1
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Shireman JM, White Q, Ni Z, Mohanty C, Cai Y, Zhao L, Agrawal N, Gonugunta N, Wang X, Mccarthy L, Kasulabada V, Pattnaik A, Ahmed AU, Miller J, Kulwin C, Cohen-Gadol A, Payner T, Lin CT, Savage JJ, Lane B, Shiue K, Kamer A, Shah M, Iyer G, Watson G, Kendziorski C, Dey M. Genomic analysis of human brain metastases treated with stereotactic radiosurgery reveals unique signature based on treatment failure. iScience 2024; 27:109601. [PMID: 38623341 PMCID: PMC11016778 DOI: 10.1016/j.isci.2024.109601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 03/12/2024] [Accepted: 03/25/2024] [Indexed: 04/17/2024] Open
Abstract
Stereotactic radiosurgery (SRS) has been shown to be efficacious for the treatment of limited brain metastasis (BM); however, the effects of SRS on human brain metastases have yet to be studied. We performed genomic analysis on resected brain metastases from patients whose resected lesion was previously treated with SRS. Our analyses demonstrated for the first time that patients possess a distinct genomic signature based on type of treatment failure including local failure, leptomeningeal spread, and radio-necrosis. Examination of the center and peripheral edge of the tumors treated with SRS indicated differential DNA damage distribution and an enrichment for tumor suppressor mutations and DNA damage repair pathways along the peripheral edge. Furthermore, the two clinical modalities used to deliver SRS, LINAC and GK, demonstrated differential effects on the tumor landscape even between controlled primary sites. Our study provides, in human, biological evidence of differential effects of SRS across BM's.
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Affiliation(s)
- Jack M. Shireman
- Department of Neurosurgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Quinn White
- Department of Biostatistics and Medical Informatics, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Zijian Ni
- Department of Biostatistics and Medical Informatics, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Chitrasen Mohanty
- Department of Biostatistics and Medical Informatics, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Yujia Cai
- Department of Biostatistics and Medical Informatics, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Lei Zhao
- Department of Neurosurgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Namita Agrawal
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nikita Gonugunta
- Department of Neurosurgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Xiaohu Wang
- Department of Neurosurgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Liam Mccarthy
- Department of Neurosurgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Varshitha Kasulabada
- Department of Neurosurgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Akshita Pattnaik
- Department of Neurosurgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Atique U. Ahmed
- Department of Neurological Surgery, Northwestern University, Chicago, IL, USA
| | - James Miller
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Charles Kulwin
- Goodman Campbell Brain and Spine Neurological Surgery, Indianapolis, IN, USA
| | - Aaron Cohen-Gadol
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Troy Payner
- Goodman Campbell Brain and Spine Neurological Surgery, Indianapolis, IN, USA
| | - Chih-Ta Lin
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jesse J. Savage
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Brandon Lane
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kevin Shiue
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Aaron Kamer
- Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mitesh Shah
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Gopal Iyer
- Department of Human Oncology, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Gordon Watson
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Christina Kendziorski
- Department of Biostatistics and Medical Informatics, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Mahua Dey
- Department of Neurosurgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
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2
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Dharnipragada R, Dusenbery K, Watanabe Y, Ferreira C, Chen CC. Comparison of Gamma Knife (GK) and Linear Accelerator (LINAC) radiosurgery of brain metastasis resection cavity: a systematic review and proportional meta-analysis. Clin Exp Metastasis 2024; 41:1-8. [PMID: 37943360 DOI: 10.1007/s10585-023-10240-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/16/2023] [Indexed: 11/10/2023]
Abstract
PURPOSE Stereotactic radiosurgery (SRS) to the resection cavity is essential in the treatment of brain metastasis (BM) amenable to surgical resection. The two most common platforms for SRS delivery include Gamma Knife (GK) and LINAC. Here we collated the available peer-reviewed literature and performed a meta-analysis on clinical outcomes after GK or LINAC resection cavity SRS. METHODS Following PRISMA Guidelines, a search on PUBMED and MEDLINE was performed to include all studies evaluating each post-operative SRS modality. Local control, overall survival, radiation necrosis, and leptomeningeal disease were evaluated from the available data. A proportional meta-analysis was performed via R using the metafor package to pool the outcomes of studies and a moderator effect to assess the significance between groups. RESULTS We identified 21 GK studies (n = 2009) and 28 LINAC studies (n = 2219). The radiosurgery doses employed were comparable between GK and LINAC studies. The pooled estimate of 1-year local control, 1-year overall survival, and risk of leptomeningeal disease were statistically comparable between GK and LINAC (81.7 v 85.8%; 61.4 v 62.7%; 10.6 v 12.5%, respectively). However, the risk of radiation necrosis (RN) was higher for LINAC resection cavity SRS (5.4% vs. 10%, p = 0.036). The volume of the resection cavity was a significant modifying factor for RN in both modalities (p = 0.007) with a 0.5% and 0.7% increase in RN risk with every 1 cm3 increase in tumor volume for GK and LINAC, respectively. CONCLUSIONS Our meta-analysis suggests that GK and LINAC SRS of resection cavity achieve comparable 1-year local control and survival. However, resection cavity treated with GK SRS was associated with lowered RN risk relative to those treated with LINAC SRS.
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Affiliation(s)
- Rajiv Dharnipragada
- University of Minnesota Medical School, University of Minnesota Twin-Cities, 420 Delaware Street SE, Minneapolis, MN, 55455, USA.
- University of Minnesota Medical School, University of Minnesota Twin-Cities, 420 Delaware Street SE, Minneapolis, MN, 55455, USA.
| | - Kathryn Dusenbery
- Department of Radiation Oncology, University of Minnesota Twin Cities, Minneapolis, MN, 55455, USA
| | - Yoichi Watanabe
- Department of Radiation Oncology, University of Minnesota Twin Cities, Minneapolis, MN, 55455, USA
| | - Clara Ferreira
- Department of Radiation Oncology, University of Minnesota Twin Cities, Minneapolis, MN, 55455, USA
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota Twin-Cities, Minneapolis, MN, 55455, USA
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3
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Lehrer EJ, Khosla AA, Ozair A, Gurewitz J, Bernstein K, Kondziolka D, Niranjan A, Wei Z, Lunsford LD, Mathieu D, Trudel C, Deibert CP, Malouff TD, Ruiz-Garcia H, Peterson JL, Patel S, Bonney P, Hwang L, Yu C, Zada G, Picozzi P, Franzini A, Attuati L, Prasad RN, Raval RR, Palmer JD, Lee CC, Yang HC, Fakhoury KR, Rusthoven CG, Dickstein DR, Sheehan JP, Trifiletti DM, Ahluwalia MS. Immune checkpoint inhibition and single fraction stereotactic radiosurgery in brain metastases from non-small cell lung cancer: an international multicenter study of 395 patients. J Neurooncol 2023; 165:63-77. [PMID: 37889444 DOI: 10.1007/s11060-023-04413-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/02/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE Approximately 80% of brain metastases originate from non-small cell lung cancer (NSCLC). Immune checkpoint inhibitors (ICI) and stereotactic radiosurgery (SRS) are frequently utilized in this setting. However, concerns remain regarding the risk of radiation necrosis (RN) when SRS and ICI are administered concurrently. METHODS A retrospective study was conducted through the International Radiosurgery Research Foundation. Logistic regression models and competing risks analyses were utilized to identify predictors of any grade RN and symptomatic RN (SRN). RESULTS The study included 395 patients with 2,540 brain metastases treated with single fraction SRS and ICI across 11 institutions in four countries with a median follow-up of 14.2 months. The median age was 67 years. The median margin SRS dose was 19 Gy; 36.5% of patients had a V12 Gy ≥ 10 cm3. On multivariable analysis, V12 Gy ≥ 10 cm3 was a significant predictor of developing any grade RN (OR: 2.18) and SRN (OR: 3.95). At 1-year, the cumulative incidence of any grade and SRN for all patients was 4.8% and 3.8%, respectively. For concurrent and non-concurrent groups, the cumulative incidence of any grade RN was 3.8% versus 5.3%, respectively (p = 0.35); and for SRN was 3.8% vs. 3.6%, respectively (p = 0.95). CONCLUSION The risk of any grade RN and symptomatic RN following single fraction SRS and ICI for NSCLC brain metastases increases as V12 Gy exceeds 10 cm3. Concurrent ICI and SRS do not appear to increase this risk. Radiosurgical planning techniques should aim to minimize V12 Gy.
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Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA.
