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Kübler J, Wester-Ebbinghaus M, Wenz F, Stieler F, Bathen B, Mai SK, Wolff R, Hänggi D, Blanck O, Giordano FA. Postoperative stereotactic radiosurgery and hypofractionated radiotherapy for brain metastases using Gamma Knife and CyberKnife: a dual-center analysis. J Neurosurg Sci 2024; 68:22-30. [PMID: 32031357 DOI: 10.23736/s0390-5616.20.04830-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
BACKGROUND Postoperative stereotactic radiosurgery (SRS) and hypofractionated stereotactic radiotherapy (hFSRT) to tumor cavities is emerging as a new standard of care after resection of brain metastases. Both Gamma Knife (GK) and CyberKnife (CK) are modalities commonly used for stereotactic radiotherapy, but fractional schemes are not consistent. The objective of this study was to evaluate outcomes in patients receiving postoperative stereotactic radiotherapy of resected brain metastases (BM) using different fractionation schedules and modalities in two large centers. METHODS Patients with newly diagnosed BM who underwent postoperative SRS or hFSRT with either GK or CK at two large cancer centers were retrospectively evaluated. We analyzed local control (LC), regional control (RC) and overall survival (OS). RESULTS From April 14th to May 18th, 2020, 79 patients with 81 resection cavities were treated. Forty-seven patients (59.5%) received GK and 32 patients (40.5%) received CK treatment. Fifty-four cavities (66.7%) were treated with hFSRT and 27 (33.3%) with SRS. The most common hFSRT and SRS scheme was 3x10 Gy and 1x16 Gy, respectively. Median OS was 11.7 months with survival rates of 44.7% at 1 year and 18.5% at 2 years. LC was 83.3% after 1 year. Median time to regional progression was 12.0 months with RC rates of 61.1% at 6 months and 41.0% at 12 months. There was no difference in OS, LC or RC between GK and CK treatments or SRS and hFSRT. CONCLUSIONS Both SRS and hFSRT provide high local control rates in resected BM regardless of the applied modality.
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Affiliation(s)
- Jens Kübler
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Michael Wester-Ebbinghaus
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Florian Stieler
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Bastian Bathen
- Saphir Radiosurgery Center Frankfurt, Frankfurt am Main, Germany
- Department of Radiation Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Sabine K Mai
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Robert Wolff
- Saphir Radiosurgery Center Frankfurt, Frankfurt am Main, Germany
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Oliver Blanck
- Saphir Radiosurgery Center Frankfurt, Frankfurt am Main, Germany
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany -
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2
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Huang YH, Yang HC, Chiang CL, Wu HM, Luo YH, Hu YS, Lin CJ, Chung WY, Shiau CY, Guo WY, Lee CC. Gamma Knife Radiosurgery Irradiation of Surgical Cavity of Brain Metastases: Factor Analysis and Gene Mutations. LIFE (BASEL, SWITZERLAND) 2023; 13:life13010236. [PMID: 36676186 PMCID: PMC9864800 DOI: 10.3390/life13010236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/07/2023] [Accepted: 01/10/2023] [Indexed: 01/19/2023]
Abstract
(1) Background: Surgical resection for the removal of brain metastases often fails to prevent tumor recurrence within the surgical cavity; hence, researchers are divided as to the benefits of radiation treatment following surgical resection. This retrospective study assessed the effects of post-operative stereotactic radiosurgery (SRS) on local tumor control and overall survival. (2) Methods: This study examined the demographics, original tumor characteristics, and surgical outcomes of 97 patients who underwent Gamma Knife Radiosurgery (GKRS) treatment (103 brain metastases). Kaplan-Meier plots and Cox regression were used to correlate clinical features to tumor control and overall survival. (3) Results: The overall tumor control rate was 75.0% and overall 12-month survival was 89.6%. Tumor control rates in the radiation group versus the non-radiation group were as follows: 12 months (83.1% vs. 57.7%) and 24 months (66.1% vs. 50.5%). During the 2-year follow-up period after SRS, the intracranial response rate was higher in the post-craniotomy radiation group than in the non-radiation group (p = 0.027). Cox regression multivariate analysis determined that post-craniotomy irradiation of the surgical cavity is predictive of tumor control (p = 0.035). However, EGFR mutation was not predictive of overall survival or tumor control. (4) Conclusions: Irradiating the surgical cavity after surgery can enhance local tumor control; however, it does not have a significant effect on overall survival.
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Affiliation(s)
- Yi-Han Huang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei 112, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Chi-Lu Chiang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Yung-Hung Luo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Yong-Sin Hu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei 112, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Cheng-Ying Shiau
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Cancer Center, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei 112, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Correspondence: ; Tel.: +886-2-28712121
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3
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Abdulhaleem M, Ruiz J, O’Neill S, Hughes RT, Qasem S, Strowd RE, Furdui C, Watabe K, Miller LD, Debinski W, Tatter S, Metheny-Barlow L, White JJ, Lee J, McTyre ER, Laxton A, Chan MD, Su J, Soike MH. Collagen deposition within brain metastases is associated with leptomeningeal failure after
cavity-directed radiosurgery. Neurooncol Adv 2023; 5:vdac186. [PMID: 36789023 PMCID: PMC9918843 DOI: 10.1093/noajnl/vdac186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background Leptomeningeal failure (LMF) represents a devastating progression of disease following resection of brain metastases (BrM). We sought to identify a biomarker at time of BrM resection that predicts for LMF using mass spectrometry-based proteomic analysis of resected BrM and to translate this finding with histochemical assays. Methods We retrospectively reviewed 39 patients with proteomic data available from resected BrM. We performed an unsupervised analysis with false discovery rate adjustment (FDR) to compare proteomic signature of BrM from patients that developed LMF versus those that did not. Based on proteomic analysis, we applied trichrome stain to a total of 55 patients who specifically underwent resection and adjuvant radiosurgery. We used competing risks regression to assess predictors of LMF. Results Of 39 patients with proteomic data, FDR revealed type I collagen-alpha-1 (COL1A1, P = .045) was associated with LMF. The degree of trichrome stain in each block correlated with COL1A1 expression (β = 1.849, P = .001). In a cohort of 55 patients, a higher degree of trichrome staining was associated with an increased hazard of LMF in resected BrM (Hazard Ratio 1.58, 95% CI 1.11-2.26, P = .01). Conclusion The degree of trichrome staining correlated with COL1A1 and portended a higher risk of LMF in patients with resected brain metastases treated with adjuvant radiosurgery. Collagen deposition and degree of fibrosis may be able to serve as a biomarker for LMF.
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Affiliation(s)
- Mohammed Abdulhaleem
- Corresponding Author: Mohammed Abdulhaleem, MD, Department of Medicine Wake Forest School of Medicine Medical Center Blvd Winston-Salem, NC, 27157 ()
| | | | - Stacey O’Neill
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ryan T Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Shadi Qasem
- Department of Pathology, Kentucky School of Medicine, Lexington, Kentucky
| | - Roy E Strowd
- Department of Medicine (Hematology and Oncology), Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Cristina Furdui
- Department of Molecular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Konousuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Lance D Miller
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Waldemar Debinski
- Department of Cancer Biology, Brain Tumor Center of Excellence, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Stephen Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Linda Metheny-Barlow
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jaclyn J White
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jingyun Lee
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Emory R McTyre
- Department of Radiation Oncology, Greenville Health System Cancer Institute, Greenville, South Carolina
| | - Adrian Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jing Su
- Department of Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael H Soike
- Department of Radiation Oncology, Hazelrig-Salter Radiation Oncology Center, University of Alabama at Birmingham, Birmingham, Alabama
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4
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Li YD, Coxon AT, Huang J, Abraham CD, Dowling JL, Leuthardt EC, Dunn GP, Kim AH, Dacey RG, Zipfel GJ, Evans J, Filiput EA, Chicoine MR. Neoadjuvant stereotactic radiosurgery for brain metastases: a new paradigm. Neurosurg Focus 2022; 53:E8. [PMID: 36321291 PMCID: PMC10602665 DOI: 10.3171/2022.8.focus22367] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/19/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE For patients with surgically accessible solitary metastases or oligometastatic disease, treatment often involves resection followed by postoperative stereotactic radiosurgery (SRS). This strategy has several potential drawbacks, including irregular target delineation for SRS and potential tumor "seeding" away from the resection cavity during surgery. A neoadjuvant (preoperative) approach to radiation therapy avoids these limitations and offers improved patient convenience. This study assessed the efficacy of neoadjuvant SRS as a new treatment paradigm for patients with brain metastases. METHODS A retrospective review was performed at a single institution to identify patients who had undergone neoadjuvant SRS (specifically, Gamma Knife radiosurgery) followed by resection of a brain metastasis. Kaplan-Meier survival and log-rank analyses were used to evaluate risks of progression and death. Assessments were made of local recurrence and leptomeningeal spread. Additionally, an analysis of the contemporary literature of postoperative and neoadjuvant SRS for metastatic disease was performed. RESULTS Twenty-four patients who had undergone neoadjuvant SRS followed by resection of a brain metastasis were identified in the single-institution cohort. The median age was 64 years (range 32-84 years), and the median follow-up time was 16.5 months (range 1 month to 5.7 years). The median radiation dose was 17 Gy prescribed to the 50% isodose. Rates of local disease control were 100% at 6 months, 87.6% at 12 months, and 73.5% at 24 months. In 4 patients who had local treatment failure, salvage therapy included repeat resection, laser interstitial thermal therapy, or repeat SRS. One hundred thirty patients (including the current cohort) were identified in the literature who had been treated with neoadjuvant SRS prior to resection. Overall rates of local control at 1 year after neoadjuvant SRS treatment ranged from 49% to 91%, and rates of leptomeningeal dissemination from 0% to 16%. In comparison, rates of local control 1 year after postoperative SRS ranged from 27% to 91%, with 7% to 28% developing leptomeningeal disease. CONCLUSIONS Neoadjuvant SRS for the treatment of brain metastases is a novel approach that mitigates the shortcomings of postoperative SRS. While additional prospective studies are needed, the current study of 130 patients including the summary of 106 previously published cases supports the safety and potential efficacy of preoperative SRS with potential for improved outcomes compared with postoperative SRS.
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Affiliation(s)
- Yuping Derek Li
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
| | - Andrew T. Coxon
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
| | - Jiayi Huang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - Christopher D. Abraham
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - Joshua L. Dowling
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - Eric C. Leuthardt
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - Gavin P. Dunn
- Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts
| | - Albert H. Kim
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - Ralph G. Dacey
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - Gregory J. Zipfel
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
| | - John Evans
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
| | - Eric A. Filiput
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Michael R. Chicoine
- Department of Neurosurgery, Washington University School of Medicine, St. Louis
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- The Brain Tumor Center, Siteman Cancer Center, Washington University School of Medicine, St. Louis
- Department of Neurosurgery, University of Missouri, Columbia, Missouri
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5
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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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6
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Sarmey N, Kaisman-Elbaz T, Mohammadi AM. Management Strategies for Large Brain Metastases. Front Oncol 2022; 12:827304. [PMID: 35251995 PMCID: PMC8894177 DOI: 10.3389/fonc.2022.827304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Brain metastases represent the most common intracranial neoplasm and pose a significant disease burden on the individual and the healthcare system. Although whole brain radiation therapy was historically a first line approach, subsequent research and technological advancements have resulted in a larger armamentarium of strategies for treatment of these patients. While chemotherapeutic options remain limited, surgical resection and stereotactic radiosurgery, as well as their combination therapies, have shifted the paradigms for managing intracranial metastatic disease. Ultimately, no single treatment is shown to be consistently effective across patient groups in terms of overall survival, local and distant control, neurocognitive function, and performance status. However, close consideration of patient and tumor characteristics may help delineate more favorable treatment strategies for individual patients. Here the authors present a review of the recent literature surrounding surgery, whole brain radiation therapy, stereotactic radiosurgery, and combination approaches.
