest. After surgery, one patient received stereotactic radiosurgery (SRS) to the resection bed. Only one patient developed subsequent melanoma at the resection site; this patient developed the lesion recurrence once and had not received postoperative SRS. Conclusion Although small foci of metastatic disease as a source of bleeding for some patients cannot be excluded, melanoma patients with a suspected hemorrhagic brain metastasis that shows no tumor cells on pathology may benefit from close observation. The local recurrence risk in such cases appears to be low, even without adjuvant radiation.
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Affiliation(s)
- Yuanxuan Xia
- Department of Neurosurgery, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
| | - Leila A Mashouf
- Department of Neurosurgery, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
| | - Russell Maxwell
- Department of Neurosurgery, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA.,Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
| | - Luke C Peng
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
| | - Evan J Lipson
- Department of Oncology, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
| | - William H Sharfman
- Department of Oncology, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
| | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
| | - Michael Lim
- Department of Neurosurgery, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA.,Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA.,Department of Oncology, Johns Hopkins Medical Institutes, Baltimore, Maryland, USA
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23
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Xia Y, Mashouf LA, Baker BR, Maxwell R, Bettegowda C, Redmond KJ, Kleinberg LR, Lim M. Outcomes of Metastatic Brain Lesions Treated with Radioactive Cs-131 Seeds after Surgery: Experience from One Institution. Cureus 2018; 10:e3075. [PMID: 30280070 PMCID: PMC6166914 DOI: 10.7759/cureus.3075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Introduction Brain metastases are common in patients with advanced systemic cancer and often recur despite treatment with surgical resection and radiotherapy. Whole brain radiation therapy (WBRT) and stereotactic radiosurgery (SRS) have significantly improved local control rates but are limited by complications including neurocognitive deficits and radiation necrosis. These risks can be higher in the re-irradiation setting. Brachytherapy may be an alternative method of additional targeted adjuvant radiotherapy with acceptable rates of toxicity. Methods A retrospective chart review of all patients undergoing resection for metastatic brain lesions and permanent low-dose rate Cs-131 brachytherapy was performed for one institution over a 10-year period. All patients had previous radiation therapy already and, after surgery, were followed with imaging every three months. Patient demographics, disease characteristics, intracranial disease, peri- and post-operative complications, and outcomes were recorded. The primary outcome of interest was local tumor recurrence at the site of brachytherapy while secondary outcomes included distant disease progression (within the brain) and complications such as radiation necrosis. Results During the study period, nine cases of individual patients met inclusion criteria. The median preoperative lesion diameter was 3 cm (0.8–4.1). The median overall survival after surgery and brachytherapy was 10.3 months, after excluding two patients who were lost to follow-up. Six of nine patients had no local recurrence, while three patients had development or progression of distant lesions. No patients experienced acute or delayed complications. Conclusion Cs-131 brachytherapy is a promising alternative method for controlling brain metastases after previous radiation interventions and surgical resection. In this case series, there were no incidences of local tumor recurrence or complications such as radiation necrosis.
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Affiliation(s)
- Yuanxuan Xia
- Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Leila A Mashouf
- Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Brock R Baker
- Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Russell Maxwell
- Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Chetan Bettegowda
- Neurosurgery, Department of Neurosurgery/The Johns Hopkins University School of Medicine, Baltimore Maryland, Baltimore, USA
| | - Kristin J Redmond
- Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Lawrence R Kleinberg
- Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Michael Lim
- Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, USA
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24
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Gattozzi DA, Alvarado A, Kitzerow C, Funkhouser A, Bimali M, Moqbel M, Chamoun RB. Very Large Metastases to the Brain: Retrospective Study on Outcomes of Surgical Management. World Neurosurg 2018; 116:e874-e881. [PMID: 29807179 DOI: 10.1016/j.wneu.2018.05.120] [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: 03/18/2018] [Revised: 05/17/2018] [Accepted: 05/18/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND The incidence of brain metastases is rising. To our knowledge, no published study focuses exclusively on brain metastases larger than 4 cm. We present our surgical outcomes for patients with brain metastases larger than 4 cm. METHODS This is a retrospective chart review of inpatient data at our institution from January 2006 to September 2015. Primary end points included overall survival, progression-free survival, and local recurrence rate. RESULTS Sixty-one patients had a total of 67 brain metastases larger than 4 cm: 52 were supratentorial and 15 were infratentorial. Forty-three patients underwent surgical resection. Average duration of disease freedom after resection was 4.79 months (range, 0-30 months). Excluding patients with residual on immediate postoperative magnetic resonance imaging, the average rate of local recurrence was 7 months (range, 1-14 months). Overall survival after surgery excluding patients who chose palliation in the immediate postoperative period averaged 8.76 months (range, 1-37 months). Thirty-five of 43 patients (81.4%) had stable or improved neurologic examinations postoperatively. Six patients (13.95%) developed surgical complications. There were 3 major complications (6.98%): 2 pseudomeningoceles required intervention and 1 postoperative hematoma required external ventricular drain placement. There were 3 minor complications (6.98%): 1 self-limited pseudomeningocele, 1 subgaleal fluid collection, and 1 postoperative seizure. CONCLUSIONS Surgery resulted in stable or improved neurologic examination in 81.4% of cases. On statistical analysis, significantly increased overall survival was noted in patients undergoing surgical resection, and those with higher Karnofsky Performance Scale and lower number of brain metastases at presentation. There is a need for further studies to evaluate management of brain metastases larger than 4 cm.