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Atulya A Khosla
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Ahmad Ozair
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Jason Gurewitz
- Department of Radiation Oncology, NYU Langone Medical Center, New York, NY, USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Medical Center, New York, NY, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | - Claire Trudel
- Department of Medicine, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | | | - Timothy D Malouff
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Samir Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Phillip Bonney
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - Lindsay Hwang
- Department of Radiation Oncology, University of Southern California, Los Angeles, CA, USA
| | - Cheng Yu
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - Piero Picozzi
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano (Mi), Italy
| | - Andrea Franzini
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano (Mi), Italy
| | - Luca Attuati
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano (Mi), Italy
| | - Rahul N Prasad
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Raju R Raval
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Kareem R Fakhoury
- Department of Radiation Oncology, University of Colorado, Denver, CO, USA
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Denver, CO, USA
| | - Daniel R Dickstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
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4
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Nead KT, Haas A, Joo L, Wehner MR. Letter to the Editor. Challenges of immortal time biases in observational research. J Neurosurg 2023; 138:1482-1484. [PMID: 36461819 DOI: 10.3171/2022.10.jns222203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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5
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Yamamoto Y, Ohira S, Kanayama N, Inui S, Ueda Y, Koike Y, Miyazaki M, Nishio T, Koizumi M, Konishi K. Comparison of dosimetric parameters and robustness for rotational errors in fractionated stereotactic irradiation using automated noncoplanar volumetric modulated arc therapy for patients with brain metastases: single- versus multi-isocentric technique. Radiol Phys Technol 2023; 16:310-318. [PMID: 37093409 DOI: 10.1007/s12194-023-00720-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 04/25/2023]
Abstract
To compare the dosimetric parameters of automated noncoplanar volumetric modulated arc therapy plans using single-isocentric (SIC) and multi-isocentric (MIC) techniques for patients with two brain metastases (BMs) in stereotactic irradiation and to evaluate the robustness of rotational errors. The SIC and MIC plans were retrospectively generated (35 Gy/five fractions) for 58 patients. Subsequently, a receiver operating characteristic curve analysis between the tumor surface distance (TSD) and V25Gy was performed to determine the thresholds for the brain tissue. The SIC and MIC plans were recalculated based on the rotational images to evaluate the dosimetric impact of rotational error. The MIC plans showed better brain tissue sparing for TSD > 6.6 cm. The SIC plans provided a significantly better conformity index for TSD ≤ 6.6 cm, while significantly lower gradient index was obtained (3.22 ± 0.56vs. 3.30 ± 0.57, p < 0.05) in the MIC plans with TSD > 6.6 cm. For organs at risk (OARs) (brainstem, chiasm, lens, optic nerves, and retinas), D0.1 cc was significantly lower (p < 0.05) in the MIC plans than in the SIC plans. The prescription dose could be delivered (D99%) to the gross tumor volume (GTV) for patients with TSD ≤ 6.6 cm when the rotational error was < 1°, whereas 31% of the D99% of GTV fell below the prescription dose with TSD > 6.6 cm. MIC plans can be an optimal approach for reducing doses to OARs and providing robustness against rotational errors in BMs with TSD > 6.6 cm.
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Affiliation(s)
- Yuki Yamamoto
- Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shingo Ohira
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, Osaka, 537-8567, Japan.
| | - Naoyuki Kanayama
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, Osaka, 537-8567, Japan
| | - Shoki Inui
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, Osaka, 537-8567, Japan
| | - Yoshihiro Ueda
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, Osaka, 537-8567, Japan
| | - Yuhei Koike
- Department of Radiology, Kansai Medical University, Osaka, Japan
| | - Masayoshi Miyazaki
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, Osaka, 537-8567, Japan
| | - Teiji Nishio
- Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masahiko Koizumi
- Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, Suita, Japan
| | - Koji Konishi
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, Osaka, 537-8567, Japan
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6
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Shireman JM, White Q, Agrawal N, Ni Z, Chen G, Zhao L, Gonugunta N, Wang X, Mccarthy L, Kasulabada V, Pattnaik A, Ahmed AU, Miller J, Kulwin C, Cohen-Gadol A, Payner T, Lin CT, Savage JJ, Lane B, Shiue K, Kamer A, Shah M, Iyer G, Watson G, Kendziorski C, Dey M. Genomic Analysis of Human Brain Metastases Treated with Stereotactic Radiosurgery Under the Phase-II Clinical Trial (NCT03398694) Reveals DNA Damage Repair at the Peripheral Tumor Edge. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.15.23288491. [PMID: 37131583 PMCID: PMC10153341 DOI: 10.1101/2023.04.15.23288491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Stereotactic Radiosurgery (SRS) is one of the leading treatment modalities for oligo brain metastasis (BM), however no comprehensive genomic data assessing the effect of radiation on BM in humans exist. Leveraging a unique opportunity, as part of the clinical trial (NCT03398694), we collected post-SRS, delivered via Gamma-knife or LINAC, tumor samples from core and peripheral-edges of the resected tumor to characterize the genomic effects of overall SRS as well as the SRS delivery modality. Using these rare patient samples, we show that SRS results in significant genomic changes at DNA and RNA levels throughout the tumor. Mutations and expression profiles of peripheral tumor samples indicated interaction with surrounding brain tissue as well as elevated DNA damage repair. Central samples show GSEA enrichment for cellular apoptosis while peripheral samples carried an increase in tumor suppressor mutations. There are significant differences in the transcriptomic profile at the periphery between Gamma-knife vs LINAC.
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Affiliation(s)
- Jack M. Shireman
- Department of Neurosurgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Quinn White
- Department of Biostatistics and Medical Informatics, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Namita Agrawal
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Zijian Ni
- Department of Biostatistics and Medical Informatics, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Grace Chen
- Department of Biostatistics and Medical Informatics, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Lei Zhao
- Department of Neurosurgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Nikita Gonugunta
- Department of Neurosurgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Xiaohu Wang
- Department of Neurosurgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Liam Mccarthy
- Department of Neurosurgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Varshitha Kasulabada
- Department of Neurosurgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Akshita Pattnaik
- Department of Neurosurgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Atique U. Ahmed
- Department of Neurological Surgery, Northwestern University, Chicago, IL, USA
| | - James Miller
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Charles Kulwin
- Goodman Campbell Brain and Spine Neurological Surgery, Indianapolis, IN, USA
| | - Aaron Cohen-Gadol
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Troy Payner
- Goodman Campbell Brain and Spine Neurological Surgery, Indianapolis, IN, USA
| | - Chih-Ta Lin
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jesse J. Savage
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Brandon Lane
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kevin Shiue
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Aaron Kamer
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mitesh Shah
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Gopal Iyer
- Department of Human Oncology, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Gordon Watson
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Christina Kendziorski
- Department of Biostatistics and Medical Informatics, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Mahua Dey
- Department of Neurosurgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
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7
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Nardone V, Romeo C, D'Ippolito E, Pastina P, D'Apolito M, Pirtoli L, Caraglia M, Mutti L, Bianco G, Falzea AC, Giannicola R, Giordano A, Tagliaferri P, Vinciguerra C, Desideri I, Loi M, Reginelli A, Cappabianca S, Tassone P, Correale P. The role of brain radiotherapy for EGFR- and ALK-positive non-small-cell lung cancer with brain metastases: a review. LA RADIOLOGIA MEDICA 2023; 128:316-329. [PMID: 36786970 PMCID: PMC10020247 DOI: 10.1007/s11547-023-01602-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 01/24/2023] [Indexed: 02/15/2023]
Abstract
Non-small cell lung cancer (NSCLC) is frequently complicated by central nervous system (CNS) metastases affecting patients' life expectancy and quality. At the present clinical trials including neurosurgery, radiotherapy (RT) and systemic treatments alone or in combination have provided controversial results. CNS involvement is even more frequent in NSCLC patients with EGFR activating mutations or ALK rearrangement suggesting a role of target therapy in the upfront treatment in place of loco-regionals treatments (i.e. RT and/or surgery). So far clinical research has not explored the potential role of accurate brain imaging (i.e. MRI instead of the routine total-body contrast CT and/or PET/CT staging) to identify patients that could benefit of local therapies. Moreover, for patients who require concomitant RT there are no clear guidelines on the timing of intervention with respect to innovative precision medicine approaches with Tyrosine Kinase Inhibitors, ALK-inhibitors and/or immuno-oncological therapies. On this basis the present review describes the therapeutic strategies integrating medical and radiation oncology in patients with metastatic NSCLC (mNSCLC) adenocarcinoma with CNS involvement and EGFR activating mutations or ALK rearrangement.
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Affiliation(s)
- Valerio Nardone
- Department of Precision Medicine, University of Campania "L. Vanvitelli", 80138, Naples, Italy.
