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Local Ablative Therapies for Oligometastatic and Oligoprogressive Non-Small Cell Lung Cancer. ACTA ACUST UNITED AC 2021; 26:129-136. [PMID: 32205537 DOI: 10.1097/ppo.0000000000000433] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
More than half of all patients with non-small cell lung cancer (NSCLC) have metastatic disease at the time of diagnosis. A subset of these patients has oligometastatic disease, which exists in an intermediary state between locoregional and disseminated metastatic disease. In addition, some metastatic patients on systemic therapy may have limited disease progression, or oligoprogression. Historically, treatment of metastatic NSCLC was palliative in nature, with little expectation of long-term survival. However, an accumulation of evidence over the past 3 decades now demonstrates that local ablative therapy to sites of limited metastases or progression can improve patient outcomes for this complex disease. This review examines the evidence behind local ablative therapy in oligometastatic and oligoprogressive NSCLC, with a focus on surgery, stereotactic radiotherapy, and radiofrequency ablation.
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Price M, Howell EP, Dalton T, Ramirez L, Howell C, Williamson T, Fecci PE, Anders CK, Check DK, Kamal AH, Goodwin CR. Inpatient palliative care utilization for patients with brain metastases. Neurooncol Pract 2021; 8:441-450. [PMID: 34277022 DOI: 10.1093/nop/npab016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Introduction Given the high symptom burden and complex clinical decision making associated with a diagnosis of brain metastases (BM), specialty palliative care (PC) can meaningfully improve patient quality of life. However, no prior study has formally evaluated patient-specific factors associated with PC consultation among BM patients. Methods We examined the rates of PC consults in a cohort of 1303 patients with BM admitted to three tertiary medical centers from October 2015 to December 2018. Patient demographics, surgical status, 30-day readmission, and death data were collected via retrospective chart review. PC utilization was assessed by identifying encounters for which an inpatient consult to PC was placed. Statistical analyses were performed to compare characteristics and outcomes between patients who did and did not receive PC consults. Results We analyzed 1303 patients admitted to the hospital with BM. The average overall rate of inpatient PC consultation was 19.6%. Rates of PC utilization differed significantly by patient race (17.5% in White/Caucasian vs 26.0% in Black/African American patients, P = .0014). Patients who received surgery during their admission had significantly lower rates of PC consultation (3.9% vs 22.4%, P < .0001). Patients who either died during their admission or were discharged to hospice had significantly higher rates of PC than those who were discharged home or to rehabilitation (P < .0001). Conclusions In our dataset, PC consultation rates varied by patient demographic, surgical status, discharging service, and practice setting. Further work is needed to identify the specific barriers to optimally utilizing specialty PC in this population.
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Affiliation(s)
- Meghan Price
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Elizabeth P Howell
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Tara Dalton
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Luis Ramirez
- Duke Center for Brain and Spine Metastasis, Duke University Medical Center, Durham, North Carolina, USA
| | - Claire Howell
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Theresa Williamson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Carey K Anders
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Devon K Check
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Arif H Kamal
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA.,Fuqua School of Business, Duke University, Durham, North Carolina, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
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3
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Cui Y, Gao H, Zhang J, Kirkpatrick JP, Yin FF. Retrospective quality metrics review of stereotactic radiosurgery plans treating multiple targets using single-isocenter volumetric modulated arc therapy. J Appl Clin Med Phys 2020; 21:93-99. [PMID: 32239746 PMCID: PMC7324703 DOI: 10.1002/acm2.12869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 02/10/2020] [Accepted: 03/09/2020] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To characterize key plan quality metrics in multi-target stereotactic radiosurgery (SRS) plans treated using single-isocenter volumetric modulated arc therapy (VMAT) in comparison to dynamic conformal arc (DCA) plans treating single target. To investigate the feasibility of quality improvement in VMAT planning based on previous planning knowledge. MATERIALS AND METHODS 97 VMAT plans of multi-target and 156 DCA plans of single-target treated in 2017 at a single institution were reviewed. A total of 605 targets were treated with these SRS plans. The prescription dose was normalized to 20 Gy in all plans for this analysis. Two plan quality metrics, target conformity index (CI) and normal tissue volume receiving more than 12 Gy (V12Gy), were calculated for each target. The distribution of V12Gy per target was plotted as a function of the target volume. For multi-target VMAT plans, the number of targets being treated in the same plan and the distance between targets were calculated to evaluate their impact on V12Gy. VMAT plans that had a large deviation of V12Gy from the average level were re-optimized to determine the possibility of reducing the variation of V12Gy in VMAT planning. RESULTS Conformity index of multi-target VMAT plans were lower than that of DCA plans while the mean values of 12 Gy were comparable. The V12Gy for a target in VMAT plan did not show apparent dependence on the total number of targets or the distance between targets. The distribution of V12Gy exhibited a larger variation in VMAT plans compared to DCA plans. Re-optimization of outlier plans reduced V12 Gy by 33.9% and resulted in the V12Gy distribution in VMAT plans more closely resembling that of DCA plans. CONCLUSION The benchmark data on key plan quality metrics were established for single-isocenter multi-target SRS planning. It is feasible to use this knowledge to guide VMAT planning and reduce high V12Gy outliers.