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Affiliation(s)
- Domenico A Gattozzi
- Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas, USA.
| | - Anthony Alvarado
- Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Collin Kitzerow
- Department of Anesthesiology, University of Kansas School of Medicine Wichita, Wichita, Kansas, USA
| | - Alexander Funkhouser
- University of Kansas Medical School, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Milan Bimali
- Office of Research, University of Kansas School of Medicine Wichita, Wichita, Kansas, USA
| | - Murad Moqbel
- Price College of Business: Management Information Systems, University of Oklahoma, Norman, Oklahoma, USA
| | - Roukoz B Chamoun
- Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas, USA
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25
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Gui C, Moore J, Grimm J, Kleinberg L, McNutt T, Shen C, Chen L, Bettegowda C, Lim M, Redmond KJ. Local recurrence patterns after postoperative stereotactic radiation surgery to resected brain metastases: A quantitative analysis to guide target delineation. Pract Radiat Oncol 2018; 8:388-396. [PMID: 30029965 DOI: 10.1016/j.prro.2018.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 04/13/2018] [Accepted: 04/21/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE In the treatment of resected metastatic brain disease, a recent phase 3 trial by the North Central Cancer Treatment Group (N107C/CEC.3) surprisingly found that the local control rate for whole-brain radiation therapy was better than that of stereotactic radiation surgery (SRS). To optimize target delineation, we performed a quantitative analysis of local failure patterns after postoperative SRS. METHODS AND MATERIALS Patients with brain metastases who were treated with surgery and SRS to the cavity were evaluated. Local failure was defined by pathologic confirmation or magnetic resonance imaging evidence of progression leading to further overlapping radiation therapy. T1 postgadolinium magnetic resonance imaging scans that were taken preoperatively and at recurrence were co-registered to the simulation computed tomography. Three volumes were compared: (1) Preoperative tumors, (2) resection cavities that were originally contoured as clinical target volumes for SRS, and (3) recurrent tumors. Overlap volume histograms quantified the proximity of the three volumes to the meninges. RESULTS In the cohort of 173 patients, 18 patients experienced local failure in 19 resection cavities. The original SRS target volume overlapped with a median of 69.6% of the recurrent tumor. When the entire preoperative tumor was included, the overlap with the recurrent tumor increased to a median of 76.8%. Recurrent tumors were closer to the meninges than corresponding preoperative tumors (P = .03) but a median 8.2 mm expansion of the target volume from the meninges was needed to increase overlap with the recurrent tumor to 90%. Increases in overlap with the recurrent tumor were achieved most efficiently by uniformly expanding the contoured cavity and a median 2.8 mm expansion covered 90% of the recurrent tumor. CONCLUSIONS Our quantitative analysis of recurrence patterns suggests that a larger 3 mm uniform expansion of the SRS target volume substantially increases coverage of the volume that is later occupied by the recurrent tumor and may provide improved local control. The extent of the preoperative tumor in the target volume or expanding the target volume from the meninges provides little benefit.
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Affiliation(s)
- Chengcheng Gui
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Joseph Moore
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Jimm Grimm
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Lawrence Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Todd McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Colette Shen
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Linda Chen
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
| | - Michael Lim
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland.
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26
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Identifying candidates for gamma knife radiosurgery among elderly patients with brain metastases. J Neurooncol 2018; 137:559-565. [PMID: 29327172 DOI: 10.1007/s11060-018-2745-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/03/2018] [Indexed: 01/17/2023]
Abstract
We investigated the outcomes of gamma knife radiosurgery (GKRS) for elderly patients (≥ 65 years) with brain metastases, and identified survival-associated factors. We retrospectively analyzed data from 115 patients treated with GKRS for 1-15 brain metastases. The median patient age was 72 years; most primary tumors were pulmonary (n = 83). The mean lesion volume was 2.1 ± 4.8 mL. A mean dose of 19.3 Gy was delivered to the mean 63.9% isodose line. The median overall survival (OS) was 5.3 months (95% confidence interval [CI] 3.5-7.1). During follow-up (median, 5.1 months), 91 patients died of primary cancer progression while 1 died of unknown causes. The 6- and 12-month local control rates were 94.9 and 88.1%, respectively. On multivariate analysis, female sex (p = 0.005, hazard ratio [HR] 0.533, 95% CI 0.343-0.827) and a controlled primary tumor (p < 0.001, HR 0.328, 95% CI 0.180-0.596) were significantly favorable prognostic factors. Of non-small cell lung cancer patients with EGFR mutations, 76.5% were women (p = 0.005). The median OS of EGFR-mutant and EGFR-wildtype patients were 19.1 and 4.7 months, respectively (p = 0.080). Brain metastases < 3 mL showed better local control rates after GKRS (p = 0.005). GKRS produces favorable outcomes in women with brain metastases who are ≥ 65 years and have controlled primary tumors. Such patients are therefore suitable candidates for GKRS.