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7
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Abdulhaleem M, Johnston H, D'Agostino R, Lanier C, LeCompte M, Cramer CK, Ruiz J, Lycan T, Lo HW, Watabe K, O'Neill S, Whitlow C, White JJ, Tatter SB, Laxton AW, Su J, Chan MD. Local control outcomes for combination of stereotactic radiosurgery and immunotherapy for non-small cell lung cancer brain metastases. J Neurooncol 2022; 157:101-107. [PMID: 35166988 DOI: 10.1007/s11060-022-03951-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 01/20/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous series have demonstrated CNS activity for immune checkpoint inhibitors, yet no prior data exists regarding whether this activity can improve outcomes of stereotactic radiosurgery. METHODS In this single institution retrospective series, the clinical outcomes of 80 consecutive lung cancer patients treated with concurrent immune checkpoint inhibitors and stereotactic radiosurgery were compared to 235 in the historical control cohort in which patients were treated prior to immune checkpoint inhibition being standard upfront therapy. Overall survival was estimated using the Kaplan Meier method. Cumulative incidence of local progression was estimated using a competing risk model. RESULTS Median overall survival time was improved in patients receiving upfront immunotherapy compared to the historical control group (40 months vs 8 months, p < 0.001). Factors affected overall survival include concurrent immunotherapy (HR 0.23, p < 0.0001) and KPS (HR 0.97, p = 0.0001). Cumulative incidence of local failure in the historical control group was 10% at 1 year, compared to 1.1% at 1 year in the concurrent immunotherapy group (p = 0.025). Factors affected local control included use of concurrent immunotherapy (HR 0.09, p = 0.012), and lowest margin dose delivered to a metastasis (HR 0.8, p = 0.0018). CONCLUSION Local control and overall survival were both improved in patients receiving concurrent immune checkpoint inhibitors with radiosurgery compared to historical controls. While these data remain to be validated, they suggest that brain metastasis patients may benefit from concurrent use of immunotherapy with SRS.
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Affiliation(s)
- Mohammed Abdulhaleem
- Department of Medicine, Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA. .,Department of Medicine, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
| | - Hannah Johnston
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Ralph D'Agostino
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Claire Lanier
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael LeCompte
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Christina K Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jimmy Ruiz
- Department of Medicine, Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Thomas Lycan
- Department of Medicine, Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Hui-Wen Lo
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kuonosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Stacey O'Neill
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Christopher Whitlow
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jaclyn J White
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jing Su
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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8
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Lanier CM, Lecompte M, Glenn C, Hughes RT, Isom S, Jenkins W, Cramer CK, Chan M, Tatter SB, Laxton AW. A Single-Institution Retrospective Study of Patients Treated With Laser-Interstitial Thermal Therapy for Radiation Necrosis of the Brain. Cureus 2021; 13:e19967. [PMID: 34984127 PMCID: PMC8714182 DOI: 10.7759/cureus.19967] [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] [Accepted: 11/28/2021] [Indexed: 11/05/2022] Open
Abstract
Object Laser-interstitial thermal therapy (LITT) has been proposed as an alternative treatment to surgery for radiation necrosis (RN) in patients treated with stereotactic radiosurgery (SRS) for brain metastases. The present study sought to retrospectively analyze LITT outcomes in patients with RN from SRS. Methods This was a single-institution retrospective study of 30 patients treated from 2011-2018 with pathologically-proven RN after SRS for brain metastases (n=28) or proximally treated extracranial lesions treated with external beam radiotherapy (n=2). Same-day biopsy was performed in all cases. Patients were prospectively followed with Functional Assessment of Cancer Therapy - Brain (FACT-Br), EuroQol-5 Dimension (EQ-5D), Hopkins Verbal Learning Test (HVLT) and clinical history and examination. Adjusted means, standard errors and tests comparing visits to pre-LITT were generated. Kaplan-Meier method was used to estimate time overall survival. Competing risk analysis was used to estimate cumulative incidence of LITT failure. Results In our patient population, median time from radiotherapy to LITT was 13.1 months. Median SRS dose and median LITT treatment target volume were 20 Gy (IQR 18-22) and 3.5 cc (IQR 2.2-4.6), respectively. Seventy-seven percent of our patients tapered off steroids within one month. There were only two instances of RN recurrence after LITT, with recurrence defined as recurrence of symptoms after initial improvement. These recurrences occurred at 1.9 and 3.4 months. The three-, six- and nine-month freedom from recurrence rates were 95.7%, 90.9%, and 90.9%. Median survival in our patient population with pathologically confirmed RN treated with LITT was 2.1 years. Regarding the quality of life questionnaires with which some patients were followed as part of different prospective studies, completion rates were 22/30 for FACT-Br, 16/30 for the EQ-5D and 8/30 for HVLT. Quality of life questionnaire results were overall stable from baseline. Mean FACT-Br scores were stable from baseline (17.9, 16.6, 21.4 and 22.8) to three months (18.8, 15.4, 18.4 and 23.4) (p=0.38, 0.53, 0.09 and 0.59). The mean EQ-5D Aggregate score was stable from baseline (7.1) to one month (7.6) (p=0.25). Mean HVLT-R Total Recall was stable from baseline (20.6) to three months (18.4) (p=0.09). There was a statistically significant decrease in mean Karnofsky Performance Scale (KPS) score from baseline (84) to three-month follow-up (75) (p=0.03). Conclusions LITT represents a safe and durably effective treatment option for RN in the brain. Results demonstrate a median survival of 2.1 years from LITT with only two recurrences, both within four months of treatment and salvageable. Patient-reported outcomes showed no severe declines after LITT. Quality of life questionnaires demonstrated stable well-being and functionality from baseline. LITT should be considered for definitive treatment of RN, especially in cases where patients have significant side effects from standards medical therapies such as steroids or if steroids are minimally effective.
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9
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Abstract
As novel systemic therapies yield improved survival in metastatic cancer patients, the frequency of brain metastases continues to increase. Over the years, management strategies have continued to evolve. Historically, stereotactic radiosurgery has been used as a boost to whole-brain radiotherapy (WBRT) but is increasingly being used as a replacement for WBRT. Given its capacity to treat both macro- and micro-metastases in the brain, WBRT has been an important management strategy for years, and recent research has identified technologic and pharmacologic approaches to delivering WBRT more safely. In this review, we outline the current landscape of radiotherapeutic treatment options and discuss approaches to integrating radiotherapy advances in the contemporary management of brain metastases.
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Affiliation(s)
- Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville and Proton Center, Warrenville, Illinois, USA
| | | | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
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10
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Verhaak E, Schimmel WCM, Gehring K, Hanssens PEJ, Sitskoorn MM. Cognitive Functioning and Health-Related Quality of Life of Long-Term Survivors With Brain Metastases Up to 21 Months After Gamma Knife Radiosurgery. Neurosurgery 2021; 88:E396-E405. [PMID: 33575811 DOI: 10.1093/neuros/nyaa586] [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] [Received: 03/17/2020] [Accepted: 11/18/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Survival rates have improved in the past years for patients with brain metastases (BMs). OBJECTIVE To evaluate cognitive functioning and health-related quality of life (HRQoL) after Gamma Knife radiosurgery (GKRS) in a relatively large sample of long-term survivors. METHODS Data from 38 long-term survivors (assessments available ≥ 12 mo post-GKRS) with, at time of enrollment, 1 to 10 newly diagnosed BMs, expected survival > 3 mo, and Karnofsky Performance Status ≥ 70 were analyzed. Cognitive functioning and HRQoL were assessed pre-GKRS (n = 38) and at 3 (n = 38), 6 (n = 37), 9 (n = 37), 12 (n = 34), 15 (n = 28), and 21 (n = 21) mo post-GKRS. The course of cognitive test performance and of HRQoL over time was analyzed using linear mixed models. Individual changes in cognitive performance and HRQoL from pre-GKRS to 21 mo were determined using reliable change indexes (RCIs) and clinical meaningful cutoffs, respectively. RESULTS Cognitive performances and HRQoL of long-term survivors remained stable or improved up to 21 mo after GKRS. Improvements were found for immediate and delayed verbal memory, working memory, information processing speed, and emotional well-being. On the individual level, most patients had stable or improved test performances or HRQoL. For physical well-being only, most patients (47.6%) showed a decline (vs 28.6% improvement or 23.8% no change) from pre-GKRS until 21 mo post-GKRS. CONCLUSION Up to 21 mo after GKRS, cognitive functioning and overall HRQoL improved or remained stable in long-term survivors. In long-term survivors with 1 to 10 BMs, GKRS did not cause (additional) cognitive deteriorations or declines in HRQoL at longer-term follow-up.
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Affiliation(s)
- Eline Verhaak
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.,Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.,Department of Cognitive Neuropsychology, Tilburg University, Tilburg, the Netherlands
| | - Wietske C M Schimmel
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.,Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.,Department of Cognitive Neuropsychology, Tilburg University, Tilburg, the Netherlands
| | - Karin Gehring
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.,Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.,Department of Cognitive Neuropsychology, Tilburg University, Tilburg, the Netherlands
| | - Patrick E J Hanssens
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.,Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Margriet M Sitskoorn
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.,Department of Cognitive Neuropsychology, Tilburg University, Tilburg, the Netherlands
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11
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Roth O'Brien DA, Kaye SM, Poppas PJ, Mahase SS, An A, Christos PJ, Liechty B, Pisapia D, Ramakrishna R, Wernicke AG, Knisely JPS, Pannullo SC, Schwartz TH. Time to administration of stereotactic radiosurgery to the cavity after surgery for brain metastases: a real-world analysis. J Neurosurg 2021; 135:1695-1705. [PMID: 34049277 DOI: 10.3171/2020.10.jns201934] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 10/09/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Publications on adjuvant stereotactic radiosurgery (SRS) are largely limited to patients completing SRS within a specified time frame. The authors assessed real-world local recurrence (LR) for all brain metastasis (BM) patients referred for SRS and identified predictors of SRS timing. METHODS The authors retrospectively identified BM patients undergoing resection and referred for SRS between 2012 and 2018. Patients were categorized by time to SRS, as follows: 1) ≤ 4 weeks, 2) > 4-8 weeks, 3) > 8 weeks, and 4) never completed. The relationships between timing of SRS and LR, LR-free survival (LRFS), and survival were investigated, as well as predictors of and reasons for specific SRS timing. RESULTS In a cohort of 159 patients, the median age at resection was 64.0 years, 56.5% of patients were female, and 57.2% were in recursive partitioning analysis (RPA) class II. The median preoperative tumor diameter was 2.9 cm, and gross-total resection was achieved in 83.0% of patients. All patients were referred for SRS, but 20 (12.6%) did not receive it. The LR rate was 22.6%, and the time to SRS was correlated with the LR rate: 2.3% for patients receiving SRS at ≤ 4 weeks postoperatively, 14.5% for SRS at > 4-8 weeks (p = 0.03), and 48.5% for SRS at > 8 weeks (p < 0.001). No LR difference was seen between patients whose SRS was delayed by > 8 weeks and those who never completed SRS (48.5% vs 50.0%; p = 0.91). A similar relationship emerged between time to SRS and LRFS (p < 0.01). Non-small cell lung cancer pathology (p = 0.04), earlier year of treatment (p < 0.01), and interval from brain MRI to SRS (p < 0.01) were associated with longer intervals to SRS. The rates of receipt of systemic therapy also differed significantly between patients by category of time to SRS (p = 0.02). The most common reasons for intervals of > 4-8 weeks were logistic, whereas longer delays or no SRS were caused by management of systemic disease or comorbidities. CONCLUSIONS Available data on LR rates after adjuvant SRS are often obtained from carefully preselected patients receiving timely treatment, whereas significantly less information is available on the efficacy of adjuvant SRS in patients treated under "real-world" conditions. Management of these patients may merit reconsideration, particularly when SRS is not delivered within ≤ 4 weeks of resection. The results of this study indicate that a substantial number of patients referred for SRS either never receive it or are treated > 8 weeks postoperatively, at which time the SRS-treated patients have an LR risk equivalent to that of patients who never received SRS. Increased attention to the reasons for prolonged intervals from surgery to SRS and strategies for reducing them is needed to optimize treatment. For patients likely to experience delays, other radiotherapy techniques may be considered.