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Affiliation(s)
- Yunfeng Cui
- Department of Radiation Oncology, Duke University, Durham, NC, USA
| | - Hao Gao
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - Jiahan Zhang
- Department of Radiation Oncology, Duke University, Durham, NC, USA
| | | | - Fang-Fang Yin
- Department of Radiation Oncology, Duke University, Durham, NC, USA
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Tumor control and survival in patients with ten or more brain metastases treated with stereotactic radiosurgery: a retrospective analysis. J Neurooncol 2019; 143:167-174. [PMID: 30945049 DOI: 10.1007/s11060-019-03153-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 03/19/2019] [Indexed: 02/03/2023]
Abstract
INTRODUCTION To assess tumor control and survival in patients treated with stereotactic radiosurgery (SRS) for 10 or more metastatic brain tumors. METHODS Patients were retrospectively identified. Clinical records were reviewed for follow-up data, and post-treatment MRI studies were used to assess tumor control. For tumor control studies, patients were separated based on synchronous or metachronous treatment, and control was assessed at 3-month intervals. The Kaplan-Meier method was employed to create survival curves, and regression analyses were employed to study the effects of several variables. RESULTS Fifty-five patients were treated for an average of 17 total metastases. Forty patients received synchronous treatment, while 15 received metachronous treatment. Univariate analysis revealed an association between larger brain volumes irradiated with 12 Gy and decreased overall survival (p = 0.0406); however, significance was lost on multivariate analysis. Among patients who received synchronous treatment, the median percentage of tumors controlled was 100%, 91%, and 82% at 3, 6, and 9 months, respectively. Among patients who received metachronous treatment, the median percentage of tumors controlled after each SRS encounter was 100% at all three time points. CONCLUSIONS SRS can be used to treat patients with 10 or more total brain metastases with an expectation of tumor control and overall survival that is equivalent to that reported for patients with four or fewer tumors. Development of new metastases leading to repeat SRS is not associated with worsened tumor control or survival. Survival may be adversely affected in patients having a higher volume of normal brain irradiated.