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27
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Ma R, Levy M, Gui B, Lu SE, Narra V, Goyal S, Danish S, Hanft S, Khan AJ, Malhotra J, Motwani S, Jabbour SK. Risk of leptomeningeal carcinomatosis in patients with brain metastases treated with stereotactic radiosurgery. J Neurooncol 2018; 136:395-401. [PMID: 29159778 DOI: 10.1007/s11060-017-2666-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 11/04/2017] [Indexed: 11/27/2022]
Abstract
There is limited available literature examining factors that predispose patients to the development of LMC after stereotactic radiosurgery (SRS) for brain metastases. We sought to evaluate risk factors that may predispose patients to LMC after SRS treatment in this case-control study of patients with brain metastases who underwent single-fraction SRS between 2011 and 2016. Demographic and clinical information were collected retrospectively for 19 LMC cases and 30 controls out of 413 screened patients with brain metastases. Risk factors of interest were evaluated by univariate and multivariate logistic regression analyses and overall survival rates were evaluated by Kaplan-Meier survival analysis. About 5% of patients with brain metastases treated with SRS developed LMC. Patients with LMC (median 154 days, 95% CI 33-203 days) demonstrated a poorer overall survival than matched controls (median 417 days, 95% CI 121-512 days, p = 0.002). The most common primary tumor histologies that lead to the development of LMC were non-small cell lung cancer (36.8%), breast cancer (26.3%), and melanoma (21.1%). No association was found between the risk of LMC and the location of the brain lesion or total volume of brain metastases. Prior surgical resection of brain metastases before SRS was associated with a 6.5 times higher odds (95% CI 1.45-29.35, p = 0.01) of developing LMC post-radiosurgery compared to those with no prior resections of brain metastases. Additionally, adjuvant WBRT may help to reduce the risk of LMC and can be considered in decision-making for patients who have had brain metastasectomy.
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Affiliation(s)
- Rosaline Ma
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, 195 Little Albany Street, New Brunswick, NJ, 08901, USA
| | - Morgan Levy
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, 195 Little Albany Street, New Brunswick, NJ, 08901, USA
| | - Bin Gui
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, 195 Little Albany Street, New Brunswick, NJ, 08901, USA
| | - Shou-En Lu
- Department of Biostatistics, Rutgers School of Public Health, Piscataway, NJ, USA
| | | | - Sharad Goyal
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, 195 Little Albany Street, New Brunswick, NJ, 08901, USA
| | - Shabbar Danish
- Department of Neurosurgery, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Simon Hanft
- Department of Neurosurgery, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Atif J Khan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, 195 Little Albany Street, New Brunswick, NJ, 08901, USA
| | - Jyoti Malhotra
- Department of Medical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Sabin Motwani
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, 195 Little Albany Street, New Brunswick, NJ, 08901, USA
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, 195 Little Albany Street, New Brunswick, NJ, 08901, USA.
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Abstract
The cognitive evaluation is essential to arrest the impact of brain tumours on brain functions. Radiation therapy on the brain has side effects, which can impact on the cognitive functioning. The cognitive disorders constitute a predictive factor of the quality of life of the patients impacting on their autonomy, as well as on their social and professional life. This problem thus takes a more and more important place in the reflection on the cancer care. A better detection of these cognitive disorders requires a better cognitive evaluation from the diagnosis. What would allow the implementation of preventive actions upstream. This prospect of improvement of the coverage of the cognitive consequences of the irradiation should allow a better social reinstatement after the treatment, as well as a facilitation for the preservation of autonomy and functional independence. However, a complete cognitive evaluation is expensive in time and asks for a qualified personnel, which often slows down the exploration and the follow-up of the disorders.
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Keller A, Doré M, Cebula H, Thillays F, Proust F, Darié I, Martin SA, Delpon G, Lefebvre F, Noël G, Antoni D. Hypofractionated Stereotactic Radiation Therapy to the Resection Bed for Intracranial Metastases. Int J Radiat Oncol Biol Phys 2017; 99:1179-1189. [DOI: 10.1016/j.ijrobp.2017.08.014] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 07/27/2017] [Accepted: 08/11/2017] [Indexed: 11/30/2022]
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[Delineation of the surgical bed of operated brain metastases treated with adjuvant stereotactic irradiation: A review]. Cancer Radiother 2017; 21:804-813. [PMID: 29170039 DOI: 10.1016/j.canrad.2017.04.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/30/2017] [Accepted: 04/19/2017] [Indexed: 11/22/2022]
Abstract
Stereotactic radiotherapy of the surgical bed of brain metastases is a technique that comes supplant indications of adjuvant whole brain radiotherapy after surgery. After a growing number of retrospective studies, a phase III trial has been presented and validated this indication. However, several criteria such as the dose, the fractionation, the use of a margin and definition of volumes remain to be defined. Our study consisted in making a literature review in order to provide a guideline of delineation of surgical beds of brain metastases, as well as the different modalities of their implementation process.