| | - Caterina Romeo
- Medical Oncology Unit, "Bianchi Melacrino Morelli" Grand Metropolitan Hospital, Reggio Calabria, Italy
| | - Emma D'Ippolito
- Department of Precision Medicine, University of Campania "L. Vanvitelli", 80138, Naples, Italy
| | | | - Maria D'Apolito
- Medical Oncology Unit, "Bianchi Melacrino Morelli" Grand Metropolitan Hospital, Reggio Calabria, Italy
| | - Luigi Pirtoli
- Sbarro Institute for Cancer Research and Molecular Medicine and Center of Biotechnology, College of Science and Technology, Temple University, Philadelphia, PA, 19122, USA
| | - Michele Caraglia
- Department of Precision Medicine, University of Campania "L. Vanvitelli", 80138, Naples, Italy
| | - Luciano Mutti
- Sbarro Institute for Cancer Research and Molecular Medicine and Center of Biotechnology, College of Science and Technology, Temple University, Philadelphia, PA, 19122, USA
| | - Giovanna Bianco
- Medical Oncology Unit, "Bianchi Melacrino Morelli" Grand Metropolitan Hospital, Reggio Calabria, Italy
| | - Antonella Consuelo Falzea
- Medical Oncology Unit, "Bianchi Melacrino Morelli" Grand Metropolitan Hospital, Reggio Calabria, Italy
| | - Rocco Giannicola
- Medical Oncology Unit, "Bianchi Melacrino Morelli" Grand Metropolitan Hospital, Reggio Calabria, Italy
| | - Antonio Giordano
- Sbarro Institute for Cancer Research and Molecular Medicine and Center of Biotechnology, College of Science and Technology, Temple University, Philadelphia, PA, 19122, USA
- Department of Medical Biotechnologies, University of Siena, 53100, Siena, Italy
| | - Pierosandro Tagliaferri
- Department of Experimental and Clinical Medicine, Magna Græcia University, 88100, Catanzaro, Italy
| | | | - Isacco Desideri
- Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Florence, Italy
| | - Mauro Loi
- Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Florence, Italy
| | - Alfonso Reginelli
- Department of Precision Medicine, University of Campania "L. Vanvitelli", 80138, Naples, Italy
| | - Salvatore Cappabianca
- Department of Precision Medicine, University of Campania "L. Vanvitelli", 80138, Naples, Italy
| | - Pierfrancesco Tassone
- Department of Experimental and Clinical Medicine, Magna Græcia University, 88100, Catanzaro, Italy
| | - Pierpaolo Correale
- Medical Oncology Unit, "Bianchi Melacrino Morelli" Grand Metropolitan Hospital, Reggio Calabria, Italy
- Sbarro Institute for Cancer Research and Molecular Medicine and Center of Biotechnology, College of Science and Technology, Temple University, Philadelphia, PA, 19122, USA
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8
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Scorsetti M, Navarria P, Cozzi L, Clerici E, Bellu L, Franceschini D, Marzo AM, Franzese C, Torri V, Reggiori G, Lobefalo F, Raspagliesi L, Attuati L, Pessina F, Franzini A, Picozzi P, Tomatis S. Radiosurgery of limited brain metastases from primary solid tumor: results of the randomized phase III trial (NCT02355613) comparing treatments executed with a specialized or a C-arm linac-based platform. Radiat Oncol 2023; 18:28. [PMID: 36750848 PMCID: PMC9906937 DOI: 10.1186/s13014-023-02216-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/30/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Comparative prospective data regarding different radiosurgery (SRS) modalities for treating brain metastases (BMs) from solid tumors are not available. To investigate with a single institute phase III randomized trial whether SRS executed with linac (Arm-B) is superior to a dedicated multi-source gamma-ray stereotactic platform (Arm-A). METHODS Adults patients with 1-4 BMs from solid tumors up to 30 mm in maximum diameter were randomly assigned to arms A and B. The primary endpoint was cumulative incidence of symptomatic (grade 2-3) radionecrosis (CIRN). Secondary endpoints were local progression cumulative incidence (CILP), distant brain failure, disease-free survival (DFS), and overall survival (OS). RESULTS A total of 251 patients were randomly assigned to Arm-A (121) or Arm-B (130). The 1-year RN cumulative incidence was 6.7% in whole cohort, 3.8% (95% CI 1.9-7.4%) in Arm-B, and 9.3% (95% CI 6.2-13.8%) in the Arm-A (p = 0.43). CIRN was influenced by target volume irradiated only for the Arm-A (p << 0.001; HR 1.36 [95% CI 1.25-1.48]). Symptomatic RN occurred in 56 cases at a median time of 10.3 months (range 1.15-54.8 months), 27 in the Arm-B at a median time of 15.9 months (range 4.9-54.8 months), and 29 in the Arm-A at a median time of 6.9 months (1.2-32.3 months), without statistically significant differences between the two arms. No statistically significant differences were recorded between the two arms in CILP, BDF, DFS or OS. The mean beam-on time to deliver SRS was 49.0 ± 36.2 min in Arm-A, and 3.1 ± 1.6 min in Arm-B. CONCLUSIONS Given the technical differences between the treatment platforms investigated in this single-institution study, linac-based SRS (Arm-B) did not lead to significantly lower grade 2-3 RN rates versus the multi-source gamma-ray system (Arm-A) in a population of patients with limited brain metastases of small volume. No significant difference in local control was observed between both arms. For Arm-B, the treatment delivery time was significantly lower than for Arm-A. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT02355613.
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Affiliation(s)
- Marta Scorsetti
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan Italy
| | - Pierina Navarria
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Luca Cozzi
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan Italy
| | - Elena Clerici
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Luisa Bellu
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Davide Franceschini
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Antonio Marco Marzo
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Ciro Franzese
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan Italy
| | - Valter Torri
- grid.4527.40000000106678902Oncology Department, IRCCS Istituto Mario Negri, Milan, Italy
| | - Giacomo Reggiori
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Francesca Lobefalo
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Luca Raspagliesi
- grid.417728.f0000 0004 1756 8807Neurosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan Italy
| | - Luca Attuati
- grid.417728.f0000 0004 1756 8807Neurosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan Italy
| | - Federico Pessina
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan Italy
| | - Andrea Franzini
- grid.417728.f0000 0004 1756 8807Neurosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan Italy
| | - Piero Picozzi
- grid.417728.f0000 0004 1756 8807Neurosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan Italy
| | - Stefano Tomatis
- grid.417728.f0000 0004 1756 8807Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan Italy
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Lehrer EJ, Kowalchuk RO, Ruiz-Garcia H, Merrell KW, Brown PD, Palmer JD, Burri SH, Sheehan JP, Quninoes-Hinojosa A, Trifiletti DM. Preoperative stereotactic radiosurgery in the management of brain metastases and gliomas. Front Surg 2022; 9:972727. [PMID: 36353610 PMCID: PMC9637863 DOI: 10.3389/fsurg.2022.972727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 10/04/2022] [Indexed: 01/24/2023] Open
Abstract
Stereotactic radiosurgery (SRS) is the delivery of a high dose ionizing radiation in a highly conformal manner, which allows for significant sparing of nearby healthy tissues. It is typically delivered in 1-5 sessions and has demonstrated safety and efficacy across multiple intracranial neoplasms and functional disorders. In the setting of brain metastases, postoperative and definitive SRS has demonstrated favorable rates of tumor control and improved cognitive preservation compared to conventional whole brain radiation therapy. However, the risk of local failure and treatment-related complications (e.g. radiation necrosis) markedly increases with larger postoperative treatment volumes. Additionally, the risk of leptomeningeal disease is significantly higher in patients treated with postoperative SRS. In the setting of high grade glioma, preclinical reports have suggested that preoperative SRS may enhance anti-tumor immunity as compared to postoperative radiotherapy. In addition to potentially permitting smaller target volumes, tissue analysis may permit characterization of DNA repair pathways and tumor microenvironment changes in response to SRS, which may be used to further tailor therapy and identify novel therapeutic targets. Building on the work from preoperative SRS for brain metastases and preclinical work for high grade gliomas, further exploration of this treatment paradigm in the latter is warranted. Presently, there are prospective early phase clinical trials underway investigating the role of preoperative SRS in the management of high grade gliomas. In the forthcoming sections, we review the biologic rationale for preoperative SRS, as well as pertinent preclinical and clinical data, including ongoing and planned prospective clinical trials.
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Affiliation(s)
- Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Roman O. Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Kenneth W. Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Paul D. Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Joshua D. Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Stuart H. Burri
- Department of Radiation Oncology, Atrium Health, Charlotte, NC, United States
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | | | - Daniel M. Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States,Correspondence: Daniel M. Trifiletti
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10
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Chew CH, Chen JC, Hung SK, Wu TH, Lee MS, Chiou WY, Chen LC, Lin HY. Clinical outcomes of benign brain tumors treated with single fraction LINAC-based stereotactic radiosurgery: Experience of a single institute. Tzu Chi Med J 2022; 34:462-472. [PMID: 36578643 PMCID: PMC9791860 DOI: 10.4103/tcmj.tcmj_260_21] [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] [Received: 09/16/2021] [Revised: 10/25/2021] [Accepted: 01/14/2022] [Indexed: 12/31/2022] Open
Abstract
Objectives Accelerator-based stereotactic radiosurgery (SRS) is a noninvasive and effective treatment modality widely used for benign brain tumors. This study aims to report 20-year treatment outcomes in our institute. Materials and Methods From May 2001 to December 2020, 127 patients treated with LINAC-based single-fraction SRS for their benign brain lesions were included. A neurosurgeon and two radiation oncologists retrospectively reviewed all data. Computed tomography (CT) simulation was performed after head-frame fixation under local anesthesia. All planning CT images were co-registered and fused with gadolinium-enhanced magnetic resonance imaging taken within 3 months for lesions targeting and critical organs delineation. The marginal dose was prescribed at 60%-90% isodose lines, respectively, to cover ≥95% planning target volume. Outcome evaluations included clinical tumor control rate (TCR), defined as the need for salvage therapy, and radiological response, defined as no enlargement of >2 cm in the maximal diameter. Overall survival (OS) and adverse reaction (defined according to CTCAE 5.0) were also analyzed. Results The present study included 76 female and 51 male patients for analysis. The median age was 59 years (range, 20-88 years). Their diagnoses were vestibular schwannoma (VS, n = 54), nonvestibular cranial nerve schwannoma (n = 6), meningioma (n = 50), and pituitary adenoma (n = 17). Totally 136 lesions were treated in a single fraction, predominantly skull base tumors, accounting for 69.1%. Median and mean follow-up duration was 49 and 61 months (range, 1-214 months), Overall TCR was 92.9%. The 5-year disease-specific TCR for VS, nonvestibular schwannoma, meningioma, and pituitary adenoma were 97.4%, 91.7%, 93.8%, and 83.3%. Salvage therapy was indicated for eight patients at 4-110 months after SRS. Among symptomatic patients, post-SRS symptom(s) was improved, stable, and worse in 68.2%, 24.3%, and 3.6%, respectively. Radiological response rate for 111 evaluable patients was 94.6% (shrinkage, 28.8%; stable, 65.8%). OS was 96.1% without treatment-related mortality. One patient with post-SRS cranial nerve injury (0.8%, involving the trigeminal nerve, grade 2 toxicities). No grade 3-4 acute or late toxicity was found. Conclusion Our results suggested that LINAC-based SRS effectively controls tumor growth and tumor-related neurological symptoms for patients with benign brain tumors. SRS is less aggressive, associated with low neurological morbidity and no mortality. Continuous follow-up is indicated to conclude longer outcomes.