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5
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Ferrer C, Huertas C, Plaza R, Aza Z, Corredoira E. Dosimetric effects of a repositioning head frame system and treatment planning system dose calculation accuracy. J Appl Clin Med Phys 2018; 19:124-132. [PMID: 30255659 PMCID: PMC6236818 DOI: 10.1002/acm2.12456] [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] [Received: 07/02/2018] [Revised: 08/16/2018] [Accepted: 08/26/2018] [Indexed: 11/29/2022] Open
Abstract
This work aims to study the effect on surface dose and dose distribution caused by the Elekta Fraxion cranial immobilization system. The effect of Fraxion inclusion in Elekta Monaco treatment planning system and its calculation accuracy is also checked. To study the dose attenuation, a cylindrical phantom was located over the Elekta Fraxion with an IBA CC13 ionization chamber placed in the central insert at the linac isocenter. Dose measurements at multiple gantry angles were performed for three open fields, 10 × 10 cm, 5 × 5 cm and other smaller 2 × 2 cm. Measured doses were compared with the ones calculated by Monaco. Surface dose and dose distribution in the buildup region were measured placing several Gafchromic Films EBT3 at linac CAX between the slabs of a RW3 phantom located over Fraxion and read using FilmQA Pro software. Measures were performed for two open field sizes and results were compared with Monaco calculations. Measurements show a 1% attenuation for 180° gantry angle but it can be as high as 3.4% (5 × 5 open field) for 150°/210° gantry angle, as with these angles the beam goes through the Fraxion's headrest twice. If Fraxion is not included in the calculation Monaco calculation can result in a 3% difference between measured and calculated doses, while with Fraxion in the calculation, the maximum difference is 0.9%. Fraxion increases 3.7 times the surface dose, which can be calculated by Monaco with a difference lower than 2%. Monaco also calculated correctly the PDD for both open fields (2%) when Fraxion is included in the calculation. This work shows that the attenuation varies with gantry angle. The inclusion of Fraxion in Monaco improves the calculation from 3% difference to 1% in the worst case. Furthermore, the surface dose increment and the dose in the buildup region are correctly calculated.
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Affiliation(s)
- Carlos Ferrer
- Department of Medical Physics and Radiation Protection; H.U. La Paz; Madrid Spain
| | - Concepción Huertas
- Department of Medical Physics and Radiation Protection; H.U. La Paz; Madrid Spain
| | - Rodrigo Plaza
- Department of Medical Physics and Radiation Protection; H.U. La Paz; Madrid Spain
| | - Zulima Aza
- Department of Medical Physics and Radiation Protection; H.U. La Paz; Madrid Spain
| | - Eva Corredoira
- Department of Medical Physics and Radiation Protection; H.U. La Paz; Madrid Spain
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6
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Frega S, Bonanno L, Guarneri V, Conte P, Pasello G. Therapeutic perspectives for brain metastases in non-oncogene addicted non-small cell lung cancer (NSCLC): Towards a less dismal future? Crit Rev Oncol Hematol 2018; 128:19-29. [DOI: 10.1016/j.critrevonc.2018.05.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 05/14/2018] [Indexed: 12/16/2022] Open
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Slosarek K, Bekman B, Wendykier J, Grządziel A, Fogliata A, Cozzi L. In silico assessment of the dosimetric quality of a novel, automated radiation treatment planning strategy for linac-based radiosurgery of multiple brain metastases and a comparison with robotic methods. Radiat Oncol 2018; 13:41. [PMID: 29544504 PMCID: PMC5856310 DOI: 10.1186/s13014-018-0997-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 03/11/2018] [Indexed: 11/25/2022] Open
Abstract
Background To appraise the dosimetric features and the quality of the treatment plan for radiosurgery of multiple brain metastases optimized with a novel automated engine and to compare with plans optimized for robotic-based delivery. Methods A set of 15 patients with multiple brain metastases was selected for this in silico study. The technique under investigation is the recently introduced HyperArc. For all patients, three treatment plans were computed and compared: i: a HyperArc; ii: a standard VMAT; iii) a CyberKnife. Dosimetric features were computed for the clinical target volumes as well as for the healthy brain tissue and the organs at risk. Results The data showed that the best dose homogeneity was achieved with the VMAT technique. HyperArc allowed to minimize the volume of brain receiving 4Gy (as well as for the mean dose and the volume receiving 12Gy, although not statistically significant). The smallest dose on 1 cm3 volume for all organs at risk is for CK techniques, and the biggest for VMAT (p < 0.05). The Radiation Planning Index coefficient indicates that, there are no significant differences among the techniques investigated, suggesting an equivalence among these. Conclusion At treatment planning level, the study demonstrates that the use of HyperArc technique can significantly improve the sparing of the healthy brain while maintaining a full coverage of the target volumes.
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Affiliation(s)
- Krzysztof Slosarek
- Department of Radiotherapy Planning, Maria Sklodowska Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Barbara Bekman
- Department of Radiotherapy Planning, Maria Sklodowska Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Jacek Wendykier
- Department of Radiotherapy Planning, Maria Sklodowska Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Aleksandra Grządziel
- Department of Radiotherapy Planning, Maria Sklodowska Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland.,Department of Medical Physics, University of Silesia, Katowice, Poland
| | - Antonella Fogliata
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Hospital, Rozzano, Italy
| | - Luca Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Hospital, Rozzano, Italy. .,Department of Biomedical Sciences, Humanitas University, Rozzano, Italy.