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Affiliation(s)
| | | | | | | | - Anjile An
- 3Division of Biostatistics and Epidemiology, and
| | | | - Benjamin Liechty
- 4Department of Neuropathology, Weill Cornell Medical College/NewYork-Presbyterian Hospital
| | - David Pisapia
- 4Department of Neuropathology, Weill Cornell Medical College/NewYork-Presbyterian Hospital
| | | | | | | | | | - Theodore H Schwartz
- 2Department of Neurosurgery
- Departments of6Otolaryngology and
- 7Neuroscience, Weill Cornell Medical College/NewYork-Presbyterian Hospital, New York, New York
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12
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Mulford K, Chen C, Dusenbery K, Yuan J, Hunt MA, Chen CC, Sperduto P, Watanabe Y, Wilke C. A radiomics-based model for predicting local control of resected brain metastases receiving adjuvant SRS. Clin Transl Radiat Oncol 2021; 29:27-32. [PMID: 34095557 PMCID: PMC8164004 DOI: 10.1016/j.ctro.2021.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/29/2021] [Accepted: 05/01/2021] [Indexed: 12/02/2022] Open
Abstract
SRS has emerged as an alternative to WBRT for surgically resected brain metastases. Pre-therapy radiomic features are predictive of local control after cavity SRS. Radiomic features were superior to clinical features for predicting local control.
Purpose Adjuvant radiosurgery to the cavities of surgically resected brain metastases provides excellent local tumor control while reducing the risk of deleterious cognitive decline associated with whole brain radiotherapy. A subset of these patients, however, will develop disease recurrence following radiosurgery. In this study, we sought to assess the predictive capability of radiomic-based models, as compared with standard clinical features, in predicting local tumor control. Methods We performed a retrospective chart review of patients treated with adjuvant radiosurgery for resected brain metastases at the “Institution” from 2009 to 2019. Shape, intensity and texture based radiomics features of the cavities were extracted from the pre-radiosurgery treatment planning MRI scans and trained using a gradient boosting technique with K-fold cross validation. Results In total, 71 cavities from 67 treated patients were included for analysis. The 6 and 12 month local control estimates were 86% and 76%, respectively. The 6 and 12 month overall survival was 78% and 55%, respectively. Thirty-six patients developed intracranial failures outside of the surgical cavity. The predictive model for local control trained on imaging features from the whole cavity achieved an area-under-the-curve (AUC) of 0.73 on the validation set versus an AUC of 0.40 for the clinical features. Conclusions Here we report a single institutional experience using radiomic-based predictive modeling of local tumor control following adjuvant Gamma Knife radiosurgery for resected brain metastases. We found the radiomics features to provide more robust predictive models of local control rates versus clinical features alone. Such techniques could potentially prove useful in the clinical setting and warrant further investigation.
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Affiliation(s)
- Kellen Mulford
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Chuyu Chen
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Kathryn Dusenbery
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Jianling Yuan
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Matthew A. Hunt
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Clark C. Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Paul Sperduto
- Minneapolis Radiation Oncology and Gamma Knife Center, Minneapolis, MN, USA
| | - Yoichi Watanabe
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Christopher Wilke
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN, USA
- Corresponding author at: PWB 1-255, 516 Delaware St SE, Minneapolis, MN 55455, USA.
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13
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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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14
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Su J, Song Q, Qasem S, O'Neill S, Lee J, Furdui CM, Pasche B, Metheny-Barlow L, Masters AH, Lo HW, Xing F, Watabe K, Miller LD, Tatter SB, Laxton AW, Whitlow CT, Chan MD, Soike MH, Ruiz J. Multi-Omics Analysis of Brain Metastasis Outcomes Following Craniotomy. Front Oncol 2021; 10:615472. [PMID: 33889540 PMCID: PMC8056216 DOI: 10.3389/fonc.2020.615472] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/18/2020] [Indexed: 01/27/2023] Open
Abstract
Background The incidence of brain metastasis continues to increase as therapeutic strategies have improved for a number of solid tumors. The presence of brain metastasis is associated with worse prognosis but it is unclear if distinctive biomarkers can separate patients at risk for CNS related death. Methods We executed a single institution retrospective collection of brain metastasis from patients who were diagnosed with lung, breast, and other primary tumors. The brain metastatic samples were sent for RNA sequencing, proteomic and metabolomic analysis of brain metastasis. The primary outcome was distant brain failure after definitive therapies that included craniotomy resection and radiation to surgical bed. Novel prognostic subtypes were discovered using transcriptomic data and sparse non-negative matrix factorization. Results We discovered two molecular subtypes showing statistically significant differential prognosis irrespective of tumor subtype. The median survival time of the good and the poor prognostic subtypes were 7.89 and 42.27 months, respectively. Further integrated characterization and analysis of these two distinctive prognostic subtypes using transcriptomic, proteomic, and metabolomic molecular profiles of patients identified key pathways and metabolites. The analysis suggested that immune microenvironment landscape as well as proliferation and migration signaling pathways may be responsible to the observed survival difference. Conclusion A multi-omics approach to characterization of brain metastasis provides an opportunity to identify clinically impactful biomarkers and associated prognostic subtypes and generate provocative integrative understanding of disease.
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Affiliation(s)
- Jing Su
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States.,Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Qianqian Song
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Shadi Qasem
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Stacey O'Neill
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Jingyun Lee
- Proteomics and Metabolomics Shared Resource, Comprehensive Cancer Center, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Cristina M Furdui
- Proteomics and Metabolomics Shared Resource, Comprehensive Cancer Center, Wake Forest University School of Medicine, Winston-Salem, NC, United States.,Department of Internal Medicine, Section on Molecular Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Boris Pasche
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Linda Metheny-Barlow
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Adrianna H Masters
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Hui-Wen Lo
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Fei Xing
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Lance D Miller
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Christopher T Whitlow
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Michael H Soike
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, United States.,Department of Radiation Oncology, University of Alabama-Birmingham, Birmingham, AL, United States
| | - Jimmy Ruiz
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC, United States.,Section of Hematology & Oncology, W.G. (Bill) Hefner Veterans Affair Medial Center (VAMC), Salisbury, NC, United States
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15
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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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16
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Asher AL, Alvi MA, Bydon M, Pouratian N, Warnick RE, McInerney J, Grills IS, Sheehan J. Local failure after stereotactic radiosurgery (SRS) for intracranial metastasis: analysis from a cooperative, prospective national registry. J Neurooncol 2021; 152:299-311. [PMID: 33481148 DOI: 10.1007/s11060-021-03698-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/08/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Stereotactic radiosurgery (SRS) has been increasingly employed to treat patients with intracranial metastasis, both as a salvage treatment after failed whole brain radiation therapy (WBRT) and as an initial treatment. "Several studies have shown that SRS may be as effective as WBRT with the added benefit of preserving neuro-cognition". However, some patients may have local failure following SRS for intracranial metastasis, defined as increase in total lesion volume by 25% after at least 3 months of follow up. METHODS The SRS registry, established by the Neuro point alliance (NPA) under the auspices of the American Association of Neurological Surgeons (AANS), was queried for patients with intracranial metastasis receiving SRS at the participating sites. Demographic, clinical symptoms, tumor, and treatment characteristics as well as follow up status were summarized for the cohort. A multivariable explanatory cox- regression was performed to evaluate the impact of each of the factors on time to local failure.at last follow-up. RESULTS A total of 441 patients with 1255 intracranial metastatic lesions undergoing SRS were identified. The most common primary cancer histology was non-small cell lung cancer (43.8%, n = 193). More than half of the cohort had more than 1 metastatic lesion (2-3 lesions: 29.5%, n = 130; more than 3 lesions: 25.2% (n = 111). The average duration of follow-up for the cohort was found to be 8.4 months (SD = 7.61). The mean clinical treatment volume (CTV), after adding together the volume of each lesion for each patient was 5.39 cc (SD = 7.6) at baseline. A total of 20.2% (n = 89) had local failure (increase in volume by > 25%) with a mean time to progression of 7.719 months (SD = 6.09). The progression free survival (PFS) for the cohort at 3, 6 and 12 months were found to be 94.9%, 84.3%, and 69.4%, respectively. On multivariable cox regression analysis, factors associated with increased hazard of local failure included male gender (HR 1.65, 95% CI 1.03-2.66, p = 0.037), chemotherapy at or before SRS (HR = 2.39, 95% CI 1.41-4.05, p = 0.001), WBRT at or before SRS (HR = 2.21, 95% CI 1.16- 4.22, p = 0.017), while surgical resection (HR 0.45, 95% CI 0.21-0. 97, p = 0.04) and immunotherapy (0.34, 95% CI 0.16-0.50, p = 0.014) were associated with lower hazard of local failure. CONCLUSION Factors found to be predictive of local failure included higher RPA score and those receiving chemotherapy, while patients undergoing surgical resection and those with occipital lobe lesions were less likely to experience local failure. Our analyses not only corroborate those previously reported but also demonstrate the utility of a multi-institutional registry to advance real-world SRS research for patients with intracranial metastatic lesions.
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Affiliation(s)
- Anthony L Asher
- Neuroscience Institute, Carolinas Healthcare System and Carolina, Neurosurgery & Spine Associates, Charlotte, NC, 28204, USA
| | - Mohammed Ali Alvi
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 55902, USA
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 55902, USA
| | - Nader Pouratian
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| | - Ronald E Warnick
- Department of Neurosurgery, The Jewish Hospital, Cincinnati, OH, USA
| | - James McInerney
- Department of Neurosurgery, Penn State Health, Hershey, PA, USA
| | - Inga S Grills
- Department of Neurological Surgery, Beaumont Health System, Royal Oak, MI, USA
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia Health System, 1300 Jefferson Park Ave, Charlottesville, VA, 22908, USA.
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17
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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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18
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Kerschbaumer J, Pinggera D, Holzner B, Delazer M, Bodner T, Karner E, Dostal L, Kvitsaridze I, Minasch D, Thomé C, Seiz-Rosenhagen M, Nevinny-Stickel M, Freyschlag CF. Sector Irradiation vs. Whole Brain Irradiation After Resection of Singular Brain Metastasis-A Prospective Randomized Monocentric Trial. Front Oncol 2020; 10:591884. [PMID: 33330076 PMCID: PMC7732624 DOI: 10.3389/fonc.2020.591884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/29/2020] [Indexed: 12/03/2022] Open
Abstract
To minimize recurrence following resection of a cerebral metastasis, whole-brain irradiation therapy (WBRT) has been established as the adjuvant standard of care. With prolonged overall survival in cancer patients, deleterious effects of WBRT gain relevance. Sector irradiation (SR) aims to spare uninvolved brain tissue by applying the irradiation to the resection cavity and the tumor bed. 40 were randomized to receive either WBRT (n = 18) or SR (n = 22) following resection of a singular brain metastasis. Local tumor control was satisfactory in both groups. Recurrence was observed earlier in the SR (median 3 months, 1–6) than in the WBRT cohort (median 8 months, 7–9) (HR, 0.63; 95% CI, 0.03–10.62). Seventeen patients experienced a distant intracranial recurrence. Most relapses (n = 15) occurred in the SR cohort, whereas only two patients in the WBRT group had new distant tumor manifestation (HR, 6.59; 95% CI, 1.71–11.49; p = 0.002). Median overall survival (OS) was 15.5 months (range: 1–61) with longer OS in the SR group (16 months, 1–61) than in the WBRT group (13 months, 3–52), without statistical significance (HR, 0.55; 95% CI, 0.69–3.64). Concerning neurocognition, patients in the SR group improved in the follow-up assessments, while this was not observed in the WBRT group. There were positive signals in terms of QOL within the SR group, but no significant differences in the global QLQ and QLQ-C30 summary scores were found. Our results indicate comparable efficacy of SR in terms of local control, with better maintenance of neurocognitive function. Unsurprisingly, more distant intracranial relapses occurred. Clinical Trial Registration:ClinicalTrials.gov, identifier NCT01667640.