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Increasing time to postoperative stereotactic radiation therapy for patients with resected brain metastases: investigating clinical outcomes and identifying predictors associated with time to initiation. J Neurooncol 2017; 136:545-553. [PMID: 29143275 DOI: 10.1007/s11060-017-2679-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 11/11/2017] [Indexed: 10/18/2022]
Abstract
We sought to determine the impact of time to initiation (TTI) of post-operative radiosurgery on clinical outcomes for patients with resected brain metastases and to identify predictors associated with TTI. All patients with resected brain metastases treated with postoperative SRS or fractionated stereotactic radiation therapy (fSRT) from 2012 to 2016 at a single institution were reviewed. TTI was defined as the interval from resection to first day of radiosurgery. Receiver operating characteristic (ROC) curves were used to identify an optimal threshold for TTI with respect to local failure (LF). Survival outcomes were estimated using the Kaplan-Meier method and analyzed using the log-rank test and Cox proportional hazards models. Logistic regression models were used to identify factors associated with ROC-determined TTI covariates. A total of 79 resected lesions from 73 patients were evaluated. An ROC curve of LF and TTI identified an optimal threshold for TTI of 30.5 days, with an area under the curve of 0.637. TTI > 30 days was associated with an increased hazard of LF (HR 4.525, CI 1.239-16.527) but was not significantly associated with survival (HR 1.002, CI 0.547-1.823) or distant brain failure (DBF, HR 1.943, CI 0.989-3.816). Fifteen patients (20.5%) required post-operative inpatient rehabilitation. Post-operative rehabilitation was associated with TTI > 30 days (OR 1.48, CI 1.142-1.922). In our study of resected brain metastases, longer time to initiation of post-operative radiosurgery was associated with increased local failure. Ideally, post-op SRS should be initiated within 30 days of resection if feasible.
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Liu Z, Lei B, Zheng M, Li Z, Huang S, Deng Y. Prognostic factors in patients treated with surgery for brain metastases: A single-center retrospective analysis of 125 patients. Int J Surg 2017; 44:204-209. [PMID: 28528216 DOI: 10.1016/j.ijsu.2017.05.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/11/2017] [Accepted: 05/13/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUD Brain metastases are the most common malignant intracranial tumors, however, the prognosis of patients is still poor despite multiple treatment have been applicated. The aim of this study was to analyse parameters influence overall survival from patient, tumor and treatment. Summarized characteristics of long-time (>2 years) survivors furtherly. MATERIALS AND METHODS In total, clinical data of 125patients between 2004 and 2015 were collected and the parameters from patients, tumor and treatment were evaluated. Univariate analysis was performed using Kaplan-Meier and Log-rank test, multivariate analysis was performed using Cox proportional hazards regression model, respectively. RESULTS Median overall survival time was 14.5 (95% confidence interval were 12.3-16.7) months and median survival time was 34.5 (95% confidence interval were 30.1-38.9) months in long-time survivors, respectively.KPS, RPA, GPA, number of brain metastases, extracranial metastases, treatment pattern and resection method were identified influence survival time significantly by univariate analysis. KPS, number of brain metastases, extracranial metastases and treatment pattern were independent prognosis factors by multivariate analysis. Long-time survivors obtain higher KPS, complete resection, adjuvant therapy postoperative more commonly. CONCLUSION Higher KPS, GPA I,RPA3.5∼4, single brain metastases, adjuvant therapy postoperative and complete resection were significant improve survival time, however, extracranial metastases significant decreased survival time. Patients who have good status and received multimodality therapy involved complete resection can survive longer time more commonly.
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Affiliation(s)
- Zhenghao Liu
- Department of Neurosurgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Bingxi Lei
- Department of Neurosurgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Meiguang Zheng
- Department of Neurosurgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zhongjun Li
- Department of Neurosurgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Shuaibin Huang
- Department of Neurosurgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yuefei Deng
- Department of Neurosurgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
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Tsakonas G, De Petris L, Ekman S. Management of brain metastasized non-small cell lung cancer (NSCLC) – From local treatment to new systemic therapies. Cancer Treat Rev 2017; 54:122-131. [DOI: 10.1016/j.ctrv.2017.02.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 01/31/2017] [Accepted: 02/07/2017] [Indexed: 01/24/2023]
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Sinha R, Sage W, Watts C. The evolving clinical management of cerebral metastases. Eur J Surg Oncol 2016; 43:1173-1185. [PMID: 27986364 DOI: 10.1016/j.ejso.2016.10.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 10/05/2016] [Indexed: 11/26/2022] Open
Abstract
Concepts in the management of brain metastases are evolving. Until recently, brain metastases have been considered as a homogenous condition, managed with whole brain radiotherapy, surgical resection for large lesions and stereotactic radiosurgery for smaller lesions. Increasingly, specific systemic medical therapies are being used to treat brain metastases based on the primary site of disease. This disease specific management is causing a change in perspective about brain metastases and has led to improved survival for patients with primary disease subtypes amenable to tailored medical therapies. We review the recent literature to present evidence for the use of subtype specific medical therapies, advances in surgical resection techniques and stereotactic radiosurgery as the primary treatment modalities. The decline in use of whole brain radiotherapy as first line treatment is also discussed. Based on the recent literature, we propose a new management algorithm to reflect the progress in available options for tailoring disease specific treatments and support the change in paradigm to consider brain metastases as separate disease states based on the primary site of cancer rather than as a homogenous entity.
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Affiliation(s)
- R Sinha
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - W Sage
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - C Watts
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK.