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Jindal V, Gupta S. Expected Paradigm Shift in Brain Metastases Therapy-Immune Checkpoint Inhibitors. Mol Neurobiol 2018; 55:7072-7078. [PMID: 29383686 DOI: 10.1007/s12035-018-0905-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/11/2018] [Indexed: 01/02/2023]
Abstract
Brain metastasis (BM) is one of the dreadful complications of malignancies. The prognosis after BM is extremely poor and life expectancy is meager. Currently, our treatment modalities are limited to radiotherapy and surgical resection, which also has poor outcomes and leads to various neurological deficits and affects the quality of life of patients. New treatment modality, i.e., immune checkpoint inhibitors, has brought revolution in management of melanoma, renal cancer, and non-small cell lung cancer (NSCLC). Immune checkpoint inhibitors basically enhance the immune response of the body to fight against cancers. Immune response in the brain is highly regulated; therefore, it is challenging to use immune-modulator drugs in BM. The microenvironment of BM is rich in cytotoxic T lymphocytes and which is the target of immune checkpoint inhibitors. Few studies have shown some hope regarding use of immune checkpoint inhibitors in management of BM. It works through inhibiting immune check point gates, i.e., CTLA-4 (cytotoxic T-lymphocyte-associated protein) and PD-1/PD-L1 (programmed cell death protein-1/program death ligand-1). This article explains the basic mechanism of immune check point inhibitors, rationale behind their usage in BM, and some of the clinical studies which have shown the efficacy of immune check point inhibitors in BM.
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Affiliation(s)
- Vishal Jindal
- St. Vincent Hospital, 123 Summer Street, Worcester, 01608, USA.
| | - Sorab Gupta
- Einstein Medical Center, 5501 Old York Rd, Philadelphia, 19141, USA
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Single fraction stereotactic radiosurgery for multiple brain metastases. Adv Radiat Oncol 2017; 2:555-563. [PMID: 29204522 PMCID: PMC5707418 DOI: 10.1016/j.adro.2017.09.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 08/27/2017] [Accepted: 09/05/2017] [Indexed: 12/25/2022] Open
Abstract
Introduction Due to the neurocognitive side effects of whole brain radiation therapy (WBRT), stereotactic radiosurgery (SRS) is being used with increasing frequency. The use of SRS is expanding for patients with multiple (>4) brain metastases (BM). This study summarizes our institutional experience with single-fraction, linear-accelerator-based SRS for multiple BM. Methods and materials All patients who were treated between January 1, 2013, and September 30, 2015, with single-fraction SRS for ≥4 BM were included in this institutional review board–approved, retrospective, single-institution study. Patients were treated with linear accelerator–based image guided SRS. Results A total of 59 patients with ≥4 BM were treated with single-fraction SRS. The median follow-up was 15.2 months, and the median overall survival for the entire cohort was 5.8 months. The median number of treated lesions per patient was 5 (range, 4-23). Per patient, the median planning target volume (PTV) was 4.8 cc (range, 0.7-28.8 cc). The prescribed dose across all 380 BM for the 59 patients ranged from 7 to 20 Gy. The median of the mean dose to the total PTV was 19.5 Gy. Although the number of treated lesions (4-5 vs ≥6) did not influence survival, better survival was noted for a total PTV <10 cc versus ≥10 cc (7.1 vs 4.2 months, respectively; P = .0001). A mean dose of ≥19 Gy to the entire PTV was also associated with increased survival (6.6 vs 5.0 months, respectively; P = .0172). Patients receiving a dose of >12 Gy to ≥10 cc of normal brain had worse survival (5.1 vs 8.6 months, respectively; P = .0028). Conclusion In single-fraction SRS for patients with multiple BM, smaller total tumor volume, higher total dose, and lower volume of normal brain receiving >12 Gy were associated with increased survival. These data suggest that using SRS for the treatment of multiple BM is efficacious and that outcomes may be affected more by total tumor volume than by the number of lesions.