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Affiliation(s)
- Chia-Hui Chew
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Jin-Cherng Chen
- Department of Neurosurgery, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Shih-Kai Hung
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Tsung-Hsien Wu
- Department of Neurosurgery, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Moon-Sing Lee
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Wen-Yen Chiou
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Liang-Cheng Chen
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Hon-Yi Lin
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Institute of Molecular Biology, National Chung Cheng University, Chiayi, Taiwan
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11
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Devan SP, Luo G, Jiang X, Xie J, Dean D, Johnson LS, Morales-Paliza M, Harmsen H, Xu J, Kirschner AN. Rodent Model of Brain Radionecrosis using Clinical LINAC-based Stereotactic Radiosurgery. Adv Radiat Oncol 2022; 7:101014. [PMID: 36060637 PMCID: PMC9436710 DOI: 10.1016/j.adro.2022.101014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 06/21/2022] [Indexed: 11/18/2022] Open
Abstract
Purpose Methods and Materials Results Conclusions
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Affiliation(s)
- Sean P. Devan
- Chemical and Physical Biology Program, Vanderbilt University, Nashville, Tennessee
- Vanderbilt University Institute of Imaging Science
| | | | - Xiaoyu Jiang
- Vanderbilt University Institute of Imaging Science
- Radiology and Radiologic Sciences
| | - Jingping Xie
- Vanderbilt University Institute of Imaging Science
| | | | | | | | - Hannah Harmsen
- Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Junzhong Xu
- Vanderbilt University Institute of Imaging Science
- Radiology and Radiologic Sciences
| | - Austin N. Kirschner
- Departments of Radiation Oncology
- Corresponding author: Austin N. Kirschner, MD, PhD
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12
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Gamma knife radiosurgery versus transcatheter arterial chemoembolization for hepatocellular carcinoma with portal vein tumor thrombus: a propensity score matching study. Hepatol Int 2022; 16:858-867. [PMID: 35729469 PMCID: PMC9349123 DOI: 10.1007/s12072-022-10339-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/09/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND The optimal locoregional treatment for hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus (PVTT) is unclear. This study aimed to investigate the efficacy of Gamma knife radiosurgery (GKR) versus transcatheter arterial chemoembolization (TACE) in HCC patients with PVTT. METHODS This retrospective study included 544 HCC patients with PVTT (GKR, 202; TACE, 342). Propensity score matching (PSM) analysis identified 171 matched pairs of patients. The primary endpoint was overall survival (OS). RESULTS Before PSM, the GKR group exhibited longer median OS (mOS) than the TACE group (17.2 vs. 8.0 months, p < 0.001). We followed the Cheng's classification for PVTT. In the subgroup analysis, GKR was associated with significantly longer mOS for patients with PVTT II-IV (17.5 vs. 8.7 months, p < 0.001; 17.2 vs. 7.8 months, p = 0.001; 14.5 vs. 6.5 months, p = 0.001, respectively) and comparable OS for patients with PVTT I. After PSM, the GKR group had also a longer mOS than the TACE group (15.8 vs. 10.4 months, p < 0.001). In the subgroup analysis, the GKR group demonstrated superior mOS for patients with PVTT II-IV (all p < 0.05) and comparable OS for patients with PVTT I. CONCLUSIONS GKR was associated better OS than TACE in HCC patients with PVTT, especially for patients with PVTT II-IV. CLINICAL TRIALS REGISTRATION The study was registered in the Chinese Clinical Trials Registry under the registration number ChiCTR2100051057.
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13
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Pudsey L, Haworth A, White P, Moutrie Z, Jonker B, Foote M, Poder J. Current status of intra-cranial stereotactic radiotherapy and stereotactic radiosurgery in Australia and New Zealand: key considerations from a workshop and surveys. Phys Eng Sci Med 2022; 45:251-259. [PMID: 35113342 PMCID: PMC8901507 DOI: 10.1007/s13246-022-01108-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/20/2022] [Indexed: 12/22/2022]
Abstract
Recently, there has been increased interest worldwide in the use of conventional linear accelerator (linac)-based systems for delivery of stereotactic radiosurgery/radiotherapy (SRS/SRT) contrasting with historical delivery in specialised clinics with dedicated equipment. In order to gain an understanding and define the current status of SRS/SRT delivery in Australia and New Zealand (ANZ) we conducted surveys and provided a single-day workshop. Prior to the workshop ANZ medical physicists were invited to complete two surveys: a departmental survey regarding SRS/SRT practises and equipment; and an individual survey regarding opinions on current and future SRS/SRT practices. At the workshop conclusion, attendees completed a second opinion-based survey. Workshop discussion and survey data were utilised to identify areas of consensus, and areas where a community consensus was unclear. The workshop was held on the 8th Sept 2020 virtually due to pandemic-related travel restrictions and was attended by 238 radiation oncology medical physicists from 39 departments. The departmental survey received 32 responses; a further 89 and 142 responses were received to the pre-workshop and post-workshop surveys respectively. Workshop discussion indicated a consensus that for a department to offer an SRS/SRT service, a minimum case load should be considered depending on availability of training, peer-review, resources and equipment. It was suggested this service may be limited to brain metastases only, with less common indications reserved for departments with comprehensive SRS/SRT programs. Whilst most centres showed consensus with treatment delivery techniques and image guidance, opinions varied on the minimum target diameter and treatment margin that should be applied.
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Affiliation(s)
- Lauren Pudsey
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW, Australia
| | - Annette Haworth
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, Australia
| | - Paul White
- Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Zoe Moutrie
- Department of Radiation Oncology, Mater Hospital, GenesisCare, Crows Nest, Sydney, NSW, Australia
| | - Benjamin Jonker
- RPA Institute of Academic Surgery, University of Sydney, Sydney, Australia
| | - Matthew Foote
- University of Queensland, Princess Alexandra Hospital, ICON Cancer Care Queensland, Southport, Australia
| | - Joel Poder
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW, Australia.
- St George Hospital Cancer Care Centre, Kogarah, NSW, Australia.
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14
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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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15
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Desai AD, Shah VP, Tseng CC, Povolotskiy R, Wackym PA, Ying YLM. Impact of Social Determinants of Health on Stereotactic Radiotherapy for Vestibular Schwannoma. Laryngoscope 2022; 132:2232-2240. [PMID: 35076095 DOI: 10.1002/lary.30016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/02/2021] [Accepted: 01/04/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS Linear accelerator (LINAC) and Gamma Knife (GK) are common stereotactic radiation therapies for treating vestibular schwannoma (VS). There is currently limited literature examining specific demographic and socioeconomic factors, which influence the type of stereotactic radiation therapy a patient with VS receives. STUDY DESIGN Retrospective database review. METHODS The National Cancer Database was queried for cases of VS between 2004 and 2016. Patient demographic characteristics were compared using chi-squared and t-tests between GK and LINAC treated groups. Multivariate regression analysis was performed to assess predictors of stereotactic radiation therapy received. RESULTS Of the 6,208 included patients, 5,306 (85.5%) received GK and 902 (14.5%) received LINAC. The mean age of GK patients was significantly lower than that of LINAC patients (58.0 vs. 59.7, P < .001). Individuals treated with GK had greater proportions of private insurance (P < .001) and incomes greater than $63,332 (P = .003). A greater proportion of GK patients were treated in academic centers (P < .001), in high-volume facilities (P < .001), in metropolitan areas (P < .001), and in the Northeastern United States (P < .001). On multivariate logistic regression analysis, region, metropolitan area, facility type, tumor size, and distance traveled by patients independently predict receipt of GK versus LINAC. CONCLUSION Differences in patient demographics and other social determinants of health influence choice of GK versus LINAC therapy for VS patients. Future studies focused on addressing barriers to care, which may influence postprocedural quality of life and clinical outcomes associated with these two treatments are necessary to better understand the impact of these social differences. LEVEL OF EVIDENCE 4 Laryngoscope, 2022.