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Hypofractionated Stereotactic Radiosurgery and Radiotherapy to Large Resection Cavity of Metastatic Brain Tumors. World Neurosurg 2016; 97:571-579. [PMID: 27777153 DOI: 10.1016/j.wneu.2016.10.076] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the efficacy of postoperative fractionated stereotactic radiosurgery (FSRS) and hypofractionated stereotactic radiotherapy (SRT) to large surgical cavities after gross total resection of brain metastases. METHODS A retrospective analysis of 41 patients who had received tumor-bed FSRS (5 fractions) or SRT (10 fractions) after resection of brain metastasis between 2005 and 2015 was performed. All resection cavities were treated with a frameless linear accelerator-based system. Patients who underwent subtotal resection, single-dose SRS to the resection cavity, or were treated with a fractionation schedule other than 5 or 10 fractions, were excluded. RESULTS Twenty-six patients were treated with 5 fractions and 15 patients with 10 fractions. The median planning target volume was 19.78 cm3 (12.3-28 cm3) to the 5-fraction group and 29.79 cm3 (26.3-47.6 cm3) to the 10-fraction group (P = 0.020). The 1-year and 2-year local control rates for all patients were 89.4% and 77.1%, respectively, and 89.6% and 78.6% were free from distant intracranial progression, respectively. No difference was observed in local control or freedom from distant intracranial progression between the 5-fraction or 10-fraction groups. The median overall survival was 28.27 months (95% confidence interval, 19.42-37.12) for all patients. No patient developed necrosis at the resection cavity. CONCLUSIONS Fractionation offers the potential to exploit the different biological responses between neoplastic and normal tissues to ionizing radiation. The use of 5 daily doses of 5-6 Gy or 10 daily doses of 3 Gy is a good strategy to have a reasonable local control and avoid neurotoxicity.
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36
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Latorzeff I, Antoni D, Gaudaire-Josset S, Feuvret L, Tallet-Richard A, Truc G, Noël G. Radiothérapie des métastases cérébrales. Cancer Radiother 2016; 20 Suppl:S80-7. [DOI: 10.1016/j.canrad.2016.07.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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38
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Wernicke AG, Smith AW, Taube S, Yondorf MZ, Parashar B, Trichter S, Nedialkova L, Sabbas A, Christos P, Ramakrishna R, Pannullo SC, Stieg PE, Schwartz TH. Cesium-131 brachytherapy for recurrent brain metastases: durable salvage treatment for previously irradiated metastatic disease. J Neurosurg 2016; 126:1212-1219. [PMID: 27257835 DOI: 10.3171/2016.3.jns152836] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Managing patients whose intraparenchymal brain metastases recur after radiotherapy remains a challenge. Intraoperative cesium-131 (Cs-131) brachytherapy performed at the time of neurosurgical resection may represent an excellent salvage treatment option. The authors evaluated the outcomes of this novel treatment with permanent intraoperative Cs-131 brachytherapy. METHODS Thirteen patients with 15 metastases to the brain that recurred after stereotactic radiosurgery and/or whole brain radiotherapy were treated between 2010 and 2015. Stranded Cs-131 seeds were placed as a permanent volume implant. Prescription dose was 80 Gy at 5-mm depth from the resection cavity surface. The primary end point was resection cavity freedom from progression (FFP). Resection cavity freedom from progression (FFP), regional FFP, distant FFP, median survival, overall survival (OS), and toxicity were assessed. RESULTS The median duration of follow-up after salvage treatment was 5 months (range 0.5-18 months). The patients' median age was 64 years (range 51-74 years). The median resected tumor diameter was 2.9 cm (range 1.0-5.6 cm). The median number of seeds implanted was 19 (range 10-40), with a median activity per seed of 2.25 U (range 1.98-3.01 U) and median total activity of 39.6 U (range 20.0-95.2 U). The 1-year actuarial local FFP was 83.3%. The median OS was 7 months, and 1-year OS was 24.7%. Complications included infection (3), pseudomeningocele (1), seizure (1), and asymptomatic radionecrosis (RN) (1). CONCLUSIONS After failure of prior irradiation of brain metastases, re-irradiation with intraoperative Cs-131 brachytherapy implants provides durable local control and limits the risk of RN. The authors' initial experience demonstrates that this treatment approach is well tolerated and safe for patients with previously irradiated tumors after failure of more than 1 radiotherapy regimen and that it results in excellent response rates and minimal toxicity.
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Affiliation(s)
| | - Andrew W Smith
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | | | | | | | | | | | | | - Paul Christos
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy and Research, and
| | - Rohan Ramakrishna
- Department of Neurosurgery, Weill Medical College of Cornell University, New York; and
| | - Susan C Pannullo
- Department of Neurosurgery, Weill Medical College of Cornell University, New York; and
| | - Philip E Stieg
- Department of Neurosurgery, Weill Medical College of Cornell University, New York; and
| | - Theodore H Schwartz
- Department of Neurosurgery, Weill Medical College of Cornell University, New York; and
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Frameless LINAC-based stereotactic radiation therapy to brain metastasis resection cavity without whole-brain radiation therapy: A systematic review. Pract Radiat Oncol 2016; 6:324-330. [PMID: 26922701 DOI: 10.1016/j.prro.2016.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 12/24/2015] [Accepted: 01/03/2016] [Indexed: 11/23/2022]
Abstract
PURPOSE The aim of this systematic review was to summarize the findings from the published data of frameless stereotactic radiation therapy (RT) to the resection cavity delivered with nonrobotic linear accelerator in patients with brain metastases. METHODS The studies cited in this systematic review were identified through a search of the PubMed database, using the search terms: "stereotactic [Title/Abstract]" and "Brain [Title/Abstract]," and "Metas* [Title/Abstract]." The search was unlimited to language and publication year. RESULTS A total of 9 studies were included in our review. Stereotactic RT to the resection cavity appears to provide excellent local control rates that are comparable to framed stereotactic RT. There are various factors that influence local control. Distant intracranial control rates are poor with the use of postoperative stereotactic RT compared with local treatment (surgery or stereotactic RT) plus whole-brain RT. CONCLUSIONS Stereotactic RT to the resection cavity appears to provide good local control rates and poor distant intracranial control. Postoperative treatment should be discussed by a multidisciplinary team and tailored to each case individually.