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Westphal D, Glitza Oliva IC, Niessner H. Molecular insights into melanoma brain metastases. Cancer 2017; 123:2163-2175. [PMID: 28543697 DOI: 10.1002/cncr.30594] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 12/19/2016] [Accepted: 12/28/2016] [Indexed: 01/26/2023]
Abstract
Substantial proportions of patients with metastatic melanoma develop brain metastases during the course of their disease, often resulting in significant morbidity and death. Despite recent advances with BRAF/MEK and immune-checkpoint inhibitors in the treatment of patients who have melanoma with extracerebral metastases, patients who have melanoma brain metastases still have poor overall survival, highlighting the need for further therapy options. A deeper understanding of the molecular pathways involved in the development of melanoma brain metastases is required to develop more brain-specific therapies. Here, the authors summarize the currently known preclinical data and describe steps involved in the development of melanoma brain metastases. Only by knowing the molecular background is it possible to design new therapeutic agents that can be used to improve the outcome of patients with melanoma brain metastases. Cancer 2017;123:2163-75. © 2017 American Cancer Society.
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Affiliation(s)
- Dana Westphal
- Department of Dermatology, Carl Gustav Carus Medical Center, Technical University of Dresden, Dresden, Germany.,Center for Regenerative Therapies, Technical University of Dresden, Dresden, Germany
| | - Isabella C Glitza Oliva
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Heike Niessner
- Department of Dermatology, University Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
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Perilesional edema in brain metastasis from non-small cell lung cancer (NSCLC) as predictor of response to radiosurgery (SRS). Neurol Sci 2017; 38:975-982. [PMID: 28260188 DOI: 10.1007/s10072-017-2876-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 02/24/2017] [Indexed: 01/08/2023]
Abstract
Radiosurgery (SRS) is widely used in the treatment of brain oligo-metastases from NSCLC. The aim of present study is to evaluate the extent of perilesional edema in brain metastases as predictive factor of treatment response. This single center retrospective study included 42 consecutive patients (January 2011-December 2014) with 1-2 brain metastasis from NSCLC treated with Radiosurgery (SRS). Extent of perilesional edema was measured as maximal extension from the edge of lesion and classified as minor (<10 mm) or major (≥10 mm). We analyzed Modality of Brain Recurrence (MBR), classified as in-field or out-of- field, and Brain Progression Free-Survival (BPFS) after treatment stratified according to extent of perilesional edema. Analyzing modality of brain recurrence and BPFS, after a median follow-up of 6 months, we found that patients with minor edema had a better radiological response to SRS with none in-field recurrences and a lower risk of the onset of new brain lesions (out-of-field recurrence). Instead, patients group with major edema had a worse response rate of lesions treated, further, a higher risk of out-of-field brain relapse. Extent of perilesional edema in brain metastasis from NSCLC could be a predictive factor of response and brain progression after SRS treatment alone.
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12
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Optimization of Treatment Geometry to Reduce Normal Brain Dose in Radiosurgery of Multiple Brain Metastases with Single-Isocenter Volumetric Modulated Arc Therapy. Sci Rep 2016; 6:34511. [PMID: 27688047 PMCID: PMC5043272 DOI: 10.1038/srep34511] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 09/15/2016] [Indexed: 11/09/2022] Open
Abstract
Treatment of patients with multiple brain metastases using a single-isocenter volumetric modulated arc therapy (VMAT) has been shown to decrease treatment time with the tradeoff of larger low dose to the normal brain tissue. We have developed an efficient Projection Summing Optimization Algorithm to optimize the treatment geometry in order to reduce dose to normal brain tissue for radiosurgery of multiple metastases with single-isocenter VMAT. The algorithm: (a) measures coordinates of outer boundary points of each lesion to be treated using the Eclipse Scripting Application Programming Interface, (b) determines the rotations of couch, collimator, and gantry using three matrices about the cardinal axes, (c) projects the outer boundary points of the lesion on to Beam Eye View projection plane, (d) optimizes couch and collimator angles by selecting the least total unblocked area for each specific treatment arc, and (e) generates a treatment plan with the optimized angles. The results showed significant reduction in the mean dose and low dose volume to normal brain, while maintaining the similar treatment plan qualities on the thirteen patients treated previously. The algorithm has the flexibility with regard to the beam arrangements and can be integrated in the treatment planning system for clinical application directly.