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Affiliation(s)
- Amar D Desai
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Vraj P Shah
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Christopher C Tseng
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Roman Povolotskiy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - P Ashley Wackym
- Department of Otolaryngology-Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, U.S.A
| | - Yu-Lan Mary Ying
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
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16
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Ho HW, Yang CC, Lin HM, Chen HY, Huang CC, Wang SC, Lin YW. The new SRS/FSRT technique HyperArc for benign brain lesions: a dosimetric analysis. Sci Rep 2021; 11:21029. [PMID: 34702859 PMCID: PMC8548509 DOI: 10.1038/s41598-021-00381-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 10/05/2021] [Indexed: 11/30/2022] Open
Abstract
To evaluate the potential benefit of HyperArc (HA) fractionated stereotactic radiotherapy (FSRT) for the benign brain lesion. Sixteen patients with a single deep-seated, centrally located benign brain lesion treated by CyberKnife (CK, G4 cone-based model) were enrolled. Treatment plans for HA with two different optimization algorithms (SRS NTO and ALDO) and coplanar RapidArc (RA) were generated for each patient to meet the corresponding treatment plan criteria. These four FSRT treatment plans were divided into two groups—the homogeneous delivery group (HA-SRS NTO and coplanar RA) and the inhomogeneous delivery group (HA-ALDO and cone-based CK)—to compare for dosimetric outcomes. For homogeneous delivery, the brain V5, V12, and V24 and the mean brainstem dose were significantly lower with the HA-SRS NTO plans than with the coplanar RA plans. The conformity index, high and intermediate dose spillage, and gradient radius were significantly better with the HA-SRS NTO plans than with the coplanar RA plans. For inhomogeneous delivery, the HA-ALDO exhibited superior PTV coverage levels to the cone-based CK plans. Almost all the doses delivered to organs at risk and dose distribution metrics were significantly better with the HA-ALDO plans than with the cone-based CK plans. Good dosimetric distribution makes HA an attractive FSRT technique for the treatment of benign brain lesions.
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Affiliation(s)
- Hsiu-Wen Ho
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan
| | - Ching-Chieh Yang
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan.,Department of Pharmacy, Chia-Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Hsiu-Man Lin
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan
| | - Hsiao-Yun Chen
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan.,Department of Radiation Oncology, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chun-Chiao Huang
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan
| | - Shih-Chang Wang
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Wei Lin
- Department of Radiation Oncology, Kaohsiung Veterans General Hospital, No.386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813414, Taiwan.
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17
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Impact of hospital volume on mortality for brain metastases treated with radiation. REPORTS OF PRACTICAL ONCOLOGY AND RADIOTHERAPY : JOURNAL OF GREATPOLAND CANCER CENTER IN POZNAN AND POLISH SOCIETY OF RADIATION ONCOLOGY 2021; 26:626-634. [PMID: 34434579 DOI: 10.5603/rpor.a2021.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/27/2021] [Indexed: 11/25/2022]
Abstract
Background The impact of hospital volume on cancer patient survival has been demonstrated in the surgical literature, but sparsely for patients receiving radiation therapy (RT). This analysis addresses the impact of hospital volume on patients receiving RT for the most common central nervous system tumor: brain metastases. Materials and methods Analysis was conducted using the National Cancer Database (NCDB) from 2010-2015 for patients with metastatic brain disease from lung cancer, breast cancer, and colorectal cancer requiring RT. Hospital volume was stratified as high-volume (≥ 12 brain RT/year), moderate (5-11 RT/year), and low (< 5 RT/year). The effect of hospital volume on overall survival was assessed using a multivariable Cox regression model. Results A total of 18,841 patients [9479 (50.3%) men, 9362 (49.7%) women; median age 64 years] met the inclusion criteria. 16.7% were treated at high-volume hospitals, 36.5% at moderate-volume, and the remaining 46.8% at low-volume centers. Multivariable analysis revealed that mortality was significantly improved in high-volume centers (HR: 0.95, p = 0.039) compared with low-volume centers after accounting for multiple demographics including age, sex, race, insurance status, income, facility type, Charlson-Deyo score and receipt of palliative care. Conclusion Hospitals performing 12 or more brain RT procedures per year have significantly improved survival in brain metastases patients receiving radiation as compared to lower volume hospitals. This finding, independent of additional demographics, indicates that the increased experience associated with increased volume may improve survival in this patient population.
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Radionecrosis and Complete Response After Multiple Reirradiations to Recurrent Brain Metastases From Lung Cancer Over 10 Years: Is There a Limit? Adv Radiat Oncol 2021; 6:100733. [PMID: 34286165 PMCID: PMC8273226 DOI: 10.1016/j.adro.2021.100733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 05/10/2021] [Accepted: 05/19/2021] [Indexed: 11/22/2022] Open
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Kim E, McClelland S, Jaboin JJ, Attia A. Disparities in Patterns of Conventional Versus Stereotactic Body Radiotherapy in the Treatment of Spine Metastasis in the United States. J Palliat Care 2020; 36:130-134. [PMID: 33356987 DOI: 10.1177/0825859720982204] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The improved survival of patients even with metastatic cancer has led to an increase in the incidence of spine metastases, suggesting the need for a more aggressive palliative treatment than conventional external beam radiation therapy (cEBRT). Consequently, spinal stereotactic body radiation therapy (SBRT) has increased in popularity over the past decade. However, there has been no comparison of patterns of usage of cEBRT versus SBRT in the treatment of spinal metastases in the US. METHODS The National Cancer Data Base (NCDB) from 2004-2013 was used for analysis. cEBRT was defined as 30 Gy in 10 fractions, 20 Gy in 5 fractions, or 8 Gy in 1 fraction. SBRT was defined as 25-32 Gy infive5 fractions, 24-32 Gy in 4 fractions, 20-32 Gy in three fractions, 14-32 Gy in 2 fractions, or 14-24 Gy in 1 fraction. Single and multivariable associations between patient demographic and cancer characteristics and type of radiation were performed. RESULTS From 2004-2013, 23,181 patients with spinal metastases in the United States received cEBRT, while 1,030 received SBRT as part of their first course of treatment. Most patients (88%) received 10 fractions of radiation. Multivariable analysis suggested that non-Medicare or private insurance (adjusted OR 0.4-0.7), African-American race (adjusted OR = 0.8, 95%CI = 0.7-1.0), age 65+ (adjusted OR = 0.8), living in a region with lower population (adjusted OR 0.7), earlier year of diagnosis (OR = 0.9), and receiving treatment in a non-academic/research facility (adjusted OR 0.6) were associated with cEBRT. After controlling for other variables, regional education level was no longer significantly associated with cEBRT. CONCLUSIONS Most patients with spine metastases were treated with cEBRT, usually with 10 fractions. Receipt of SBRT was significantly associated with race, insurance, geography, population, type of treatment facility, and year of diagnosis, even after controlling for other factors. These findings raise questions about disparities in access to and delivery of care that deserve further investigation.
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Affiliation(s)
- Ellen Kim
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, USA
| | - Shearwood McClelland
- Department of Radiation Oncology, 12250Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jerry J Jaboin
- Department of Radiation Medicine, 6684Oregon Health and Science University, Portland, OR, USA
| | - Albert Attia
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, USA
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Parker T, Rigney G, Kallos J, Stefko ST, Kano H, Niranjan A, Green AL, Aziz T, Rath P, Lunsford LD. Gamma knife radiosurgery for uveal melanomas and metastases: a systematic review and meta-analysis. Lancet Oncol 2020; 21:1526-1536. [PMID: 33152286 DOI: 10.1016/s1470-2045(20)30459-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/29/2020] [Accepted: 07/15/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Gamma knife radiosurgery is regarded as the gold-standard stereotactic radiosurgery modality for the treatment of intracranial tumours, and its use has been expanded for the treatment of intraocular malignancies. The aim of this study was to systematically evaluate the efficacy, outcomes, and complications of gamma knife radiosurgery for uveal melanomas and metastases. METHODS We did a systematic review and meta-analysis to aggregate the clinical outcomes of patients with uveal melanomas or intraocular metastases treated primarily with gamma knife radiosurgery. We searched MEDLINE and Embase for studies published between Sept 1, 1960, and Feb 1, 2020, reporting the use of gamma knife radiosurgery as primary treatment for uveal melanoma or uveal metastases. The search was restricted to clinical studies and relevant grey literature published in English. Studies reporting treatment of benign tumours, extraocular tumours, or other forms of stereotactic radiosurgery were excluded to reduce heterogeneity. No restrictions were placed on participant criteria. Local tumour control and tumour regression were extracted as the primary outcomes and analysed via a random-effects meta-analysis of proportions using the DerSimonian and Laird method with a Freeman-Tukey double arcsine transformation. This study is registered with PROSPERO, CRD42019148165. FINDINGS Our search returned 454 studies, of which 109 were assessed for full-text eligibility. 52 studies, reporting on 1010 patients with uveal melanoma and 34 intraocular metastases, were eligible for systematic review. 28 studies were included in the meta-analysis. 840 of 898 patients (0·96, 95% CI 0·94-0·97; I2=16%) from 19 studies had local control, and 378 of 478 patients (0·81, 0·70-0·90; I2=83%) from 16 studies experienced tumour regression. INTERPRETATION Gamma knife radiosurgery is an efficacious primary method of treating uveal melanomas and intraocular metastases, with reliable tumour control rates. Randomised controlled trials should further evaluate the safety and efficacy of gamma knife radiosurgery in this setting. FUNDING The Rhodes Trust and the Howard Brain Sciences Foundation.