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Affiliation(s)
| | - Daniel Pinggera
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Bernhard Holzner
- University Clinic for Psychiatry II, Medical University of Innsbruck, Innsbruck, Austria
| | - Margarete Delazer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Bodner
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Elfriede Karner
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lucie Dostal
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Irma Kvitsaridze
- Department of Therapeutic Radiology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| | - Danijela Minasch
- Department of Therapeutic Radiology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Marcel Seiz-Rosenhagen
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria.,Department of Neurosurgery, Klinikum Memmingen, Memmingen, Germany
| | - Meinhard Nevinny-Stickel
- Department of Therapeutic Radiology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
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19
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Tai P, Joseph K, Assouline A, Souied O, Leong N, Ferguson M, Yu E. Metastatic Brain Tumors: To Treat or Not to Treat, and with What? CURRENT CANCER THERAPY REVIEWS 2020. [DOI: 10.2174/1573394715666181211150849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A long time ago, metastatic brain tumors were often not treated and patients were only
given palliative care. In the past decade, researchers selected those with single or 1-3 metastases
for more aggressive treatments like surgical resection, and/or stereotactic radiosurgery (SRS),
since the addition of whole brain radiotherapy (WBRT) did not increase overall survival for the
vast majority of patients. Different studies demonstrated significantly less cognitive deterioration
in 0-52% patients after SRS versus 85-94% after WBRT at 6 months. WBRT is the treatment of
choice for leptomeningeal metastases. WBRT can lower the risk for further brain metastases, particularly
in tumors of fast brain metastasis velocity, i.e. quickly relapsing, often seen in melanoma
or small cell lung carcinoma. Important relevant literature is quoted to clarify the clinical controversies
at point of care in this review. Synchronous primary lung cancer and brain metastasis
represent a special situation whereby the oncologist should exercise discretion for curative treatments,
with reported 5-year survival rates of 7.6%-34.6%. Recent research suggests that those
patients with Karnofsky performance status less than 70, not capable of caring for themselves, are
less likely to derive benefit from aggressive treatments. Among patients with brain metastases
from non-small cell lung cancer (NSCLC), the QUARTZ trial (Quality of Life after Radiotherapy
for Brain Metastases) helps the oncologist to decide when not to treat, depending on the performance
status and other factors.
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Affiliation(s)
- Patricia Tai
- Allan Blair Cancer Center, University of Saskatchewan, Saskatoon, SK, Canada
| | - Kurian Joseph
- Cross Cancer Center, University of Alberta, Edmonton, AB, Canada
| | - Avi Assouline
- Centre Clinique de la Porte de Saint-Cloud, 30 Rue de Paris, 92100 Boulogne- Billancourt, France
| | - Osama Souied
- Allan Blair Cancer Center, University of Saskatchewan, Saskatoon, SK, Canada
| | - Nelson Leong
- Allan Blair Cancer Center, University of Saskatchewan, Saskatoon, SK, Canada
| | - Michelle Ferguson
- Allan Blair Cancer Center, University of Saskatchewan, Saskatoon, SK, Canada
| | - Edward Yu
- London Regional Cancer Program, Western University, London, ON, Canada
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20
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Mitchell TJ, Seitzman BA, Ballard N, Petersen SE, Shimony JS, Leuthardt EC. Human Brain Functional Network Organization Is Disrupted After Whole-Brain Radiation Therapy. Brain Connect 2020; 10:29-38. [PMID: 31964163 DOI: 10.1089/brain.2019.0713] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Radiation therapy (RT) plays a vital role in the treatment of brain cancers, but it frequently results in cognitive decline in the patients who receive it. Because the underlying mechanisms for this decline remain poorly understood, the brain is typically treated as a single, uniform volume when evaluating the toxic effects of RT plans. This ignorance represents a significant deficit in the field of radiation oncology, as the technology exists to manipulate dose distributions to spare regions of the brain, but there exists no body of knowledge regarding what is critical to spare. This deficit exists due to the numerous confounding factors that are frequently associated with radiotherapy, including the tumors themselves, other treatments such as surgery and chemotherapy, and dose gradients across the brain. Here, we present a case in which a 57-year-old male patient received a uniform dose of radiation across the whole brain, did not receive concurrent chemotherapy, had minimal surgical intervention and a small tumor burden, and received resting-state functional magnetic resonance imaging (fMRI) scans both before and after RT. To our knowledge, this is the first study on the effects of whole-brain radiotherapy on functional network organization, and this patient's treatment regimen represents a rare and non-replicable opportunity to isolate the effects of radiation on functional connectivity. We observed substantial changes in the subject's behavior and functional network organization over a 12-month timeframe. Interestingly, the homogenous radiation dose to the brain had a heterogeneous effect on cortical networks, and the functional networks most affected correspond with observed cognitive behavioral deficits. This novel study suggests that the cognitive decline that occurs after whole-brain radiation therapy may be network specific and related to the disruption of large-scale distributed functional systems, and it indicates that fMRI is a promising avenue of study for optimizing cognitive outcomes after RT.
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Affiliation(s)
- Timothy J Mitchell
- Department of Radiation Oncology and Washington University in St. Louis-School of Medicine, St. Louis, Missouri
| | - Benjamin A Seitzman
- Department of Neurology, Washington University in St. Louis-School of Medicine, St. Louis, Missouri
| | - Nicholas Ballard
- Department of Radiation Oncology and Washington University in St. Louis-School of Medicine, St. Louis, Missouri
| | - Steven E Petersen
- Department of Neurology, Washington University in St. Louis-School of Medicine, St. Louis, Missouri.,Mallinckrodt Institute of Radiology, Washington University in St. Louis-School of Medicine, St. Louis, Missouri.,Department of Neuroscience, Washington University in St. Louis-School of Medicine, St. Louis, Missouri.,Department of Biomedical Engineering, Washington University in St. Louis-School of Engineering and Applied Science, St. Louis, Missouri.,Department of Psychological and Brain Sciences, Washington University in St. Louis, St. Louis, Missouri
| | - Joshua S Shimony
- Mallinckrodt Institute of Radiology, Washington University in St. Louis-School of Medicine, St. Louis, Missouri
| | - Eric C Leuthardt
- Department of Neuroscience, Washington University in St. Louis-School of Medicine, St. Louis, Missouri.,Department of Biomedical Engineering, Washington University in St. Louis-School of Engineering and Applied Science, St. Louis, Missouri.,Department of Mechanical Engineering and Materials Science, Washington University in St. Louis-School of Engineering and Applied Science, St. Louis, Missouri.,Center for Innovation in Neuroscience and Technology and Washington University in St. Louis-School of Medicine, St. Louis, Missouri.,Brain Laser Center, Washington University in St. Louis-School of Medicine, St. Louis, Missouri.,Department of Neurological Surgery, Washington University in St. Louis-School of Medicine, St. Louis, Missouri
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21
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Jiang X. Identification of Patients with Brain Metastases with Favorable Prognosis After Local and Distant Recurrence Following Stereotactic Radiosurgery. Cancer Manag Res 2020; 12:4139-4149. [PMID: 32581585 PMCID: PMC7276324 DOI: 10.2147/cmar.s251285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/13/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose This retrospective study aimed to determine the prognostic factors associated with overall survival after intracranial local and distant recurrence in patients undergoing stereotactic radiosurgery (SRS) for brain metastases. Patients and Methods Clinical characteristics and therapeutic parameters of 251 patients, who were treated with initial stereotactic radiosurgery for brain metastases and later experienced intracranial recurrence, were analyzed to identify prognostic factors of post-recurrence overall survival (PROS). A Cox proportional hazard model was applied for univariate and multivariate analyses. Results Among the 251 patients, the median post-recurrence overall survival was 8 months, and the six-month PROS rate was 60.2%. The interval from initial radiosurgery treatment to intracranial recurrence (hazard ratio [HR]:0.970), the number of brain recurrent tumors (HR:1.245), the number of extracranial metastatic organs (HR:1.183), recursive partition analysis (RPA) (HR:1.778), and Eastern Cooperative Oncology Group Performance Status (ECOG PS) (HR:2.442) were identified as independent prognostic factors. The patients who received local treatment for solitary brain recurrence achieved better survival (the median survival time after recurrence was 22 months). In patients without extracranial metastasis, the median post-recurrence overall survival of the local treatment group was longer than that in the whole brain radiation therapy (WBRT) group (P<0.001) and the systemic therapy group (P<0.001). Conclusion A shorter interval from initial stereotactic radiosurgery to recurrence, an increasing number of brain recurrences and extracranial metastatic organs, and poor RPA and ECOG PS values are associated with poor post-recurrence prognosis. When the number of brain recurrent tumors and extracranial metastatic organs was limited, local treatment including stereotactic radiosurgery, surgery or intensity-modulated radiation therapy (IMRT) improved the post-recurrence overall survival.
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Affiliation(s)
- Xuechao Jiang
- Department of Radiation Oncology, Binzhou Center Hospital Affiliated to Binzhou Medical College, Binzhou, Shandong, People's Republic of China
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22
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Gui C, Grimm J, Kleinberg LR, Zaki P, Spoleti N, Mukherjee D, Bettegowda C, Lim M, Redmond KJ. A Dose-Response Model of Local Tumor Control Probability After Stereotactic Radiosurgery for Brain Metastases Resection Cavities. Adv Radiat Oncol 2020; 5:840-849. [PMID: 33083646 PMCID: PMC7557194 DOI: 10.1016/j.adro.2020.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 05/09/2020] [Accepted: 06/15/2020] [Indexed: 11/09/2022] Open
Abstract
Purpose Recent randomized controlled trials evaluating stereotactic surgery (SRS) for resected brain metastases question the high rates of local control previously reported in retrospective studies. Tumor control probability (TCP) models were developed to quantify the relationship between radiation dose and local control after SRS for resected brain metastases. Methods and Materials Patients with resected brain metastases treated with SRS were evaluated retrospectively. Melanoma, sarcoma, and renal cell carcinoma were considered radio-resistant histologies. The planning target volume (PTV) was the region of enhancement on T1 post-gadolinium magnetic resonance imaging plus a 2-mm uniform margin. The primary outcome was local recurrence, defined as tumor progression within the resection cavity. Cox regression evaluated predictors of local recurrence. Dose-volume histograms for the PTV were obtained from treatment plans and converted to 3-fraction equivalent doses (α/β = 12 Gy). TCP models evaluated local control at 1-year follow-up as a logistic function of dose-volume histogram data. Results Among 150 cavities, 41 (27.3%) were radio-resistant. The median PTV volume was 14.6 mL (range, 1.3-65.3). The median prescription was 21 Gy (range, 15-25) in 3 fractions (range, 1-5). Local control rates at 12 and 24 months were 86% and 82%. On Cox regression, larger cavities (PTV > 12 cm3) predicted increased risk of local recurrence (P = .03). TCP modeling demonstrated relationships between improved 1-year local control and higher radiation doses delivered to radio-resistant cavities. Maximum PTV doses of 30, 35, and 40 Gy predicted 78%, 89%, and 94% local control among all radio-resistant cavities, versus 69%, 79%, and 86% among larger radio-resistant cavities. Conclusions After SRS for resected brain metastases, larger cavities are at greater risk of local recurrence. TCP models suggests that higher radiation doses may improve local control among cavities of radio-resistant histology. Given maximum tolerated doses established for single-fraction SRS, fractionated regimens may be required to optimize local control in large radio-resistant cavities.
