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McCutcheon IE. Stereotactic Radiosurgery to Prevent Local Recurrence of Brain Metastasis After Surgery: Neoadjuvant Versus Adjuvant. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 128:85-100. [PMID: 34191064 DOI: 10.1007/978-3-030-69217-9_9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Over the past 15-20 years, stereotactic radiosurgery (SRS) has become the dominant method for treating patients with brain metastases (BM). The role of surgery for management of large tumors also remains important. Combining these two treatment modalities may well achieve the best local control, safety, and symptomatic relief in cases of neoplasms for which resection is desirable. After 10 years of retrospective studies that suggested patients might do better if surgery were followed by early adjuvant SRS, a prospective, randomized, controlled trial was conducted to compare such treatment with postoperative observation after tumor removal, and it showed significantly better local control in the former cohort, especially in smaller lesions, but no difference in overall survival. On the other hand, in the past 5 years, some groups have argued that neoadjuvant SRS before resection of BM might be superior to adjuvant SRS, while no clinical trial has yet been concluded that compares these two treatment strategies. For now, adjuvant and neoadjuvant SRS show evidence of utility in achieving better local control after surgical removal of BM in comparison with surgery alone, but no specific guidelines exist favoring one method over the other, and both should be considered beneficial in clinical care.
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Affiliation(s)
- Ian E McCutcheon
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Andreou T, Rippaus N, Wronski K, Williams J, Taggart D, Cherqui S, Sunderland A, Kartika YD, Egnuni T, Brownlie RJ, Mathew RK, Holmen SL, Fife C, Droop A, Lorger M. Hematopoietic Stem Cell Gene Therapy for Brain Metastases Using Myeloid Cell-Specific Gene Promoters. J Natl Cancer Inst 2020; 112:617-627. [PMID: 31501884 PMCID: PMC7301153 DOI: 10.1093/jnci/djz181] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 07/16/2019] [Accepted: 09/04/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Brain metastases (BrM) develop in 20-40% of cancer patients and represent an unmet clinical need. Limited access of drugs into the brain because of the blood-brain barrier is at least partially responsible for therapeutic failure, necessitating improved drug delivery systems. METHODS Green fluorescent protein (GFP)-transduced murine and nontransduced human hematopoietic stem cells (HSCs) were administered into mice (n = 10 and 3). The HSC progeny in mouse BrM and in patient-derived BrM tissue (n = 6) was characterized by flow cytometry and immunofluorescence. Promoters driving gene expression, specifically within the BrM-infiltrating HSC progeny, were identified through differential gene-expression analysis and subsequent validation of a series of promoter-green fluorescent protein-reporter constructs in mice (n = 5). One of the promoters was used to deliver tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) to BrM in mice (n = 17/21 for TRAIL vs control group). RESULTS HSC progeny (consisting mostly of macrophages) efficiently homed to macrometastases (mean [SD] = 37.6% [7.2%] of all infiltrating cells for murine HSC progeny; 27.9% mean [SD] = 27.9% [4.9%] of infiltrating CD45+ hematopoietic cells for human HSC progeny) and micrometastases in mice (19.3-53.3% of all macrophages for murine HSCs). Macrophages were also abundant in patient-derived BrM tissue (mean [SD] = 8.8% [7.8%]). Collectively, this provided a rationale to optimize the delivery of gene therapy to BrM within myeloid cells. MMP14 promoter emerged as the strongest promoter construct capable of limiting gene expression to BrM-infiltrating myeloid cells in mice. TRAIL delivered under MMP14 promoter statistically significantly prolonged survival in mice (mean [SD] = 19.0 [3.4] vs mean [SD] = 15.0 [2.0] days for TRAIL vs control group; two-sided P = .006), demonstrating therapeutic and translational potential of our approach. CONCLUSIONS Our study establishes HSC gene therapy using a myeloid cell-specific promoter as a new strategy to target BrM. This approach, with strong translational value, has potential to overcome the blood-brain barrier, target micrometastases, and control multifocal lesions.