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40
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Wernicke AG, Yondorf MZ, Parashar B, Nori D, Clifford Chao KS, Boockvar JA, Pannullo S, Stieg P, Schwartz TH. The cost-effectiveness of surgical resection and cesium-131 intraoperative brachytherapy versus surgical resection and stereotactic radiosurgery in the treatment of metastatic brain tumors. J Neurooncol 2016; 127:145-53. [DOI: 10.1007/s11060-015-2026-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 12/24/2015] [Indexed: 10/22/2022]
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41
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Choi JW, Im YS, Kong DS, Seol HJ, Nam DH, Lee JI. Effectiveness of Postoperative Gamma Knife Radiosurgery to the Tumor Bed After Resection of Brain Metastases. World Neurosurg 2015. [DOI: 10.1016/j.wneu.2015.07.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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42
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Bauman G. Choosing Wisely? "It's Complicated!". Pract Radiat Oncol 2015; 6:71-3. [PMID: 26437834 DOI: 10.1016/j.prro.2015.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 06/02/2015] [Accepted: 06/04/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Glenn Bauman
- Department of Oncology, London Health Sciences Centre and Western University, London, Ontario, Canada.
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43
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Dose painting with Gamma Knife: Two techniques for delivering different doses to areas of recurrent or residual tumor after resection of brain metastases. Pract Radiat Oncol 2015; 5:390-7. [PMID: 26412338 DOI: 10.1016/j.prro.2015.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 08/05/2015] [Accepted: 08/06/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE We investigated the feasibility of using Gamma Knife (GK) radiosurgery for "dose painting" to deliver higher doses to residual or recurrent nodules and surgical cavity after resection of brain metastases. METHODS AND MATERIALS Two integrated boost techniques were developed with GK. The single-target technique delineated both the surgical cavity (cavity) and gross disease (nodule) as a single target. Dose was prescribed to the target with the goal of covering the nodule with a higher dose. The 2-target technique delineated the cavity and nodule as separate target volumes, each prescribed to its own dose and planned separately. Two cases were used to illustrate each technique. The single-target technique was used to deliver 16 Gy to a smaller cavity (7 cm(3)) and a 20-Gy integrated boost to 2 nodules (case 1). The 2-target technique was used to deliver 12 Gy to a larger cavity (21.5 cm(3)) and 20 Gy to a single nodule (case 2). RESULTS For both cases, the cavity coverage with the prescribed dose was 100% with the standard plan and integrated boost techniques. For case 1, compared with a standard plan, the single-target technique improved the 20-Gy nodule coverage from 89.7% (nodule 1) and 97.9% (nodule 2) to 100% (both) and increased the minimum dose from 16.6 Gy to 20.8 Gy (nodule 1) and from 19.4 Gy to 20.8 Gy (nodule 2). For case 2, compared with a standard plan, the 2-target technique improved the 20-Gy nodule coverage from 4% to 100% and the minimum dose from 13.8 Gy to 21 Gy. CONCLUSIONS Both GK integrated boost approaches allowed for effective delivery of higher doses to residual or recurrent nodules in a surgical cavity. In our experience, the single-target technique works well for small cavities, whereas the 2-target technique is well suited for larger cavities.
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Abstract
Brain metastases (BMs) occur in 10% to 20% of adult patients with cancer, and with increased surveillance and improved systemic control, the incidence is likely to grow. Despite multimodal treatment, prognosis remains poor. Current evidence supports use of whole-brain radiation therapy when patients present with multiple BMs. However, its associated cognitive impairment is a major deterrent in patients likely to live longer than 6 months. In patients with oligometastases (one to three metastases) and even some with multiple lesions less than 3 to 4 cm, especially if the primary tumor is considered radiotherapy resistant, stereotactic radiosurgery is recommended; if the BMs are greater than 4 cm, surgical resection with or without postoperative whole-brain radiation therapy should be considered. There is increasing evidence that systemic therapy, including targeted therapy and immunotherapy, is effective against BM and may be an early choice, especially in patients with sensitive primary tumors. In patients with progressive systemic disease, limited treatment options, and poor performance status, best supportive care may be appropriate. Regardless of treatment goals, use of corticosteroids or antiepileptic medications is helpful in symptomatic patients. In this review, we provide a summary of current therapy, as well as developments in the treatment of BM from solid tumors.
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Affiliation(s)
- Xuling Lin
- All authors: Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lisa M DeAngelis
- All authors: Memorial Sloan Kettering Cancer Center, New York, NY.