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Affiliation(s)
- Chengcheng Gui
- 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 Richard Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Peter Zaki
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Nicholas Spoleti
- Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
| | - Debraj Mukherjee
- Department of Neurosurgery, 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 Janson Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
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23
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Post-operative radiation therapy to the surgical cavity with standard fractionation in patients with brain metastases. Sci Rep 2020; 10:6331. [PMID: 32286375 PMCID: PMC7156661 DOI: 10.1038/s41598-020-63158-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 03/23/2020] [Indexed: 12/11/2022] Open
Abstract
The paradigm for post-operative cavity radiation therapy has shifted to more targeted, less morbid approaches. Single-fraction or hypofractionated radiation therapy is a common approach to treating the postoperative cavity but is associated with a local failure rate 20–40%. We employed an alternative treatment strategy involving fractionated partial brain radiation therapy to the surgical cavity. Patients with brain metastases who underwent radiation treatment 30–42 Gy in 3 Gy/fraction regimens to surgical cavity were retrospectively identified. The 6-month and 12-month freedom from local failure rates were 97.0% and 88.2%. Three patients (7%) experienced local failure at 4, 6, and 22 months. Of these, the histologies were colorectal adenocarcinoma (N = 1) and breast adenocarcinoma (N = 2). The 6-month and 12-month freedom from distant brain metastases rates were 74.1% and 68.8%, respectively, and the 6-month and 12-month overall survival rates were 84.9% and 64.3% respectively. The median overall survival was 39 months, and there were no events of late radionecrosis. Fractionated partial brain irradiation to the surgical cavity of resected brain metastases results in low rates of local failure. This strategy represents an alternative to SRS and WBRT.
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24
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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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25
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Sinclair G, Stenman M, Benmakhlouf H, Johnstone P, Wersäll P, Lindskog M, Hatiboglu MA, Harmenberg U. Adaptive radiosurgery based on two simultaneous dose prescriptions in the management of large renal cell carcinoma brain metastases in critical areas: Towards customization. Surg Neurol Int 2020; 11:21. [PMID: 32123609 PMCID: PMC7049890 DOI: 10.25259/sni_275_2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 12/13/2019] [Indexed: 12/23/2022] Open
Abstract
Background: The long-term benefits of local therapy in metastatic renal cell carcinoma (mRCC) have been widely documented. In this context, single fraction gamma knife radiosurgery (SF-GKRS) is routinely used in the management of brain metastases. However, SF-GKRS is not always feasible due to volumetric and regional constraints. We intend to illustrate how a dose-volume adaptive hypofractionated GKRS technique based on two concurrent dose prescriptions termed rapid rescue radiosurgery (RRR) can be utilized in this particular scenario. Case Description: A 56-year-old man presented with left-sided hemiparesis; the imaging showed a 13.1 cc brain metastasis in the right central sulcus (Met 1). Further investigation confirmed the histology to be a metastatic clear cell RCC. Met 1 was treated with upfront RRR. Follow-up magnetic resonance imaging (MRI) at 10 months showed further volume regression of Met 1; however, concurrently, a new 17.3 cc lesion was reported in the boundaries of the left frontotemporal region (Met 2) as well as a small metastasis (<1 cc) in the left temporal lobe (Met 3). Met 2 and Met 3 underwent RRR and SF-GKRS, respectively. Results: Gradual and sustained tumor ablation of Met 1 and Met 2 was demonstrated on a 20 months long follow- up. The patient succumbed to extracranial disease 21 months after the treatment of Met 1 without evidence of neurological impairment post-RRR. Conclusion: Despite poor prognosis and precluding clinical factors (failing systemic treatment, eloquent location, and radioresistant histology), RRR provided optimal tumor ablation and salvage of neurofunction with limited toxicity throughout follow-up.
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Affiliation(s)
- Georges Sinclair
- Departments of Neurosurgery, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Bezmialem Vakif University Medical School, Istanbul, Turkey.,Department of Oncology, Royal Berkshire NHS Foundation Trust, Reading, United Kingdom
| | - M Stenman
- Department of Immunology Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - H Benmakhlouf
- Departments of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - P Johnstone
- Department of Oncology, Royal Berkshire NHS Foundation Trust, Reading, United Kingdom
| | - P Wersäll
- Department of Oncology-Pathology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - M Lindskog
- Department of Immunology Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - M A Hatiboglu
- Department of Neurosurgery, Bezmialem Vakif University Medical School, Istanbul, Turkey
| | - U Harmenberg
- Department of Oncology-Pathology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
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26
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Verhaak E, Gehring K, Hanssens PEJ, Aaronson NK, Sitskoorn MM. Health-related quality of life in adult patients with brain metastases after stereotactic radiosurgery: a systematic, narrative review. Support Care Cancer 2020; 28:473-484. [PMID: 31792879 PMCID: PMC6954134 DOI: 10.1007/s00520-019-05136-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 10/16/2019] [Indexed: 01/03/2023]
Abstract
PURPOSE A growing number of patients with brain metastases (BM) are being treated with stereotactic radiosurgery (SRS), and the importance of evaluating the impact of SRS on the health-related quality of life (HRQoL) in these patients has been increasingly acknowledged. This systematic review summarizes the current knowledge about the HRQoL of patients with BM after SRS. METHODS We searched EMBASE, Medline Ovid, Web-of-Science, the Cochrane Database, PsycINFO Ovid, and Google Scholar up to November 15, 2018. Studies in patients with BM in which HRQoL was assessed before and after SRS and analyzed over time were included. Studies including populations of several types of brain cancer and/or several types of treatments were included if the results for patients with BM and treatment with SRS alone were described separately. RESULTS Out of 3638 published articles, 9 studies met the eligibility criteria and were included. In 4 out of 7 studies on group results, overall HRQoL of patients with BM remained stable after SRS. In small study samples of longer-term survivors, overall HRQoL remained stable up to 12 months post-SRS. Contradictory results were reported for physical and general/global HRQoL, which might be explained by the different questionnaires that were used. CONCLUSIONS In general, SRS does not have significant negative effects on patients' overall HRQoL over time. Future research is needed to analyze different aspects of HRQoL, differences in individual changes in HRQoL after SRS, and factors that influence these changes. These studies should take into account several methodological issues as discussed in this review.
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Affiliation(s)
- Eline Verhaak
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Warandelaan 2, 5037 AB, Tilburg, The Netherlands
| | - Karin Gehring
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands.
- Department of Cognitive Neuropsychology, Tilburg University, Warandelaan 2, 5037 AB, Tilburg, The Netherlands.
| | - Patrick E J Hanssens
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
| | - Neil K Aaronson
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Margriet M Sitskoorn
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Warandelaan 2, 5037 AB, Tilburg, The Netherlands
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Post-operative stereotactic radiosurgery following excision of brain metastases: A systematic review and meta-analysis. Radiother Oncol 2020; 142:27-35. [DOI: 10.1016/j.radonc.2019.08.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 07/21/2019] [Accepted: 08/27/2019] [Indexed: 11/23/2022]
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LeCompte MC, Hughes RT, Farris M, Masters A, Soike MH, Lanier C, Glenn C, Cramer CK, Watabe K, Su J, Ruiz J, Whitlow CT, Wang G, Laxton AW, Tatter SB, Chan MD. Impact of brain metastasis velocity on neurologic death for brain metastasis patients experiencing distant brain failure after initial stereotactic radiosurgery. J Neurooncol 2020; 146:285-292. [PMID: 31894518 DOI: 10.1007/s11060-019-03368-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 12/09/2019] [Accepted: 12/11/2019] [Indexed: 01/04/2023]
Abstract
PURPOSE Patients with high rates of developing new brain metastases have an increased likelihood of dying of neurologic death. It is unclear, however, whether this risk is affected by treatment choice following failure of primary stereotactic radiosurgery (SRS). METHODS From July 2000 to March 2017, 440 patients with brain metastasis were treated with SRS and progressed to have a distant brain failure (DBF). Eighty-seven patients were treated within the immunotherapy era. Brain metastasis velocity (BMV) was calculated for each patient. In general, the institutional philosophy for use of salvage SRS vs whole brain radiotherapy (WBRT) was to postpone the use of WBRT for as long as possible and to treat with salvage SRS when feasible. No further treatment was reserved for patients with poor life expectancy and who were not expected to benefit from salvage treatment. RESULTS Two hundred and eighty-five patients were treated with repeat SRS, 91 patients were treated with salvage WBRT, and 64 patients received no salvage radiation therapy. One-year cumulative incidence of neurologic death after salvage SRS vs WBRT was 15% vs 23% for the low- (p = 0.06), 30% vs 37% for the intermediate- (p < 0.01), and 31% vs 48% (p < 0.01) for the high-BMV group. Salvage WBRT was associated with increased incidence of neurologic death on multivariate analysis (HR 1.64, 95% CI 1.13-2.39, p = 0.01) when compared to repeat SRS. One-year cumulative incidence of neurologic death for patients treated within the immunotherapy era was 9%, 38%, and 38% for low-, intermediate-, and high-BMV groups, respectively (p = 0.01). CONCLUSION Intermediate and high risk BMV groups are predictive of neurologic death. The association between BMV and neurologic death remains strong for patients treated within the immunotherapy era.
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Affiliation(s)
- Michael C LeCompte
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA.
| | - Ryan T Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Michael Farris
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Adrianna Masters
- Department of Radiation Oncology, University Radiologists, S.C., Southern Illinois School of Medicine, Springfield, IL, 62781, USA
| | - Michael H Soike
- Hazelrig-Salter Radiation Oncology Center, University of Alabama at Birmingham, Birmingham, AL, 35233, USA
| | - Claire Lanier
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Chase Glenn
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Christina K Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Jing Su
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA.,Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Jimmy Ruiz
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA.,W.G. (Bill) Hefner Veteran Administration Medical Center, Cancer Center, Salisbury, NC, 28144, USA
| | - Christopher T Whitlow
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Ge Wang
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY, 12180, USA
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
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The Choice of Local Treatment Modalities for Patients with Brain Metastases from Digestive Cancers. JOURNAL OF ONCOLOGY 2019; 2019:1568465. [PMID: 31871456 PMCID: PMC6907058 DOI: 10.1155/2019/1568465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 09/13/2019] [Indexed: 11/17/2022]
Abstract
Background Brain metastases (BMs) from digestive cancers are rare; therefore, no optimal treatment modality has been defined. Methods We retrospectively reviewed the clinical data of 68257 patients with digestive cancers. Propensity score matching (PSM) was used to balance patient backgrounds between groups. Survival differences between different treatment modalities were compared. Univariate and multivariate Cox proportional hazards models were performed to identify prognostic factors on overall survival (OS). Results 270 patients with BM entered the study. In the entire group, the median survival time after diagnosis of brain metastases was 10.25 months (95% CI: 8.41–12.09 months); local treatment could significantly prolong OS (respectively, P < 0.01; even after PSM, P < 0.01); combination treatment was more effective than single treatment modality (respectively, P < 0.01; even after PSM, P < 0.01). However, each combination modality was identically effective (P > 0.05). When patients were divided into three groups based on 1, 2-3, or more than 3 metastatic lesion(s), same results were identified between local treatment and without local treatment (1 lesion, P < 0.01; 2-3 lesions, P < 0.01; more than 3 lesions, P < 0.01, respectively) and combination and single treatment (P < 0.01, P=0.02, P=0.03, respectively). However, there was no difference between different combined treatments (P > 0.05). Multivariate analysis revealed that performance status (P < 0.01), presence of extracranial metastasis (P=0.04), number of BM (P < 0.01), and local treatment for BM (P < 0.01) were independent prognostic factors. Conclusions Regardless of the number of brain lesions, local treatment achieved higher overall survival times than no local treatment, and combination therapy could offer survival benefit to patients as compared with single therapy.