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Affiliation(s)
| | - Nora Rippaus
- School of Medicine, University of Leeds, Leeds, UK
| | | | | | | | | | | | | | - Teklu Egnuni
- School of Medicine, University of Leeds, Leeds, UK
| | | | - Ryan K Mathew
- School of Medicine, University of Leeds, Leeds, UK
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sheri L Holmen
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | | | - Alastair Droop
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
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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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Higuchi Y, Yamamoto M, Serizawa T, Aiyama H, Sato Y, Barfod BE. Modern management for brain metastasis patients using stereotactic radiosurgery: literature review and the authors' gamma knife treatment experiences. Cancer Manag Res 2018; 10:1889-1899. [PMID: 30013395 PMCID: PMC6038887 DOI: 10.2147/cmar.s116718] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Historically, whole brain radiotherapy was administered to most patients with brain metastases. However, over the past three decades, stereotactic radiosurgery (SRS), targeted at individual cranial lesions, has been accepted widely. In this study, based on the authors' experiences along with published data, recent trends in SRS for brain metastases are discussed. This article focuses on the following issues: 1) How many tumors can or should be treated with SRS? 2) Two-/three-staged SRS for relatively large tumors, 3) post- or preoperative SRS, and 4) repeat SRS.
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Affiliation(s)
- Yoshinori Higuchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | | | - Toru Serizawa
- Tokyo Gamma Unit Center, Tsukiji Neurological Clinic, Tokyo, Japan
| | | | - Yasunori Sato
- Department of Global Clinical Research, Chiba University Graduate School of Medicine, Chiba, Japan
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Tsao MN, Rades D, Wirth A, Lo SS, Danielson BL, Gaspar LE, Sperduto PW, Vogelbaum MA, Radawski JD, Wang JZ, Gillin MT, Mohideen N, Hahn CA, Chang EL. Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es): An American Society for Radiation Oncology evidence-based guideline. Pract Radiat Oncol 2012; 2:210-225. [PMID: 25925626 PMCID: PMC3808749 DOI: 10.1016/j.prro.2011.12.004] [Citation(s) in RCA: 421] [Impact Index Per Article: 35.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 12/09/2011] [Accepted: 12/15/2011] [Indexed: 12/25/2022]
Abstract
Purpose To systematically review the evidence for the radiotherapeutic and surgical management of patients newly diagnosed with intraparenchymal brain metastases. Methods and Materials Key clinical questions to be addressed in this evidence-based Guideline were identified. Fully published randomized controlled trials dealing with the management of newly diagnosed intraparenchymal brain metastases were searched systematically and reviewed. The U.S. Preventative Services Task Force levels of evidence were used to classify various options of management. Results The choice of management in patients with newly diagnosed single or multiple brain metastases depends on estimated prognosis and the aims of treatment (survival, local treated lesion control, distant brain control, neurocognitive preservation). Single brain metastasis and good prognosis (expected survival 3 months or more): For a single brain metastasis larger than 3 to 4 cm and amenable to safe complete resection, whole brain radiotherapy (WBRT) and surgery (level 1) should be considered. Another alternative is surgery and radiosurgery/radiation boost to the resection cavity (level 3). For single metastasis less than 3 to 4 cm, radiosurgery alone or WBRT and radiosurgery or WBRT and surgery (all based on level 1 evidence) should be considered. Another alternative is surgery and radiosurgery or radiation boost to the resection cavity (level 3). For single brain metastasis (less than 3 to 4 cm) that is not resectable or incompletely resected, WBRT and radiosurgery, or radiosurgery alone should be considered (level 1). For nonresectable single brain metastasis (larger than 3 to 4 cm), WBRT should be considered (level 3). Multiple brain metastases and good prognosis (expected survival 3 months or more): For selected patients with multiple brain metastases (all less than 3 to 4 cm), radiosurgery alone, WBRT and radiosurgery, or WBRT alone should be considered, based on level 1 evidence. Safe resection of a brain metastasis or metastases causing significant mass effect and postoperative WBRT may also be considered (level 3). Patients with poor prognosis (expected survival less than 3 months): Patients with either single or multiple brain metastases with poor prognosis should be considered for palliative care with or without WBRT (level 3). It should be recognized, however, that there are limitations in the ability of physicians to accurately predict patient survival. Prognostic systems such as recursive partitioning analysis, and diagnosis-specific graded prognostic assessment may be helpful. Conclusions Radiotherapeutic intervention (WBRT or radiosurgery) is associated with improved brain control. In selected patients with single brain metastasis, radiosurgery or surgery has been found to improve survival and locally treated metastasis control (compared with WBRT alone).