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Nardone V, Tini P, Biondi M, Sebaste L, Vanzi E, De Otto G, Rubino G, Carfagno T, Battaglia G, Pastina P, Cerase A, Mazzoni LN, Banci Buonamici F, Pirtoli L. Prognostic Value of MR Imaging Texture Analysis in Brain Non-Small Cell Lung Cancer Oligo-Metastases Undergoing Stereotactic Irradiation. Cureus 2016; 8:e584. [PMID: 27226944 PMCID: PMC4876005 DOI: 10.7759/cureus.584] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
UNLABELLED BACKGROUND : Stereotactic irradiation is widely used in brain oligo-metastases treatment. The aim of this study is to evaluate the prognostic value of magnetic resonance imaging (MRI) texture analysis (TA) of brain metastases (BM) of non-small cell lung cancer (NSCLC). MATERIALS AND METHODS : This study included thirty-eight consecutive patients undergoing stereotactic irradiation, that is, stereotactic fractionated radiotherapy (SRT) or radiosurgery (SRS), from January 2011 to December 2014 for 1-2 brain BM from NSCLC. Whole-brain radiotherapy (WBRT) was not delivered. The diagnostic MRI DICOM (Digital Imaging and Communications in Medicine) images were collected and analyzed with a homemade ImageJ macro, and typical TA parameters (mean, standard deviation, skewness, kurtosis, entropy, and uniformity) were evaluated for: brain progression-free survival; modality of brain metastatic progression (local progression or/and new metastases); and overall survival, after SRT/SRS. RESULTS After SRT/SRS 14 patients (36.8%) experienced recurrence in the brain, with a recurrence in the irradiated site (five patients, 13.2%), new metastases (11 patients, 28.9%), local recurrence and new metastases (two patients, 5.25%). Nineteen patients (50%) died of tumor progression or other causes. Entropy and uniformity were significantly associated with local progression, whereas kurtosis was significantly associated with both local progression and new brain metastases. CONCLUSIONS : These results appear promising, since the knowledge of factors correlated with the modality of brain progression after stereotactic irradiation of brain oligo-metastatic foci of NSCLC might help in driving the best treatment in these patients (association of SRT/SRS with WBRT? Increase of SRT/SRS dose?). Our preliminary data needs confirmation in large patient series.
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Affiliation(s)
- Valerio Nardone
- Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy
| | - Paolo Tini
- Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy
| | | | - Lucio Sebaste
- Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy
| | - Eleonora Vanzi
- Department of Medical Physics, University Hospital of Siena, Siena, Italy
| | - Gianmarco De Otto
- Department of Medical Physics, University Hospital of Siena, Siena, Italy
| | - Giovanni Rubino
- Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy
| | - Tommaso Carfagno
- Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy
| | | | - Pierpaolo Pastina
- Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy
| | - Alfonso Cerase
- Unit of Neuro Radiology, University Hospital of Siena, Siena, Italy
| | | | | | - Luigi Pirtoli
- Unit of Radiation Oncology, University Hospital of Siena, Siena, Italy
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Treatment of high numbers of brain metastases with Gamma Knife radiosurgery: a review. Acta Neurochir (Wien) 2016; 158:625-634. [PMID: 26811300 DOI: 10.1007/s00701-016-2707-6] [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: 11/13/2015] [Accepted: 01/07/2016] [Indexed: 10/22/2022]
Abstract
Effectiveness of stereotactic radiosurgery (SRS) has been shown in patients with one to four brain metastases. Work has been done to evaluate the role of SRS alone treatment without whole-brain radiation therapy in patients with more than four metastases. A recent multiinstitutional JLGK 0901 prospective study revealed the class-2 evidence that SRS without whole-brain radiation therapy is an effective treatment for patients up to 10 metastatic lesions. Several retrospective studies exist to show the efficacy and safety of SRS for patients with even more than 10 lesions. However, patient selection is very critical for SRS alone treatment. The PubMed database was searched using combinations of search terms and synonyms for multiple brain metastases, Gamma Knife and SRS published between January 1, 2005 and January 1, 2015 in order to address the effectiveness of Gamma Knife for patients with multiple brain metastases. Good performance status, controlled primary disease, total treated tumor volume of 15 cm(3) or less have been found to be significant predictors for survival among patients with two or more brain lesions. The data suggest that SRS can be used and whole brain radiation therapy can be withheld in selected patients with multiple lesions to avoid acute or chronic adverse effects, especially neurocognitive decline, without causing survival disadvantage. In this review, we assessed the evidence for SRS treatment of patients with multiple brain metastases.