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CD138 plasma cells may predict brain metastasis recurrence following resection and stereotactic radiosurgery. Sci Rep 2019; 9:14385. [PMID: 31591443 PMCID: PMC6779906 DOI: 10.1038/s41598-019-50298-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 08/14/2019] [Indexed: 12/24/2022] Open
Abstract
We sought to identify candidate biomarkers for early brain metastasis (BM) recurrence in patients who underwent craniotomy followed by adjuvant stereotactic radiosurgery. RNA sequencing was performed on eight resected brain metastasis tissue samples and revealed B-cell related genes to be highly expressed in patients who did not experience a distant brain failure and had prolonged overall survival. To translate the findings from RNA sequencing data, we performed immunohistochemistry to stain for B and T cell markers from formalin-fixed parffin-embedded tissue blocks on 13 patients. CD138 expressing plasma cells were identified and quantitatively assessed for each tumor sample. Patients’ tumor tissues that expressed high levels of CD138 plasma cells (N = 4) had a statistically significant improvement in OS compared to low levels of CD138 (N = 9) (p = 0.01). Although these findings are preliminary, the significance of CD138 expressing plasma cells within BM specimens should be investigated in a larger cohort. Immunologic markers based on resection cavity analysis could be predictive for determining patient outcomes following cavity-directed SRS.
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Palmer JD, Greenspoon J, Brown PD, Johnson DR, Roberge D. Neuro-Oncology Practice Clinical Debate: stereotactic radiosurgery or fractionated stereotactic radiotherapy following surgical resection for brain metastasis. Neurooncol Pract 2019; 7:263-267. [PMID: 32537175 DOI: 10.1093/nop/npz047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The treatment of resected brain metastasis has shifted away from the historical use of whole-brain radiotherapy (WBRT) toward adjuvant radiosurgery (stereotactic radiosurgery [SRS]) based on a recent prospective clinical trial demonstrating less cognitive decline with the use of SRS alone and equivalent survival as compared with WBRT. Whereas all level 1 evidence to date concerns single-fraction SRS for postoperative brain metastasis, there is emerging evidence that fractionated stereotactic radiotherapy (FSRT) may improve local control at the resected tumor bed. The lack of direct comparative data for SRS vs FSRT results in a diversity in clinical practice. In this article, Greenspoon and Roberge defend the use of SRS as the standard of care for resected brain metastasis, whereas Palmer and Brown argue for FSRT.
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Affiliation(s)
- Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital at The Ohio State University Wexner Medical Center, Columbus, USA
| | | | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - David Roberge
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Quebec, Canada
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Yuan M, Behrami E, Pannullo S, Schwartz TH, Wernicke AG. The Relationship Between Tumor Volume and Timing of Post-resection Stereotactic Radiosurgery to Maximize Local Control: A Critical Review. Cureus 2019; 11:e5762. [PMID: 31723521 PMCID: PMC6825444 DOI: 10.7759/cureus.5762] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
After maximally safe neurosurgical resection of brain metastases, stereotactic radiosurgery (SRS) is now recommended as an alternative to whole-brain radiation therapy (WBRT), which has been associated with cognitive decline. One complicating factor associated with SRS is that postoperative cavity dynamics can change dramatically, creating significant variability in the recommended timing of SRS. While SRS has been shown to improve local control (LC) in smaller tumor cavities, achieving excellent LC rates still remains a challenge in larger ones. Furthermore, factors predicting the optimal timing of SRS in relation to the cavity size need to be defined and implemented. Variables such as the delay between postoperative MRI and treatment are critical but poorly understood. One potential treatment option that may improve outcomes is brachytherapy, but the widespread implementation of this technique has been slow. This critical review analyzes the relationship between preoperative tumor volume, resection cavity size, and timing of SRS and explores how these variables must be understood in order to achieve the highest LC possible.
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Affiliation(s)
- Melissa Yuan
- Neurological Surgery, NewYork-Presbyterian/Weill Cornell Medical Center, New York, USA
| | - Eltion Behrami
- Radiation Oncology, NewYork-Presbyterian/Weill Cornell Medical Center, New York, USA
| | - Susan Pannullo
- Neurological Surgery, NewYork-Presbyterian/Weill Cornell Medical Center, New York, USA
| | | | - A Gabriella Wernicke
- Radiation Oncology, NewYork-Presbyterian/Weill Cornell Medical Center, New York, USA
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Multidimensional assessment of fatigue in patients with brain metastases before and after Gamma Knife radiosurgery. J Neurooncol 2019; 144:377-384. [PMID: 31350667 PMCID: PMC6700236 DOI: 10.1007/s11060-019-03240-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 07/13/2019] [Indexed: 01/09/2023]
Abstract
PURPOSE Fatigue is a common and distressing symptom in cancer patients which negatively affects patients' daily functioning and health-related quality of life. The aim of this study was to assess multidimensional fatigue in patients with brain metastases (BM) before, and after Gamma Knife radiosurgery (GKRS). METHODS Patients with BM, an expected survival > 3 months, and a Karnofsky Performance Status ≥ 70 and 104 Dutch non-cancer controls were recruited. The Multidimensional Fatigue Inventory (MFI), measuring general fatigue, physical fatigue, mental fatigue, reduced activity and reduced motivation, was used. Baseline levels of fatigue between patients and controls were compared using independent-samples t-tests. The course of fatigue over time, and clinical and psychological predictors thereof, were analyzed using linear mixed models (within-group analyses). RESULTS Ninety-two, 67 and 53 patients completed the MFI at baseline, and 3 and 6 months after GKRS. Before GKRS, patients with BM experienced significantly higher levels of fatigue on all subscales compared to controls (medium to large effect sizes). Over 6 months, general and physical fatigue increased significantly (p = .009 and p < .001), and levels of mental fatigue decreased significantly (p = .027). No significant predictors of the course of fatigue over time could be identified. CONCLUSIONS Fatigue is a major problem for patients with BM. Different patterns over time were observed for the various aspects of fatigue in patients with BM. Information on the various aspects of fatigue is important because fatigue may negatively affect patients' functional independence, health-related quality of life, and adherence to therapy.
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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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Dohm AE, Hughes R, Wheless W, Lecompte M, Lanier C, Ruiz J, Watabe K, Xing F, Su J, Cramer C, Laxton A, Tatter S, Chan MD. Surgical resection and postoperative radiosurgery versus staged radiosurgery for large brain metastases. J Neurooncol 2018; 140:749-756. [PMID: 30367382 DOI: 10.1007/s11060-018-03008-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 09/20/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The purpose of this study was to retrospectively evaluate the new treatment paradigm of staged stereotactic radiosurgery (SRS) for the treatment of large brain metastases (BM) compared to the standard of surgical resection followed by SRS. METHODS We evaluated 78 patients with large BM treated 2012-2017 with surgical resection and postoperative SRS (surgery + SRS) or staged SRS separated by 1 month. Overall survival (OS) was estimated using the Kaplan Meier method and compared across groups using the log-rank test. Cumulative incidence of neurologic death and local and distant brain failure (LF, DBF) were estimated using competing risk methodology. RESULTS Forty patients were treated with surgery + SRS and 38 patients were treated with staged SRS. Median follow-up was 23.2 months (95% CI 20.5-39.3). Median OS was 13.2 months for staged SRS compared to surgery + SRS 9.7 months (p = 0.53). Cumulative incidence of neurologic death at 1 year was 23% after surgery + SRS, 27% after staged SRS (p = 0.69); cumulative incidence of LF at 1 year was 6% and 8% (p = 0.65) and 1-year DBF was 59% and 21% (p ≤ 0.01). Overall rates of leptomeningeal failure and radiation necrosis were similar between the groups (p = 0.63 and p = 1.0). CONCLUSIONS Though surgery and postoperative SRS is the standard, staged SRS represents an attractive treatment paradigm for treating large BM without sacrificing LC or survival, and potentially decreases DBF. Prospective studies are needed to validate these findings.
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Affiliation(s)
- Ammoren E Dohm
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - Ryan Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - William Wheless
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Michael Lecompte
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Claire Lanier
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Jimmy Ruiz
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Fei Xing
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jing Su
- Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Christina Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Adrian Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Stephen Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
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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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Marchan EM, Peterson J, Sio TT, Chaichana KL, Harrell AC, Ruiz-Garcia H, Mahajan A, Brown PD, Trifiletti DM. Postoperative Cavity Stereotactic Radiosurgery for Brain Metastases. Front Oncol 2018; 8:342. [PMID: 30234013 PMCID: PMC6127288 DOI: 10.3389/fonc.2018.00342] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 08/06/2018] [Indexed: 11/26/2022] Open
Abstract
During the past decade, tumor bed stereotactic radiosurgery (SRS) after surgical resection has been increasingly utilized in the management of brain metastases. SRS has risen as an alternative to adjuvant whole brain radiation therapy (WBRT), which has been shown in several studies to be associated with increased neurotoxicity. Multiple recent articles have shown favorable local control rates compared to those of WBRT. Specifically, improvements in local control can be achieved by adding a 2 mm margin around the resection cavity. Risk factors that have been established as increasing the risk of local recurrence after resection include: subtotal resection, larger treatment volume, lower margin dose, and a long delay between surgery and SRS (>3 weeks). Moreover, consensus among experts in the field have established the importance of (a) fusion of the pre-operative magnetic resonance imaging scan to aid in volume delineation (b) contouring the entire surgical tract and (c) expanding the target to include possible microscopic disease that may extend to meningeal or venous sinus territory. These strategies can minimize the risks of symptomatic radiation-induced injury and leptomeningeal dissemination after postoperative SRS. Emerging data has arisen suggesting that multifraction postoperative SRS, or alternatively, preoperative SRS could provide decreased rates of radiation necrosis and leptomeningeal disease. Future prospective randomized clinical trials comparing outcomes between these techniques are necessary in order to improve outcomes in these patients.
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Affiliation(s)
- Eduardo M Marchan
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Jennifer Peterson
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Kaisorn L Chaichana
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, United States
| | - Anna C Harrell
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States.,Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, United States
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Kim IY, Jung S, Jung TY, Moon KS, Jang WY, Park JY, Song TW, Lim SH. Repeat Stereotactic Radiosurgery for Recurred Metastatic Brain Tumors. J Korean Neurosurg Soc 2018; 61:633-639. [PMID: 30064202 PMCID: PMC6129758 DOI: 10.3340/jkns.2017.0238] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 11/24/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE We investigated the outcomes of repeat stereotactic radiosurgery (SRS) for metastatic brain tumors that locally recurred despite previous SRS, focusing on the tumor control. METHODS A total of 114 patients with 176 locally recurring metastatic brain tumors underwent repeat SRS after previous SRS. The mean age was 59.4 years (range, 33 to 85), and there were 68 male and 46 female patients. The primary cancer types were non-small cell lung cancer (n=67), small cell lung cancer (n=12), gastrointestinal tract cancer (n=15), breast cancer (n=10), and others (n=10). The number of patients with a single recurring metastasis was 95 (79.8%), and another 19 had multiple recurrences. At the time of the repeat SRS, the mean volume of the locally recurring tumors was 5.94 mL (range, 0.42 to 29.94). We prescribed a mean margin dose of 17.04 Gy (range, 12 to 24) to the isodose line at the tumor border primarily using a 50% isodose line. RESULTS After the repeat SRS, we obtained clinical and magnetic resonance imaging follow-up data for 84 patients (73.7%) with a total of 108 tumors. The tumor control rate was 53.5% (58 of the 108), and the median and mean progression-free survival (PFS) periods were 246 and 383 days, respectively. The prognostic factors that were significantly related to better tumor control were prescription radiation dose of 16 Gy (p=0.000) and tumor volume less than both 4 mL (p=0.001) and 10 mL at the repeat SRS (p=0.008). The overall survival (OS) periods for all 114 patients after repeat SRS varied from 1 to 56 months, and median and mean OS periods were 229 and 404 days after the repeat SRS, respectively. The main cause of death was systemic problems including pulmonary dysfunction (n=58, 51%), and the identified direct or suspected brain-related death rate was around 20%. CONCLUSION The tumor control following repeat SRS for locally recurring metastatic brain tumors after a previous SRS is relatively lower than that for primary SRS. However, both low tumor volume and high prescription radiation dose were significantly related to the tumor control following repeat SRS for these tumors after previous SRS, which is a general understanding of primary SRS for metastatic brain tumors.