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Affiliation(s)
- Tariq Parker
- Nuffield Department of Surgery, University of Oxford, Oxford, UK.
| | - Grant Rigney
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Justiss Kallos
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - S Tonya Stefko
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Hideyuki Kano
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ajay Niranjan
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Tipu Aziz
- Nuffield Department of Surgery, University of Oxford, Oxford, UK
| | - Pamela Rath
- Everett and Hurite Ophthalmic Association, Pittsburgh, PA, USA
| | - L Dade Lunsford
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Sebastian NT, Glenn C, Hughes R, Raval R, Chu J, DiCostanzo D, Bell EH, Grecula J, Arnett A, Gondal H, McGregor J, Elder JB, Lonser R, Chakravarti A, Trifiletti D, Brown PD, Chan M, Palmer JD. Linear accelerator-based radiosurgery is associated with lower incidence of radionecrosis compared with gamma knife for treatment of multiple brain metastases. Radiother Oncol 2020; 147:136-143. [PMID: 32294607 DOI: 10.1016/j.radonc.2020.03.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 02/22/2020] [Accepted: 03/22/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Gamma knife (GK) and linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) both offer excellent local control in the management of multiple brain metastases. The efficacy and toxicity of LINAC and GK SRS have not been directly compared in the modern era. We studied outcomes in patients treated with LINAC SRS and GK at two separate institutions. METHODS We identified patients treated with either LINAC or GK who were treated to ≥2 lesions and had available follow up. LINAC patients were treated using single-isocenter multitarget technique. We used Cox regression, Fine and Gray competing risks regression, and nearest neighbor propensity score matching to account for confounders and imbalance between cohorts. Kaplan-Meier curves were used to estimate overall survival and rates of radionecrosis. RESULTS We identified 391 patients who were treated in 537 courses to a total 2699 lesions (LINAC: 1014, GK: 1685). After propensity score matching, GK was associated with similar overall survival (HR = 0.86; 95% CI 0.59-1.24; p = 0.41) and higher rate of radionecrosis (HR = 3.83; 95% CI 1.66-8.84; p = 0.002) compared to LINAC. In a secondary propensity score matched analysis comparing radionecrosis in single-fraction LINAC and GK, GK remained associated with higher incidence of radionecrosis (HR = 4.42; 95% CI 1.28-15.29; p = 0.019). CONCLUSIONS In this multi-institutional study, we found similar overall survival with lower incidence of radionecrosis in patients treated with LINAC compared to GK SRS. These findings are hypothesis generating and should be validated in an independent cohort.
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Affiliation(s)
- Nikhil T Sebastian
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Chase Glenn
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, USA
| | - Ryan Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, USA
| | - Raju Raval
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Jacqueline Chu
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Dominic DiCostanzo
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Erica H Bell
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - John Grecula
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Andrea Arnett
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Hasan Gondal
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, USA
| | - John McGregor
- Department of Neurological Surgery, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - James B Elder
- Department of Neurological Surgery, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Russell Lonser
- Department of Neurological Surgery, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | - Arnab Chakravarti
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA
| | | | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | - Michael Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA; Department of Neurological Surgery, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA.
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Park S, Rim CH, Yoon WS. Where is clinical research for radiotherapy going? Cross-sectional comparison of past and contemporary phase III clinical trials. Radiat Oncol 2020; 15:36. [PMID: 32059729 PMCID: PMC7023759 DOI: 10.1186/s13014-020-01489-4] [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: 11/20/2019] [Accepted: 02/10/2020] [Indexed: 11/17/2022] Open
Abstract
Purpose The features of past and contemporary phase III clinical trials for radiotherapy were reviewed to activate future clinical trials and to advise on actual clinical practice. Methods and materials The phase III clinical trials for radiotherapy were searched in the database of ‘ClinicalTrials.gov’ by the U.S. National Institute of Health. Using the staring date, the studies during each period of 4 years were collected for the past (from Jan 2000 to Dec 2003) and contemporary (July 2014 to June 2018) years. For the investigated subjects, the patterns of studies were classified as: Category A, the comparisons of rival radiotherapy protocols; Category B, the comparisons of multidisciplinary approaches; Category C, the investigation of supplementary agents; and Category D, the investigation of optimal partners for concurrent radiotherapy. Results The number of studies increased, from 96 past to 158 contemporary studies. The patterns of studies were similar with the mild increase of Category A in the contemporary years (22.9% vs. 29.1%). For the study locations and the funding sources, the Chinese studies (2.1% vs. 34.2%, P < 0.001) and the affiliated institutions of researchers (37.5% vs. 72.2%, P < 0.001) markedly increased in the contemporary years from the past Western studies and non-profit organization, respectively. The robust radiation techniques were more usual in the contemporary years (11.5% vs. 44.9%, P < 0.001). The fractionation schedule and delivery technique were the common issues in both past and contemporary years of Category A. In Category B, the indications of stereotactic radiotherapy was the rising concern, with eight ongoing studies. Except for the studies of palliative or prophylactic goals and stereotactic radiotherapy, the escape from conventional fraction size was 37.9% (36/95) in the contemporary years with the median fraction size of 2.5 Gy (range 2.05–6.6 Gy) in the comparison with 19.0% (15/79) in the past years (P = 0.006). Conclusions To activate the clinical trials for radiotherapy, the funding sources would be diversified, including industrial support. Hypofractionated schedules using robust techniques could be preemptively considered in actual clinical practice.
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Affiliation(s)
- Sunmin Park
- Radiation Oncology, Ansan Hospital, Korea University, 123 Jeokgeum-ro, Danwon-gu, Ansan, Gyeonggi-do, 15355, Republic of Korea
| | - Chai Hong Rim
- Radiation Oncology, Ansan Hospital, Korea University, 123 Jeokgeum-ro, Danwon-gu, Ansan, Gyeonggi-do, 15355, Republic of Korea
| | - Won Sup Yoon
- Radiation Oncology, Ansan Hospital, Korea University, 123 Jeokgeum-ro, Danwon-gu, Ansan, Gyeonggi-do, 15355, Republic of Korea.
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Trifiletti DM, Lehrer EJ, Sheehan JP. Radiosurgery. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Liu H, Thomas EM, Li J, Yu Y, Andrews D, Markert JM, Fiveash JB, Shi W, Popple RA. Interinstitutional Plan Quality Assessment of 2 Linac-Based, Single-Isocenter, Multiple Metastasis Radiosurgery Techniques. Adv Radiat Oncol 2019; 5:1051-1060. [PMID: 33089021 PMCID: PMC7560574 DOI: 10.1016/j.adro.2019.10.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 10/28/2019] [Indexed: 12/05/2022] Open
Abstract
Purpose Interest and application of stereotactic radiosurgery for multiple brain metastases continue to increase. Various planning systems are available for linear accelerator (linac)–based single-isocenter multiple metastasis radiosurgery. Two of the most advanced systems are BrainLAB Multiple Metastases Elements (MME), a dynamic conformal arc (DCA) approach, and Varian RapidArc (RA), a volumetric modulated arc therapy (VMAT) approach. In this work, we systematically compared plan quality between the 2 techniques. Methods and Materials Thirty patients with 4 to 10 metastases (217 total; median 7.5; Vmin = 0.014 cm3; Vmax = 17.73 cm3) were planned with both Varian RA and MME at 2 different institutions with extensive experience in each respective technique. All plans had a single isocenter and used Varian linac equipped with high-definition multileaf collimator. RA plans used 2 to 4 noncoplanar VMAT arcs with 10 MV flattening filter-free beam. MME plans used 4 to 9 noncoplanar DCAs and 6 MV flattening filter-free beam, (minimum planning target volume [PTVmin] = 0.49 cm3; PTVmax = 27.32 cm3; PTVmedian = 7.05 cm3). Prescriptions were 14 to 24 Gy in a single fraction. Target coverage goal was 99% of volume receiving prescription dose (D99% ≥ 100%). Plans were evaluated by Radiation Therapy Oncology Group/Paddick conformity index (CI) score, 12 Gy volume (V12Gy), V8Gy, V5Gy, mean brain dose (Dmean), and beam-on time. Results Conformity was favorable among RA plans (median: MME CIRTOG = 1.38; RA CIRTOG = 1.21; P < .0001). V12Gy and V8Gy were lower for RA plans (median: MME V12 = 23.7 cm3; RA V12 = 19.2 cm3; P = .0001; median: MME V8Gy = 53.6 cm3; RA V8Gy = 44.1 cm3; P = .024). V5Gy was lower for MME plans (median: MME V5Gy = 141.4 cm3; RA V5Gy = 142.8 cm3; P = .009). Mean brain was lower for MME plans (median: MME Dmean = 2.57 Gy; RA Dmean = 2.76 Gy; P < .0001). Conclusions For linac-based multiple metastasis stereotactic radiosurgery, RapidArc VMAT facilitates favorable conformity and V12Gy/V8Gy volume compared with the MME DCA plan. MME planning facilitates reduced dose spill at levels ≤V5Gy.