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15
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Bowden G, Kano H, Caparosa E, Park SH, Niranjan A, Flickinger J, Lunsford LD. Gamma Knife radiosurgery for the management of cerebral metastases from non–small cell lung cancer. J Neurosurg 2015; 122:766-72. [DOI: 10.3171/2014.12.jns141111] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Non–small cell lung cancer (NSCLC) is the most frequent cancer that metastasizes to brain. Stereotactic radiosurgery (SRS) has become the management of choice for most patients with such metastatic tumors. Therefore, the authors endeavored to elucidate the survival and SRS outcomes for patients with NSCLC metastasis at their center.
METHODS
In this single-institution retrospective analysis, the authors reviewed their experience with NSCLC metastasis during a 10-year period from 2001 to 2010. Seven hundred twenty patients underwent Gamma Knife radiosurgery. A total of 1004 SRS procedures were performed, and 3143 tumors were treated. The NSCLC subtype was adenocarcinoma in 386 patients, squamous cell carcinoma in 111 patients, and large cell carcinoma in 34 patients. The median aggregate tumor volume was 4.5 cm3 (range 0.1–88 cm3).
RESULTS
The median survival time after diagnosis of brain metastasis from NSCLC was 12.6 months, and the median survival after SRS was 8.5 months. The 1-, 2-, and 5-year survival rates after SRS were 39%, 21%, and 10%, respectively. Postradiosurgery survival was decreased in patients treated with prior whole-brain radiation therapy compared with SRS alone (p = 0.003). Aggregate tumor volume was inversely related to survival after SRS (p < 0.001), and the histological subgroups demonstrated significant survival differences (p = 0.023). The overall local tumor control rate in the entire group was 92.8%. One hundred seventy-four patients (24%) underwent repeat SRS for new or resistant metastatic deposits.
CONCLUSIONS
Stereotactic radiosurgery is an effective means of providing local control for NSCLC metastases. Neurological function and survival benefit from serial patient monitoring and repeat SRS for new tumors.
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Affiliation(s)
- Greg Bowden
- Departments of 1Neurological Surgery and
- 3Center for Image-Guided Neurosurgery,
- 5Department of Neurological Surgery, University of Western Ontario, London, Ontario, Canada
| | - Hideyuki Kano
- Departments of 1Neurological Surgery and
- 3Center for Image-Guided Neurosurgery,
| | - Ellen Caparosa
- 4University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Seong-Hyun Park
- Departments of 1Neurological Surgery and
- 3Center for Image-Guided Neurosurgery,
| | - Ajay Niranjan
- Departments of 1Neurological Surgery and
- 3Center for Image-Guided Neurosurgery,
| | - John Flickinger
- 2Radiation Oncology, and
- 3Center for Image-Guided Neurosurgery,
| | - L. Dade Lunsford
- Departments of 1Neurological Surgery and
- 3Center for Image-Guided Neurosurgery,
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16
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Jairam V, Chiang VL, Bond J, Yu JB. Equivalent whole brain dose for patients undergoing gamma knife for multiple lesions. JOURNAL OF RADIOSURGERY AND SBRT 2015; 3:187-191. [PMID: 29296401 PMCID: PMC5746333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 07/22/2014] [Indexed: 06/07/2023]
Abstract