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Affiliation(s)
- In-Young Kim
- Department of Neurosurgery, Brain Tumor Clinic & Gamma Knife Center, Chonnam National University Hwasun Hospital, Chonnam National University College of Medecine, Hwasun, Korea.,Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Shin Jung
- Department of Neurosurgery, Brain Tumor Clinic & Gamma Knife Center, Chonnam National University Hwasun Hospital, Chonnam National University College of Medecine, Hwasun, Korea.,Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Tae-Young Jung
- Department of Neurosurgery, Brain Tumor Clinic & Gamma Knife Center, Chonnam National University Hwasun Hospital, Chonnam National University College of Medecine, Hwasun, Korea.,Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Kyung-Sub Moon
- Department of Neurosurgery, Brain Tumor Clinic & Gamma Knife Center, Chonnam National University Hwasun Hospital, Chonnam National University College of Medecine, Hwasun, Korea.,Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Woo-Youl Jang
- Department of Neurosurgery, Brain Tumor Clinic & Gamma Knife Center, Chonnam National University Hwasun Hospital, Chonnam National University College of Medecine, Hwasun, Korea
| | - Jae-Young Park
- Department of Neurosurgery, Brain Tumor Clinic & Gamma Knife Center, Chonnam National University Hwasun Hospital, Chonnam National University College of Medecine, Hwasun, Korea
| | - Tae-Wook Song
- Department of Neurosurgery, Brain Tumor Clinic & Gamma Knife Center, Chonnam National University Hwasun Hospital, Chonnam National University College of Medecine, Hwasun, Korea
| | - Sa-Hoe Lim
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
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Dohm A, McTyre ER, Okoukoni C, Henson A, Cramer CK, LeCompte MC, Ruiz J, Munley MT, Qasem S, Lo HW, Xing F, Watabe K, Laxton AW, Tatter SB, Chan MD. Staged Stereotactic Radiosurgery for Large Brain Metastases: Local Control and Clinical Outcomes of a One-Two Punch Technique. Neurosurgery 2018; 83:114-121. [PMID: 28973432 DOI: 10.1093/neuros/nyx355] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 06/11/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Treatment options are limited for large, unresectable brain metastases. OBJECTIVE To report a single institution series of staged stereotactic radiosurgery (SRS) that allows for tumor response between treatments in order to optimize the therapeutic ratio. METHODS Patients were treated with staged SRS separated by 1 mo with a median dose at first SRS of 15 Gy (range 10-21 Gy) and a median dose at second SRS of 14 Gy (range 10-18 Gy). Overall survival was evaluated using the Kaplan-Meier method. Cumulative incidences were estimated for neurological death, radiation necrosis, local failure (marginal or central), and distant brain failure. Absolute cumulative dose-volume histogram was created for each treated lesion. Logistic regression and competing risks regression were performed for each discrete dose received by a certain volume. RESULTS Thirty-three patients with 39 lesions were treated with staged radiosurgery. Overall survival at 6 and 12 mo was 65.0% and 60.0%, respectively. Cumulative incidence of local failure at 6 and 12 mo was 3.2% and 13.3%, respectively. Of the patients who received staged therapy, 4 of 33 experienced local failure. Radiation necrosis was seen in 4 of 39 lesions. Two of 33 patients experienced a Radiation Therapy Oncology Group toxicity grade > 2 (2 patients had grade 4 toxicities). Dosimetric analysis revealed that dose (Gy) received by volume of brain (ie, VDose(Gy)) was associated with radiation necrosis, including the range V44.5Gy to V87.8Gy. CONCLUSION Staged radiosurgery is a safe and effective option for large, unresectable brain metastases. Prospective studies are required to validate the findings in this study.
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Affiliation(s)
- Ammoren Dohm
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Emory R McTyre
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Catherine Okoukoni
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Adrianna Henson
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Christina K Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael C LeCompte
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jimmy Ruiz
- Department of Medicine (Hematology and Oncology), Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael T Munley
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Shadi Qasem
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Hui-Wen Lo
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Fei Xing
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael D Chan
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Bilger A, Bretzinger E, Fennell J, Nieder C, Lorenz H, Oehlke O, Grosu A, Specht HM, Combs SE. Local control and possibility of tailored salvage after hypofractionated stereotactic radiotherapy of the cavity after brain metastases resection. Cancer Med 2018; 7:2350-2359. [PMID: 29745035 PMCID: PMC6010898 DOI: 10.1002/cam4.1486] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/07/2018] [Accepted: 03/09/2018] [Indexed: 02/03/2023] Open
Abstract
In patients undergoing surgical resection of brain metastases, the risk of local recurrence remains high. Adjuvant whole brain radiation therapy (WBRT) can reduce the risk of local relapse but fails to improve overall survival. At two tertiary care centers in Germany, a retrospective study was performed to evaluate the role of hypofractionated stereotactic radiotherapy (HFSRT) in patients with brain metastases after surgical resection. In particular, need for salvage treatment, for example, WBRT, surgery, or stereotactic radiosurgery (SRS), was evaluated. Both intracranial local (LF) and locoregional (LRF) failures were analyzed. A total of 181 patients were treated with HFSRT of the surgical cavity. In addition to the assessment of local control and distant intracranial control, we analyzed treatment modalities for tumor recurrence including surgical strategies and reirradiation. Imaging follow-up for the evaluation of LF and LRF was available in 159 of 181 (88%) patients. A total of 100 of 159 (63%) patients showed intracranial progression after HFSRT. A total of 81 of 100 (81%) patients received salvage therapy. Fourteen of 81 patients underwent repeat surgery, and 78 of 81 patients received radiotherapy as a salvage treatment (53% WBRT). Patients with single or few metastases distant from the initial site or with WBRT in the past were retreated by HFSRT (14%) or SRS, 33%. Some patients developed up to four metachronous recurrences, which could be salvaged successfully. Eight (4%) patients experienced radionecrosis. No other severe side effects (CTCAE≥3) were observed. Postoperative HFSRT to the resection cavity resulted in a crude rate for local control of 80.5%. Salvage therapy for intracranial progression was commonly needed, typically at distant sites. Salvage therapy was performed with WBRT, SRS, and surgery or repeated HFSRT of the resection cavity depending on the tumor spread and underlying histology. Prospective studies are warranted to clarify whether or not the sequence of these therapies is important in terms of quality of life, risk of radiation necrosis, and likelihood of neurological cause of death.
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Affiliation(s)
- Angelika Bilger
- Department of Radiation OncologyMedical Center, Medical FacultyUniversity of FreiburgFreiburg im BreisgauGermany
| | - Eva Bretzinger
- Department of Radiation OncologyMedical Center, Medical FacultyUniversity of FreiburgFreiburg im BreisgauGermany
| | - Jamina Fennell
- Department of Radiation OncologyMedical Center, Medical FacultyUniversity of FreiburgFreiburg im BreisgauGermany
| | - Carsten Nieder
- Department of Oncology and Palliative MedicineNordland HospitalBodøNorway
- Institute of Clinical Medicine, Faculty of Health SciencesUniversity of TromsøTromsøNorway
| | - Hannah Lorenz
- Department of Radiation OncologyMedical Center, Medical FacultyUniversity of FreiburgFreiburg im BreisgauGermany
| | - Oliver Oehlke
- Department of Radiation OncologyMedical Center, Medical FacultyUniversity of FreiburgFreiburg im BreisgauGermany
| | - Anca‐Ligia Grosu
- Department of Radiation OncologyMedical Center, Medical FacultyUniversity of FreiburgFreiburg im BreisgauGermany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site FreiburgFreiburg im BreisgauGermany
| | - Hanno M. Specht
- Department of Radiation Oncology, Klinikumrechts der IsarTechnical University of MunichMunichGermany
| | - Stephanie E. Combs
- Department of Radiation Oncology, Klinikumrechts der IsarTechnical University of MunichMunichGermany
- Institute of Innovative Radiotherapy (iRT)Helmholtz Zentrum MunichOberschleißheimGermany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site MunichMunichGermany
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41
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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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42
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El Shafie RA, Paul A, Bernhardt D, Hauswald H, Welzel T, Sprave T, Hommertgen A, Krisam J, Schmitt D, Klüter S, Schubert K, Klose C, Kieser M, Debus J, Rieken S. Evaluation of Stereotactic Radiotherapy of the Resection Cavity After Surgery of Brain Metastases Compared to Postoperative Whole-Brain Radiotherapy (ESTRON)—A Single-Center Prospective Randomized Trial. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Neurosurgical resection is recommended for symptomatic brain metastases, in oligometastatic patients or for histology acquisition. Without adjuvant radiotherapy, roughly two-thirds of the patients relapse at the resection site within 24 mo, while the risk of new metastases in the untreated brain is around 50%. Adjuvant whole-brain radiotherapy (WBRT) can reduce the risk of both scenarios of recurrence significantly, although the associated neurocognitive toxicity is substantial, while stereotactic radiotherapy (SRT) improves local control at comparably low toxicity.
OBJECTIVE
To compare locoregional control and treatment-associated toxicity for postoperative SRT and WBRT after the resection of 1 brain metastasis in a single-center prospective randomized study.
METHODS
Fifty patients will be randomized to receive either hypofractionated SRT of the resection cavity and single- or multisession SRT of all unresected brain metastases (up to 10 lesions) or WBRT. Patients will be followed-up regularly and the primary endpoint of neurological progression-free survival will be assessed by magnetic resonance imaging (MRI). Quality of life and neurocognition will be assessed in 3-mo intervals using standardized tests and EORTC questionnaires.
EXPECTED OUTCOMES
We expect to show that postoperative SRT of the resection cavity and further unresected brain metastases is a valid means of improving locoregional control over observation at less neurocognitive toxicity than caused by WBRT.
DISCUSSION
The present study is the first to compare locoregional control as well as neurocognitive toxicity for postoperative SRT and WBRT in patients with up to 10 metastases, while utilizing a highly sensitive and standardized MRI protocol for treatment planning and follow-up.
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Affiliation(s)
- Rami A El Shafie
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Angela Paul
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
- Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Henrik Hauswald
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Thomas Welzel
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Tanja Sprave
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Adriane Hommertgen
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Johannes Krisam
- Institute for Medical Biometry and Informatics (IMBI), Heidelberg University Hospital, Heidelberg, Germany
| | - Daniela Schmitt
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Sebastian Klüter
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Kai Schubert
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Christina Klose
- Institute for Medical Biometry and Informatics (IMBI), Heidelberg University Hospital, Heidelberg, Germany
| | - Meinhard Kieser
- Institute for Medical Biometry and Informatics (IMBI), Heidelberg University Hospital, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
- Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
- Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
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Vetlova ER, Golanov AV, Banov SM. [A modern strategy of combined surgical and radiation treatment in patients with brain metastases]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2018; 81:108-115. [PMID: 29393294 DOI: 10.17116/neiro2017816108-115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The treatment standards for patients with brain metastases have been developed for several decades. An important element in the evolution of approaches to the treatment of these patients is the development of microsurgery, stereotactic radiotherapy, and targeted therapy and introduction of these techniques into clinical practice. Surgery is an effective treatment option in patients having single brain metastases and/or occuring in life-threatening clinical situations. Irradiation of the whole brain after surgical treatment is a necessary step in achieving satisfactory local control of intracranial metastatic foci, but the development of neurocognitive disorders and deterioration of life quality after this irradiation necessitate the search for alternative radiotherapy techniques in this clinical situation. Currently, an alternative to postoperative irradiation of the whole brain is stereotactic radiotherapy, which is used before or after surgical treatment. Stereotactic radiotherapy improves local control of intracranial metastatic foci and reduces the risk of neurotoxicity. In this review, we analyze the literature data on outcomes of stereotactic irradiation as a component of combined treatment of patients with metastatic brain lesions.