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Affiliation(s)
- Haisong Liu
- Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Evan M Thomas
- Department of Radiation Oncology, University of Alabama at Birmingham, Comprehensive Cancer Center, Birmingham, Alabama
| | - Jun Li
- Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Yan Yu
- Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - David Andrews
- Department of Neurosurgery, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - James M Markert
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - John B Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham, Comprehensive Cancer Center, Birmingham, Alabama
| | - Wenyin Shi
- Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Richard A Popple
- Department of Radiation Oncology, University of Alabama at Birmingham, Comprehensive Cancer Center, Birmingham, Alabama
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McClelland S, Degnin C, Chen Y, Watson GA, Jaboin JJ. Impact of the American Tax Payer Relief Act on stereotactic radiosurgery utilization in the United States. J Neurooncol 2019; 145:159-165. [PMID: 31485922 DOI: 10.1007/s11060-019-03283-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 08/29/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Single-fraction stereotactic radiosurgery (SRS) is delivered predominantly via two modalities: Gamma Knife, and linear accelerator (LINAC). Implementation of the American Tax Payer Relief Act (ATRA) in 2013 represented the first time limitations specifically targeting SRS reimbursement were introduced into federal law. The subsequent impact of the ATRA on SRS utilization in the United States (US) has yet to be examined. METHODS The National Cancer Database from 2010-2016 identified brain metastases patients from non-small cell lung cancer throughout the US having undergone SRS. Utilization between GKRS and LINAC was assessed before (2010-2012), during (2013-2014) and after (2015-2016) ATRA implementation. RESULTS In 2013, there was a substantial decrease of LINAC SRS in favor of GKRS in non-academic centers. Over the 3-year span immediately preceding ATRA implementation, 39% of all eligible SRS cases received LINAC. There was a modest decrease in LINAC utilization over the 2 years immediately following ATRA implementation (35%), followed by an increase over the next two years (40%). SRS modality showed differences over the three time periods (unadjusted, p = 0.043), primarily in non-academic centers (unadjusted, p = 0.003). CONCLUSIONS ATRA implementation in 2013 caused an initial spike in Gamma Knife SRS utilization, followed by a decline to rates similar to the years before implementation. These findings indicate that the ATRA provision mandating Medicare reduction of outpatient payment rates for Gamma Knife to be equivalent with those of LINAC SRS had a significant short-term impact on the radiosurgical treatment of metastatic brain disease throughout the US, serving as a reminder of the importance/impact of public policy on treatment modality utilization by physicians and hospitals.
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Affiliation(s)
- Shearwood McClelland
- Department of Radiation Oncology, Indiana University School of Medicine, 535 Barnhill Drive, RT 041, Indianapolis, IN, 46202, USA.
| | - Catherine Degnin
- Biostatistics Shared Resource, Oregon Health and Science University, Portland, OR, USA
| | - Yiyi Chen
- Biostatistics Shared Resource, Oregon Health and Science University, Portland, OR, USA
| | - Gordon A Watson
- Department of Radiation Oncology, Indiana University School of Medicine, 535 Barnhill Drive, RT 041, Indianapolis, IN, 46202, USA
| | - Jerry J Jaboin
- Department of Radiation Medicine, Oregon Health and Science University, Portland, OR, USA
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Jiang W, Haque W, Verma V, Butler B, Teh BS. Stereotactic radiosurgery for brain metastases from newly diagnosed small cell lung cancer: practice patterns and outcomes. Acta Oncol 2019; 58:491-498. [PMID: 30676131 DOI: 10.1080/0284186x.2018.1562207] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Up-front stereotactic radiosurgery (SRS) has been historically thought of as inadequate for brain metastases (BM) from newly diagnosed small cell lung cancer (SCLC). This study evaluates national practice patterns and clinical outcomes for BM from SCLC. MATERIAL AND METHODS The National Cancer Database was queried (2004-2013) for patients with newly diagnosed metastatic SCLC receiving intracranial radiotherapy. Patients were grouped into three categories: upfront SRS, whole-brain radiotherapy (WBRT) alone, or WBRT with boost (SRS or fractionated radiotherapy). Statistics included temporal trend assessment by annual percent change (APC), logistic regression, exploratory Kaplan-Meier overall survival (OS) analysis without and with propensity matching, and Cox proportional hazards modeling. RESULTS A total of 14,722 patients met selection criteria, of whom 487 (3.3%), 13,657 (92.8%), and 578 (3.9%) received upfront SRS, WBRT and WBRT with boost, respectively. Utilization of SRS showed a slight increasing trend from 2004 to 2013 (2.7-4.3%). In addition to socioeconomic factors, other variables associated with SRS use included diagnosis after 2010, treatment at academic centers, and residing in higher-educated regions. SRS was less often delivered to patients with node-positive disease (p < .05). On exploratory analysis, SRS cohort was observed to have a higher overall survival (OS) than WBRT-based groups (p < .001), namely in patients without extracranial metastases. CONCLUSIONS Utilization of up-front SRS for SCLC BM has been increasing over time but is driven by socioeconomic disparities. Although there are likely numerous biases associated with the OS findings herein, further research is needed to validate this finding as well as the role of SRS on patients with brain metastases due to SCLC.
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Affiliation(s)
- Wei Jiang
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital & Shenzhen Hospital Chinese Academy of Medical Sciences, Shenzhen, China
| | - Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Bin S. Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
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McClelland S, Watson GA. Impact of MRI Timing on Accuracy of Stereotactic Radiosurgical Planning: Visualizing the Forest From the Trees. Int J Radiat Oncol Biol Phys 2019; 103:1012-1013. [PMID: 30784517 DOI: 10.1016/j.ijrobp.2018.11.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 11/09/2018] [Accepted: 11/10/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Shearwood McClelland
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Gordon A Watson
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana
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McClelland S, Hatfield J, Degnin C, Chen Y, Mitin T. Extent of resection and role of adjuvant treatment in resected localized breast angiosarcoma. Breast Cancer Res Treat 2019; 175:409-418. [PMID: 30820717 DOI: 10.1007/s10549-019-05172-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 02/18/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Localized breast angiosarcoma (LBA) is a rare condition with no prospective clinical trials guiding the management of afflicted patients. Management of LBA and the resulting outcomes on a nationwide scale has not been previously examined. METHODS The National Cancer Data Base (NCDB) from 2004 to 2014 identified resected LBA patients. Treatment patterns were compared between three time periods (2004-2007, 2008-2011, and 2012-2014). Demographic and tumor characteristics, as well as treatments received-extent of surgery and adjuvant therapies-were analyzed for association with overall survival after adjustment for covariates. RESULTS 826 resected localized breast angiosarcoma patients were identified. Mastectomy was the most common surgical approach (86%); over 60% of patients did not receive adjuvant therapies after surgery. On multivariate analysis, tumor grade, tumor size, and surgical margins were associated with worse survival. Extent of surgery (mastectomy versus lumpectomy) and radiation therapy use were not associated with improved survival. Adjuvant chemotherapy was associated with improved survival in patients with primary tumors 5 cm and greater. CONCLUSIONS The extent of surgery is not associated with improved survival in women with LBA, and patients may consider breast-conservation surgery. Adjuvant therapies are not associated with improved survival, with the exception of possible role of adjuvant chemotherapy in large primary tumors (5 cm or greater). Further clinical studies are needed to determine the impact of these treatments on local control, progression-free survival, and patients' quality of life. Until then, the findings of our analysis will form basis for the multi-disciplinary discussion of management of women with LBA.
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Affiliation(s)
- Shearwood McClelland
- Department of Radiation Oncology, Indiana University School of Medicine, 535 Barnhill Drive, RT 041, Indianapolis, IN, 46202, USA.
- Department of Radiation Medicine, Oregon Health and Science University, Portland, OR, USA.
| | - Jess Hatfield
- Department of Radiation Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Catherine Degnin
- Biostatistics Shared Resource, Oregon Health and Science University, Portland, OR, USA
| | - Yiyi Chen
- Biostatistics Shared Resource, Oregon Health and Science University, Portland, OR, USA
| | - Timur Mitin
- Department of Radiation Medicine, Oregon Health and Science University, Portland, OR, USA
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Modh A, Doshi A, Burmeister C, Elshaikh MA, Lee I, Shah M. Disparities in the Use of Single-fraction Stereotactic Radiosurgery for the Treatment of Brain Metastases From Non-small Cell Lung Cancer. Cureus 2019; 11:e4031. [PMID: 31011494 PMCID: PMC6456282 DOI: 10.7759/cureus.4031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 02/06/2019] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Radiation treatment patterns in patients with brain metastases from non-small cell lung cancer (NSCLC) have not been well elucidated. The National Cancer Database (NCDB) was used to evaluate trends in the use of whole brain radiation therapy (WBRT) and stereotactic radiosurgery (SRS) for brain metastasis from NSCLC. METHODS This NCDB study included patients > 18 years old with metastatic NSCLC treated with single-fraction SRS or WBRT between 2004 and 2014. Chi-square, t-test, and multivariable logistic regression analyses were used to identify predictors of SRS versus WBRT. RESULTS Of 40,803 patients, 34,183 (83.8%) received WBRT and 6,620 (16.2%) received SRS. SRS utilization increased from 7% (157 cases) in 2004 to 37% (1,346 cases) in 2014 (p < .001). SRS was utilized more by academic than community facilities (22% versus 13%, p < .001). The strongest independent predictors of SRS included year of diagnosis in 2010-2014 versus 2004-2009 (odds ratio [OR] 2.62, 95% CI 2.46-2.79, p < .0001), metropolitan versus rural (OR 2.26, CI 1.79-2.85, p < .0001), distance from cancer-reporting facility of ≥ 30 versus < 30 miles (OR 2.36, CI 2.18-2.56, p < .0001), private insurance versus non-insured patients (OR 1.96, CI 1.68-2.29, p < .0001), and academic versus community facility (OR 1.76, CI 1.66-1.87, p < .0001). CONCLUSION SRS for NSCLC brain metastases has steadily increased in the United States; however, WBRT remains the most commonly used. Wide geographic and socioeconomic variations exist in the utilization of SRS and WBRT for this patient population.