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45
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The treatment of patients with 1-3 brain metastases: is there a place for whole brain radiotherapy alone, yet? A retrospective analysis. Radiol Med 2015; 120:1146-52. [PMID: 25917339 DOI: 10.1007/s11547-015-0542-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 04/16/2015] [Indexed: 10/23/2022]
Abstract
AIM To evaluate the efficacy of whole brain radiotherapy (WBRT) with or without other treatments in patients (pts) with 1-3 brain metastases (BM). MATERIALS AND METHODS Toxicities and survival of 134 pts treated between 2009 and 2013 with WBRT alone (58 pts), WBRT plus surgery (SUR-WBRT: 42 pts) or WBRT followed by stereotactic or integrated boost radiotherapy (SRT-WBRT: 34 pts) were analyzed. Differences in toxicity (acute and late) incidence and in overall (OS), disease-free (DFS) and disease-specific survival (DSS) were evaluated (χ(2)-test, uni- and multivariate analysis). RESULTS Pts given intensified treatments (SUR- and SBRT-WBRT) had better 3-month local response compared to WBRT alone group (p < 0.045). Better 1-year local control was evident only in SRT-WBRT pts (p < 0.035). Univariate OS analysis confirmed, as favorable prognostic factors, RPA class I (p < 0.001), GPA class III and IV (p < 0.001), single metastasis (p = 0.045), stable primary disease (p = 0.03), intensified treatment (p = 0.000), systemic therapy after radiotherapy (p = 0.04) and response of metastatic lesions (p = 0.002). At multivariate analysis, OS was better in RPA class I pts (p = 0.002), who had more aggressive radiotherapy treatments (p = 0.001), chemotherapy after radiotherapy (p < 0.001) and response to RT (p = 0.003). Response to radiotherapy (p = 0.002) and BM number (p < 0.001) resulted independently prognostic for DFS. About 60 % of patients had mild acute toxicity (G1), especially headache (51 %) and fatigue (34 %); only 2 patients (2 %) had severe (G3) headache and 5 patients (4 %) severe fatigue (G3) reversible with oral steroids. No differences were evident between the different treatment groups. Among 80 pts followed up with MRI, 12 (15 %) had leukoencephalopathy (equally distributed across subgroups) and 5 (6 %) radionecroses, 4/5 asymptomatic, 5/5 in pts given intensified treatments. CONCLUSIONS This analysis confirms the known prognostic factors for BM, emphasizing the importance of intensified treatments in a population with favorable features.
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Amsbaugh MJ, Boling W, Woo S. Tumor bed radiosurgery: an emerging treatment for brain metastases. J Neurooncol 2015; 123:197-203. [PMID: 25911296 DOI: 10.1007/s11060-015-1789-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 04/20/2015] [Indexed: 11/26/2022]
Abstract
While typically used for treating small intact brain metastases, an increasing body of literature examining tumor bed directed stereotactic radiosurgery (SRS) is emerging. There are now over 1000 published cases treated with this approach, and the first prospective trial was recently published. The ideal sequencing of tumor bed SRS is unclear. Current approaches include, a neoadjuvant treatment before resection, alone as an adjuvant after resection, and following surgery combined with whole brain radiotherapy either as an adjuvant or salvage treatment. Based on available evidence, adjuvant stereotactic radiosurgery improves local control following surgery, reduces the number of patients who require whole brain radiotherapy, and is well tolerated. While results from published series vary, heterogeneity in both patient populations and methods of reporting results make comparisons difficult. Additional prospective data, including randomized trials are needed to confirm equivalent outcomes to the current standard of care. We review the current literature, identify areas of ongoing contention, and highlight ongoing studies.
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Affiliation(s)
- Mark J Amsbaugh
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville, 529 S. Jackson Street, Louisville, KY, 40206, USA,
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Ahmed Z, Balagamwala E, Murphy E, Angelov L, Suh J, Lo S, Chao S. Postoperative stereotactic radiosurgery for resected brain metastasis. CNS Oncol 2015; 3:199-207. [PMID: 25055128 DOI: 10.2217/cns.14.18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Despite therapeutic advances in management, the prognosis of patients with brain metastasis remains dismal. Treatment options include surgical resection, whole brain radiation therapy (WBRT), and stereotactic radiosurgery (SRS). Patients who undergo surgical resection typically receive WBRT as adjuvant therapy. However, several studies have demonstrated an association between WBRT and neurotoxicity. Thus, clinicians are increasingly delaying WBRT in favor of postoperative use of SRS. In this review, we will discuss the current literature exploring the efficacy and toxicity of postoperative SRS in the treatment of patients with resected brain metastasis.
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Affiliation(s)
- Zain Ahmed
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
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Quigley MR, Bello N, Jho D, Fuhrer R, Karlovits S, Buchinsky FJ. Estimating the Additive Benefit of Surgical Excision to Stereotactic Radiosurgery in the Management of Metastatic Brain Disease. Neurosurgery 2015; 76:707-12; discussion 712-3. [DOI: 10.1227/neu.0000000000000707] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
There are limited data on the benefits of surgical tumor resection plus stereotactic radiosurgery (SRS) in comparison with SRS alone for patients with oligometastatic brain disease.