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Affiliation(s)
- E R Vetlova
- Burdenko Neurosurgical Institute, Moscow, Russia, 125047
| | - A V Golanov
- Burdenko Neurosurgical Institute, Moscow, Russia, 125047
| | - S M Banov
- Gamma Knife Center, Moscow, Russia, 125047
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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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45
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Radiation Therapy in Brain Metastasis of Solid Tumors: A Challenge for the Future. Radiat Oncol 2018. [DOI: 10.1007/978-3-319-52619-5_12-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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46
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Shenker RF, Hughes RT, McTyre ER, Lanier C, Lo HW, Metheny-Barlow L, Su J, Thomas A, Brown DR, Avery T, Pasche B, Cramer CK, Laxton AW, Tatter SB, Watabe K, Chan MD. Potential prognostic markers for survival and neurologic death in patients with breast cancer brain metastases who receive upfront SRS alone. JOURNAL OF RADIOSURGERY AND SBRT 2018; 5:277-283. [PMID: 30538888 PMCID: PMC6255726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 06/26/2018] [Indexed: 06/09/2023]
Abstract
PURPOSE/OBJECTIVES Stereotactic radiosurgery (SRS) is used as a treatment option for breast cancer brain metastases. It is unclear what factors predict neurologic death for these patients. MATERIALS/METHODS A total of 128 patients with breast cancer brain metastases were treated with upfront SRS alone in this study. Survival was estimated using the Kaplan-Meier method. Clinicopathologic factors evaluated included age, ER/PR status, Her2 status, numbers of brain metastases treated, minimum SRS dose, disease-specific GPA, extracranial disease status and systemic disease burden. RESULTS ER or PR positivity was associated with a trend towards decreased neurologic death (subdistribution hazard ratio (sHR) = 0.54, p=0.06). Factors associated with non-neurologic death include extracranial disease status (sHR = 2.02, p=0.02) and dose (sHR = 1.11, p=0.02); Her2-positivity was associated with reduced hazard of non-neurologic death (sHR 0.52, p=0.05). CONCLUSIONS ER/PR positivity was associated with a trend towards less neurologic death. HER2 positivity was associated with a trend towards less non-neurologic death.
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Affiliation(s)
- Rachel F Shenker
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Ryan T Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Emory R McTyre
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Claire Lanier
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Hui-Wen Lo
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Linda Metheny-Barlow
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Jing Su
- Department of Biostatistics, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Alexandra Thomas
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Doris R Brown
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Tiffany Avery
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Boris Pasche
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Christina K Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
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LeCompte MC, McTyre ER, Strowd RE, Lanier C, Soike MH, Hughes RT, Masters AH, Cramer CK, Farris M, Ruiz J, Watabe K, Laxton AW, Tatter SB, Winkfield KM, Chan MD. Impact of diabetes mellitus on outcomes in patients with brain metastasis treated with stereotactic radiosurgery. JOURNAL OF RADIOSURGERY AND SBRT 2018; 5:285-291. [PMID: 30538889 PMCID: PMC6255719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 09/06/2018] [Indexed: 06/09/2023]
Abstract
PURPOSE To determine the influence of diabetes mellitus (DM) on outcomes in patients with brain metastasis treated with stereotactic radiosurgery (SRS). METHODS We retrospectively reviewed 498 patients with brain metastasis treated at our institution with SRS between January 2012 and March 2017. RESULTS Eight-four patients (16.9%) held a diagnosis of DM prior to SRS treatment. Diabetics compared to nondiabetics had worse overall survival (OS). DM was found to be a significant predictor of OS on multivariate analysis (HR: 1.41, CI: 1.03-1.92, p = 0.03). When stratified by DM diagnosis, there were no significant differences in incidence of radiation necrosis (p = 0.82), radiation-induced edema (p = 0.88), cerebrospinal fluid leak (p = 0.49), or postoperative infection (p = 0.68). CONCLUSIONS DM diagnosis was a significant predictor of poorer OS in patients treated for brain metastasis with SRS. Diabetics and nondiabetics experienced similar rates of radiation-associated brain toxicities.
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Affiliation(s)
- Michael C LeCompte
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA
| | - Emory R McTyre
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA
| | - Roy E Strowd
- Department of Neurology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27517, USA
| | - Claire Lanier
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA
| | - Michael H Soike
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA
| | - Ryan T Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA
| | - Adrianna H Masters
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA
| | - Christina K Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA
| | - Michael Farris
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA
| | - Jimmy Ruiz
- Department of Medicine (Hematology and Oncology), Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA
- W.G. (Bill) Hefner Veteran Administration Medical Center, Cancer Center, 1601 Brenner Ave, Salisbury, NC, 28144, USA
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA
| | - Karen M Winkfield
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, USA
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48
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McTyre ER, Johnson AG, Ruiz J, Isom S, Lucas JT, Hinson WH, Watabe K, Laxton AW, Tatter SB, Chan MD. Predictors of neurologic and nonneurologic death in patients with brain metastasis initially treated with upfront stereotactic radiosurgery without whole-brain radiation therapy. Neuro Oncol 2017; 19:558-566. [PMID: 27571883 DOI: 10.1093/neuonc/now184] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 07/22/2016] [Indexed: 11/13/2022] Open
Abstract
Background In this study we attempted to discern the factors predictive of neurologic death in patients with brain metastasis treated with upfront stereotactic radiosurgery (SRS) without whole brain radiation therapy (WBRT) while accounting for the competing risk of nonneurologic death. Methods We performed a retrospective single-institution analysis of patients with brain metastasis treated with upfront SRS without WBRT. Competing risks analysis was performed to estimate the subdistribution hazard ratios (HRs) for neurologic and nonneurologic death for predictor variables of interest. Results Of 738 patients treated with upfront SRS alone, neurologic death occurred in 226 (30.6%), while nonneurologic death occurred in 309 (41.9%). Multivariate competing risks analysis identified an increased hazard of neurologic death associated with diagnosis-specific graded prognostic assessment (DS-GPA) ≤ 2 (P = .005), melanoma histology (P = .009), and increased number of brain metastases (P<.001), while there was a decreased hazard associated with higher SRS dose (P = .004). Targeted agents were associated with a decreased HR of neurologic death in the first 1.5 years (P = .04) but not afterwards. An increased hazard of nonneurologic death was seen with increasing age (P =.03), nonmelanoma histology (P<.001), presence of extracranial disease (P<.001), and progressive systemic disease (P =.004). Conclusions Melanoma, DS-GPA, number of brain metastases, and SRS dose are predictive of neurologic death, while age, nonmelanoma histology, and more advanced systemic disease are predictive of nonneurologic death. Targeted agents appear to delay neurologic death.
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Affiliation(s)
- Emory R McTyre
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Adam G Johnson
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jimmy Ruiz
- Department of Medicine (Hematology & Oncology), Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,W. G. (Bill) Hefner Veteran Administration Medical Center, Cancer Center, Salisbury, North Carolina, USA
| | - Scott Isom
- Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, North Carolina, USA
| | - John T Lucas
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - William H Hinson
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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49
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Foreman PM, Jackson BE, Singh KP, Romeo AK, Guthrie BL, Fisher WS, Riley KO, Markert JM, Willey CD, Bredel M, Fiveash JB. Postoperative radiosurgery for the treatment of metastatic brain tumor: Evaluation of local failure and leptomeningeal disease. J Clin Neurosci 2017; 49:48-55. [PMID: 29248376 DOI: 10.1016/j.jocn.2017.12.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 10/23/2017] [Accepted: 12/03/2017] [Indexed: 11/18/2022]
Abstract
In patients undergoing surgical resection of a metastatic brain tumor, whole brain radiation therapy reduces the risk of recurrence and neurologic death. Focal radiation has the potential to mitigate neurocognitive side effects. We present an institutional experience of postoperative radiosurgery for the treatment of brain metastases. A retrospective review of a prospectively maintained institutional radiosurgery database was performed for the years 2005-2015 identifying all adult patients treated with postoperative radiosurgery to the tumor bed. Primary endpoints include local recurrence and postoperative LMD. Kaplan-Meier curves and Cox regression were used to evaluate time to local recurrence and postoperative LMD. Ninety-one patients received adjuvant focal radiation for a brain metastasis. Median radiographic follow-up among patients who had not developed a local failure was 9 months. Of the 91 patients, 20 (22%) developed local recurrence and 32 (35%) experienced postoperative LMD. Freedom from local recurrence and LMD at 1 year was 84% and 69%, respectively. In multivariable models, predictors of local failure included the presence of more than one brain metastasis (HR = 2.65, p = .04) with a preoperative tumor diameter of >3 cm (HR = 4.16, p = .06) trending toward significance. There was a trend to a higher risk of LMD with >1 tumor (HR 2.07, p = .06) and breast cancer (HR 2.37, p = .07). More than one metastasis is an independent predictor of local and leptomeningeal failure following postoperative radiosurgery. The high rate of LMD was likely related to the liberal definition of LMD to include focal dural recurrences.
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Affiliation(s)
- Paul M Foreman
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Bradford E Jackson
- Division of Preventative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Karan P Singh
- Division of Preventative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Andrew K Romeo
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Barton L Guthrie
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Winfield S Fisher
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kristen O Riley
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - James M Markert
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Christopher D Willey
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Markus Bredel
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - John B Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
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50
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Dohm A, McTyre ER, Chan MD, Fan C, Isom S, Bourland JD, Mott RT, Cramer CK, Tatter SB, Laxton AW. Early or late radiotherapy following gross or subtotal resection for atypical meningiomas: Clinical outcomes and local control. J Clin Neurosci 2017; 46:90-98. [PMID: 28917587 PMCID: PMC5693228 DOI: 10.1016/j.jocn.2017.08.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 08/10/2017] [Indexed: 10/18/2022]
Abstract
We report a single institution series of surgery followed by either early adjuvant or late radiotherapy for atypical meningiomas (AM). AM patients, by WHO 2007 definition, underwent subtotal resection (STR) or gross total resection (GTR). Sixty-three of a total 115 patients then received fractionated or stereotactic radiation treatment, early adjuvant radiotherapy (≤4months after surgery) or late radiotherapy (at the time of recurrence). Kaplan Meier method was used for survival analysis with competing risk analysis used to assess local failure. Overall survival (OS) at 1, 2, and 5years for all patients was 87%, 85%, 66%, respectively. Progression free survival (PFS) at 1, 2, and 5years for all patients was 65%, 30%, and 18%, respectively. OS at 1, 2, and 5years was 75%, 72%, 55% for surgery alone, and 97%, 95%, 75% for surgery+radiotherapy (log-rank p-value=0.0026). PFS at 1, 2, and 5years for patients undergoing surgery without early adjuvant radiotherapy was 64%, 49%, and 27% versus 81%, 73%, and 59% for surgery+early adjuvant radiotherapy (log-rank p-value=0.0026). The cumulative incidence of local failure at 1, 2, and 5years for patients undergoing surgery without early External Beam Radiation Therapy (EBRT) was 18.7%, 35.0%, and 52.9%, respectively, versus 4.2%, 13.3%, and 20.0% for surgery and early EBRT (p-value=0.02). Adjuvant radiotherapy improves OS in patients with AM. Early adjuvant radiotherapy improves PFS, likely due to the improvement in local control seen with early adjuvant EBRT.
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Affiliation(s)
- Ammoren Dohm
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, United States.
| | - Emory R McTyre
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Claire Fan
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Scott Isom
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - J Daniel Bourland
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Ryan T Mott
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Christina K Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, United States
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