INTRODUCTION The advent of new radiosurgical technology has enabled the treatment of patients with larger numbers of brain metastases. At what point the whole brain doses delivered in single fraction radiosurgical treatment begin to approximate a fraction of whole brain radiotherapy is unknown. Measuring the equivalent whole-brain dose for multiple lesions may yield useful clinical insights. METHODS Twelve representative patients were chosen from our institutional database, having undergone radiosurgery for multiple lesions. All patients were treated using the Leksell Gamma Knife Perfexion radiosurgical platform. The entire brain was contoured and mean whole brain dose (MWBD) was calculated. For each plan, all enhancing tumors were outlined and total volume of tumors recorded. RESULTS A total of 33 treatments were administered. Three patients underwent radiosurgery a single time, one patient on two occasions, four patients on three occasions, and four patients on four occasions. Median number of lesions treated was 8 (range 1-41). Dose ranged from 18-22 Gy per lesion. The median MWBD per treatment was 1.4 Gy (range 0.2-7.6 Gy). Median total tumor volume was 4.3 cm3 (range 0.048 cm3-21.72 cm3). No patients with less than 25 lesions treated had a MWBD greater than 4 Gy. Total tumor volume was also associated with greater MWBD, albeit with a greater number of outliers. CONCLUSION Both tumor number and volume were associated with increased MWBD. Patients with greater than 25 lesions treated per session or cumulative tumor volumes greater than 10 cm3 had MWBD's greater than 4 Gy. Furthermore, tumor location and proximity to vital structures are equally important to consider, highlighting the need for individualized treatment planning.
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Affiliation(s)
- Vikram Jairam
- Yale School of Medicine, Department of Therapeutic Radiology, P.O. Box 208040, New Haven, CT 06510-3221, USA
| | - Veronica L Chiang
- Yale School of Medicine, Department of Therapeutic Radiology, P.O. Box 208040, New Haven, CT 06510-3221, USA
| | - James Bond
- Yale School of Medicine, Department of Therapeutic Radiology, P.O. Box 208040, New Haven, CT 06510-3221, USA
| | - James B Yu
- Yale School of Medicine, Department of Therapeutic Radiology, P.O. Box 208040, New Haven, CT 06510-3221, USA
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17
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Lin G, Xu H, Huang C. [Advances in treatment of brain metastases from primary non-small cell lung cancer]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2014; 17:877-83. [PMID: 25539615 PMCID: PMC6000406 DOI: 10.3779/j.issn.1009-3419.2014.12.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
脑是非小细胞肺癌常见的转移部位,手术和放疗是以往脑转移治疗的基石,但近年来随着对肿瘤发生发展机制的认识深化,靶向治疗在脑转移治疗中开始崭露头角。本文主要针对一些相关热点问题如脑转移治疗手段等(手术、放疗、化疗、靶向治疗)进行简要述评。
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Affiliation(s)
- Gen Lin
- Department of Medical Thoracic Oncology, Fujian Provincial Cancer Hospital, Fujian Medical University Teaching Hospital,
Fuzhou 350014, China
| | - Haipeng Xu
- Department of Medical Thoracic Oncology, Fujian Provincial Cancer Hospital, Fujian Medical University Teaching Hospital,
Fuzhou 350014, China
| | - Cheng Huang
- Department of Medical Thoracic Oncology, Fujian Provincial Cancer Hospital, Fujian Medical University Teaching Hospital,
Fuzhou 350014, China
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18
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Lukas RV, Lesniak MS, Salgia R. Brain metastases in non-small-cell lung cancer: better outcomes through current therapies and utilization of molecularly targeted approaches. CNS Oncol 2014; 3:61-75. [PMID: 25054901 PMCID: PMC6128200 DOI: 10.2217/cns.13.66] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Non-small-cell lung cancer (NSCLC) patients experience a high incidence of brain metastases, de novo and recurrent. We review the mechanisms of brain metastases and promising NSCLC molecular markers to delineate potential future therapeutic targets. Discussed are the current and previously utilized roles of surgery, radiation (both therapeutic and prophylactic), and systemic therapies in the treatment of NSCLC brain metastases. Future directions for treatment of NSCLC brain metastases will conclude our review.
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Affiliation(s)
- Rimas V Lukas
- Department of Neurology, University of Chicago, Chicago, IL, USA.
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