OBJECTIVE:
To determine the benefit of adding resection to SRS.
METHODS:
We reviewed 162 consecutive patients with oligometastatic brain disease, who underwent surgical tumor resection and SRS boost (n = 49) or SRS alone (n = 113). Patients receiving prior whole brain radiation therapy were excluded. Factors related to patient survival and time-to-local recurrence (TTLR) were determined by Cox regression. The effect of complete resection + SRS boost on survival was further explored by propensity score matching.
RESULTS:
The average age of the cohort was 65.3 years, it was 49.4% female, and included 260 brain tumors, of which 119 tumors were single. Seventy-three brain tumors recurred (28%). TTLR was related to radiation-sensitive pathology (hazards ratio [HR] = 0.34, P = .001), treatment volume (HR = 1.078/mL, P = .002), and complete tumor resection (HR = 0.37, P = .015). Factors related to survival were age (HR = 1.21/decade, P = .037), Eastern Cooperative Oncology Group performance score (HR = 1.9, P = .001), and complete surgical resection (HR = 0.55, P = .01). Propensity score matched analysis of complete surgical resection + SRS boost (n = 40) vs SRS alone (n = 80) yielded nearly identical survival results (HR = 0.52, P = .030) compared with the initial unmatched sample. Incomplete tumor resection had both median survival and TTLR equivalent to SRS alone.
CONCLUSION:
Complete surgical resection + SRS boost is associated with improved survival and reduced likelihood of local tumor recurrence in comparison with SRS alone. Incomplete resection did not improve survival or TTLR compared with SRS alone.
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Affiliation(s)
| | - Nicholas Bello
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Diana Jho
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Russell Fuhrer
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Stephen Karlovits
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Farrel J. Buchinsky
- Department of Pediatric Otolaryngology, Allegheny General Hospital, Pittsburgh, Pennsylvania
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49
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Dhermain F, Reyns N, Colin P, Métellus P, Mornex F, Noël G. Radiothérapie en conditions stéréotaxiques des métastases cérébrales. Cancer Radiother 2015; 19:25-9. [DOI: 10.1016/j.canrad.2014.12.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 12/02/2014] [Indexed: 11/17/2022]
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50
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Iorio-Morin C, Masson-Côté L, Ezahr Y, Blanchard J, Ebacher A, Mathieu D. Early Gamma Knife stereotactic radiosurgery to the tumor bed of resected brain metastasis for improved local control. J Neurosurg 2015; 121 Suppl:69-74. [PMID: 25434939 DOI: 10.3171/2014.7.gks141488] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Optimal case management after surgical removal of brain metastasis remains controversial. Although postoperative whole-brain radiation therapy (WBRT) has been shown to prevent local recurrence and decrease deaths, this modality can substantially decrease neurocognitive function and quality of life. Stereotactic radiosurgery (SRS) can theoretically achieve the same level of local control with fewer side effects, although studies conclusively demonstrating such outcomes are lacking. To assess the effectiveness and safety profile of tumor bed SRS after resection of brain metastasis, the authors performed a retrospective analysis of 110 patients who had received such treatment at the Centre Hospitalier Universitaire de Sherbrooke. They designed the study to identify risk factors for local recurrence and placed special emphasis on factors that could potentially be addressed. METHODS Patients who had received treatment from 2004 through 2013 were included if they had undergone surgical removal of 1 or more brain metastases and if the tumor bed was treated by SRS regardless of the extent of resection or prior WBRT. All cases were retrospectively analyzed for patient and tumor-specific factors, treatment protocol, adverse outcomes, cavity outcomes, and survival for as long as follow-up was available. Univariate and multivariate Cox regression analyses were performed to identify risk factors for local recurrence and predictors of increased survival times. RESULTS Median patient age at first SRS treatment was 58 years (range 37-84 years). The most frequently diagnosed primary tumor was non-small cell lung cancer. The rate of gross-total resection was 81%. The median Karnofsky Performance Scale score was 90%. Tumor bed SRS was performed at a median of 3 weeks after surgery. Median follow-up and survival times were 10 and 11 months, respectively. Actuarial local control of the cavity at 12 months was 73%; median time to recurrence was 6 months. According to multivariate analysis, risk factors for recurrence were a longer surgery-to-SRS delay (HR 1.625, p = 0.003) and a lower maximum radiation dose delivered to the cavity (HR 0.817, p = 0.006). Factors not associated with increased recurrence were subtotal or piecemeal resections, prior WBRT, histology of the primary tumor, and larger cavity volume. No factors predictive of survival were identified. Symptomatic radiation-induced enhancement occurred in 6% of patients and leptomeningeal dissemination in 11%. Pathologically confirmed radiation-induced necrosis occurred in 1 (0.9%) patient. CONCLUSIONS Adjuvant tumor bed SRS after the resection of brain metastasis is a valuable alternative to adjuvant WBRT. Risk factors for local recurrence are lower maximum radiation dose and a surgery-to-SRS delay longer than 3 weeks. Outcomes were not worse for patients who had undergone prior WBRT and subtotal or piecemeal resections. Pending the results of prospective randomized controlled trials, the authors' study supports the safety and efficacy of adjuvant SRS after resection of brain metastasis. SRS should be performed as early as possible, ideally within 3 weeks of the surgery.
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