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Affiliation(s)
- May N Tsao
- Department of Radiation Oncology, University of Toronto, Odette Cancer Centre, Toronto, Ontario, Canada.
| | - Dirk Rades
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Luebeck, Germany (ESTRO representative)
| | - Andrew Wirth
- Peter MacCallum Cancer Center, Trans Tasman Radiation Oncology Group (TROG), East Melbourne, Australia
| | - Simon S Lo
- Department of Radiation Oncology, Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Brita L Danielson
- Department of Radiation Oncology, Cross Cancer Institute, University of Alberta, Edmonton, Canada (CARO representative)
| | - Laurie E Gaspar
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - Paul W Sperduto
- University of Minnesota Gamma Knife Center and Minneapolis Radiation Oncology, Minneapolis, Minnesota
| | | | | | - Jian Z Wang
- Department of Radiation Oncology, Ohio State University, Columbus, Ohio (deceased)
| | - Michael T Gillin
- Department of Radiation Oncology, M.D. Anderson Cancer Center, Houston, Texas
| | - Najeeb Mohideen
- Department of Radiation Oncology, Northwest Community Hospital, Arlington Heights, Illinois
| | - Carol A Hahn
- Department of Radiation Oncology, Duke University Medical School, Durham, North Carolina
| | - Eric L Chang
- Department of Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, California
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Hashimoto K, Narita Y, Miyakita Y, Ohno M, Sumi M, Mayahara H, Kayama T, Shibui S. Comparison of Clinical Outcomes of Surgery Followed by Local Brain Radiotherapy and Surgery Followed by Whole Brain Radiotherapy in Patients With Single Brain Metastasis: Single-Center Retrospective Analysis. Int J Radiat Oncol Biol Phys 2011; 81:e475-80. [DOI: 10.1016/j.ijrobp.2011.02.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Revised: 01/28/2011] [Accepted: 02/02/2011] [Indexed: 10/18/2022]
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Mathieu D, Kondziolka D, Flickinger JC, Fortin D, Kenny B, Michaud K, Mongia S, Niranjan A, Lunsford LD. Tumor bed radiosurgery after resection of cerebral metastases. Neurosurgery 2008; 62:817-23; discussion 823-4. [PMID: 18414136 DOI: 10.1227/01.neu.0000316899.55501.8b] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Adjuvant irradiation after resection of brain metastases reduces the risk of local recurrence. Whole-brain radiation therapy can be associated with significant neurotoxicity in long-term survivors of brain metastases. This retrospective study evaluates the role of tumor bed stereotactic radiosurgery as an alternative method of irradiation after initial resection of brain metastases to prevent local recurrence. METHODS Forty patients underwent tumor bed radiosurgery after resection of brain metastases at two separate academic medical centers. The median age was 59.5 years. Twenty patients (67.5%) had single metastases. Resection was complete in 80% and partial in 20% of the patients. At the time of radiosurgery, systemic disease was active in 57.5%, inactive in 32.5%, and in remission in 10% of the patients. The median Karnofsky Performance Scale score was 80% (range, 60-100%). Radiosurgery was performed a median of 4 weeks after tumor resection. The median cavity radiosurgery volume was 9.1 ml (range, 0.6-39.9 ml). The median margin and maximum radiation dose were 16 and 32 Gy, respectively. RESULTS Local control at the resection site was achieved in 73% of patients at a median follow-up period of 13 months. No variable significantly affected local control. New remote brain metastases occurred in 54% of the patients. Symptomatic radiation effect was seen in 5.4% of the patients. The median survival was 13 months after radiosurgery (range, 2-56 mo). CONCLUSION Tumor bed radiosurgery provides effective local control of the tumor after resection in most patients. These preliminary data support radiosurgery after resection rather than traditional radiation therapy.
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Affiliation(s)
- David Mathieu
- Division of Neurosurgery/Neuro-oncology, Centre Hospitalier University of Sherbrooke, Sherbrooke, Canada.
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Wan J, Milosevic M, Brade AM. Use of palliative radiotherapy trials for clinical biomarker development. Cancer Metastasis Rev 2008; 27:435-43. [PMID: 18392923 DOI: 10.1007/s10555-008-9132-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Approximately one quarter of all cancer patients will require palliative radiation treatment at some point during the course of their disease, but only a minority of these patients are entered in clinical trials. ETHICAL ASSESSMENT OF BIOMARKERS IN PALLIATIVE RADIOTHERAPY TRIALS We review the literature debating the ethics of inclusion of "palliative" patients on clinical trials. We suggest that these patients provide a potentially valuable resource that can be leveraged to facilitate the discovery and validation of biomarkers predictive of radiation response and toxicity. In addition, this patient population offers valuable opportunities to test combination of radiation and targeted therapies to screen for activity, toxicity and biomarkers in a relatively safe manner. CONCLUSION Patients undergoing palliative radiation therapy may provide new opportunities for the development and testing of predictive radiotherapy biomarkers as well as affording opportunities to test combinations of radiation and targeted therapies.
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Affiliation(s)
- Jonathan Wan
- Radiation Medicine Program, Princess Margaret Hospital, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
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