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Affiliation(s)
- Ankit Modh
- Radiation Oncology, Henry Ford Hospital, Detroit, USA
| | | | | | | | - Ian Lee
- Neurosurgery, Henry Ford Hospital, Detroit, USA
| | - Mira Shah
- Radiation Oncology, Henry Ford Hospital, Detroit, USA
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Knisely JPS. Spine Radiosurgery Dosimetry-A Simple Way Forward. Pract Radiat Oncol 2019; 9:e127-e128. [PMID: 30665863 DOI: 10.1016/j.prro.2018.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 10/17/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Jonathan P S Knisely
- Weill Cornell Medicine & New York-Presbyterian, Department of Radiation Oncology, New York, New York.
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Zani M, Marrazzo L, Calusi S, Talamonti C, Scoccianti S, Greto D, Desideri I, Fusi F, Pallotta S. TomoTherapy treatments of multiple brain lesions: an in-phantom accuracy evaluation. Phys Med Biol 2019; 64:025020. [PMID: 30561374 DOI: 10.1088/1361-6560/aaf977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Aim of the present study was to evaluate the accuracy which can be obtained with helical TomoTherapy® (HT, Accuray) systems in the case of multiple intracranial targets treatments. Set-up accuracy was measured, for different registration options and MegaVoltage CT (MVCT) slice thickness, by applying known misalignments to an ad-hoc developed phantom. End-to-end (E2E) tests were performed to assess the delivery accuracy in phantoms containing multiple targets by using radiochromic films: measured dose distribution centroids were compared with physical and calculated target positions on axial and coronal planes. A Gamma index analysis was carried out on planned and measured planar dose maps. The bone and tissue algorithm with the fine MVCT reconstruction grid gave the best results among the automatic options. The most accurate registration modality resulted to be the manual one with a sub-voxel accuracy shifts and a capability in the detection of rotations within 0.3°. For the E2E along the coronal plane (six targets), a mean deviation between measured dose distribution centroids and physical barycenters of 0.6 mm (range 0.1 mm-1.3 mm) was observed. Along the axial plane (five targets), a mean deviation of 1.2 mm (range 0.7 mm-2.1 mm) was found for the centroids shifts. Gamma index (5%, 1 mm, local) passing rates higher than 87.5% between planned and delivered dose distributions were measured. These results demonstrate that multiple brain lesion HT treatments are feasible with an accuracy at least comparable to frameless linac-based delivery, when a set-up capable to assure angular corrections and a reliable patient immobilization is employed.
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Affiliation(s)
- M Zani
- Department of Biomedical, Experimental and Clinical Sciences 'Mario Serio', Viale Morgagni, 50, 50134 Firenze. Author to whom any correspondence should be addressed
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Lehrer EJ, Peterson J, Brown PD, Sheehan JP, Quiñones-Hinojosa A, Zaorsky NG, Trifiletti DM. Treatment of brain metastases with stereotactic radiosurgery and immune checkpoint inhibitors: An international meta-analysis of individual patient data. Radiother Oncol 2019; 130:104-112. [DOI: 10.1016/j.radonc.2018.08.025] [Citation(s) in RCA: 131] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 08/25/2018] [Accepted: 08/28/2018] [Indexed: 01/20/2023]
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Mortality After Stereotactic Radiosurgery for Brain Metastases and Implications for Optimal Utilization. Am J Clin Oncol 2018; 41:1142-1147. [DOI: 10.1097/coc.0000000000000441] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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34
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Cost-effectiveness of Linac-based single-isocenter non-coplanar technique (HyperArcTM) for brain metastases radiosurgery. Clin Exp Metastasis 2018; 35:601-603. [DOI: 10.1007/s10585-018-9933-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 08/16/2018] [Indexed: 11/26/2022]
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35
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Gogineni E, Vargo JA, Glaser SM, Flickinger JC, Burton SA, Engh JA, Amankulor NM, Beriwal S, Quinn AE, Ozhasoglu C, Heron DE. Long-Term Survivorship Following Stereotactic Radiosurgery Alone for Brain Metastases: Risk of Intracranial Failure and Implications for Surveillance and Counseling. Neurosurgery 2018; 83:203-209. [PMID: 28945873 DOI: 10.1093/neuros/nyx376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 08/10/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Historically, survival for even highly select cohorts of brain metastasis patients selected for SRS alone is <2 yr; thus, limited literature on risks of recurrence exists beyond 2 yr. OBJECTIVE To investigate the possibility that for subsets of patients the risk of intracranial failure beyond 2 yr is less than the commonly quoted 50% to 60%, wherein less frequent screening may be appropriate. METHODS As a part of our institutional radiosurgery database, we identified 132 patients treated initially with stereotactic radiosurgery (SRS) alone (± pre-SRS surgical resection) with at least 2 yr of survival and follow-up from SRS. Primary study endpoints were rates of actuarial intracranial progression beyond 2 yr, calculated using the Kaplan-Meier and Cox regression methods. RESULTS The median follow-up from the first course of SRS was 3.5 yr. Significant predictors of intracranial failure beyond 2 yr included intracranial failure before 2 yr (52% vs 25%, P < .01) and total SRS tumor volume ≥5 cc (51% vs 25%, P < .01). On parsimonious multivariate analysis, failure before 2 yr (HR = 2.2, 95% CI: 1.2-4.3, P = .01) and total SRS tumor volume ≥5 cc (HR = 2.3, 95% CI: 1.2-4.3, P = .01) remained significant predictors of intracranial relapse beyond 2 yr. CONCLUSION Relapse rates beyond 2 yr following SRS alone for brain metastases are low in patients who do not suffer intracranial relapse within the first 2 yr and with low-volume brain metastases, supporting a practice of less frequent screening beyond 2 yr. For remaining patients, frequent (every 3-4 mo) screening remains prudent, as the risk of intracranial failure after 2 yr remains high.
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Affiliation(s)
- Emile Gogineni
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - John A Vargo
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Scott M Glaser
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - John C Flickinger
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Steven A Burton
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Johnathan A Engh
- Department of Neurosurgery, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Nduka M Amankulor
- Department of Neurosurgery, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Anette E Quinn
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Cihat Ozhasoglu
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Dwight E Heron
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
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McClelland S, Kim E, Passias PG, Murphy JD, Attia A, Jaboin JJ. Spinal stereotactic body radiotherapy in the United States: A decade-long nationwide analysis of patient demographics, practice patterns, and trends over time. J Clin Neurosci 2017; 46:109-112. [DOI: 10.1016/j.jocn.2017.08.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 08/10/2017] [Indexed: 11/16/2022]
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Ziemer BP, Sanghvi P, Hattangadi-Gluth J, Moore KL. Heuristic knowledge-based planning for single-isocenter stereotactic radiosurgery to multiple brain metastases. Med Phys 2017; 44:5001-5009. [DOI: 10.1002/mp.12479] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 05/22/2017] [Accepted: 06/27/2017] [Indexed: 12/15/2022] Open
Affiliation(s)
- Benjamin P. Ziemer
- Department of Radiation Medicine and Applied Sciences; University of California, San Diego; La Jolla CA USA
| | - Parag Sanghvi
- Department of Radiation Medicine and Applied Sciences; University of California, San Diego; La Jolla CA USA
| | - Jona Hattangadi-Gluth
- Department of Radiation Medicine and Applied Sciences; University of California, San Diego; La Jolla CA USA
| | - Kevin L. Moore
- Department of Radiation Medicine and Applied Sciences; University of California, San Diego; La Jolla CA USA
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McClelland S, Kim E, Murphy JD, Jaboin JJ. Impact of insurance status and race on receipt of treatment for acoustic neuroma: A national cancer database analysis. J Clin Neurosci 2017; 42:143-147. [DOI: 10.1016/j.jocn.2017.03.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 03/06/2017] [Indexed: 11/30/2022]
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Oravec CS, Motiwala M, Reed K, Kondziolka D, Barker FG, Michael LM, Klimo P. Big Data Research in Neurosurgery: A Critical Look at this Popular New Study Design. Neurosurgery 2017; 82:728-746. [DOI: 10.1093/neuros/nyx328] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 05/17/2017] [Indexed: 01/10/2023] Open
Affiliation(s)
- Chesney S Oravec
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mustafa Motiwala
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kevin Reed
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Fred G Barker
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - L Madison Michael
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
- Semmes Murphey Clinic, Memphis, Tennessee
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
- Semmes Murphey Clinic, Memphis, Tennessee
- Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, Tennessee
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40
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Survival Patterns of 5750 Stereotactic Radiosurgery-Treated Patients with Brain Metastasis as a Function of the Number of Lesions. World Neurosurg 2017; 107:944-951.e1. [PMID: 28735121 DOI: 10.1016/j.wneu.2017.07.062] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 07/11/2017] [Accepted: 07/12/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND The number of brain metastases (BMs) plays an important role in the decision between stereotactic radiosurgery (SRS) and whole-brain radiation therapy. METHODS We analyzed the survival of 5750 SRS-treated patients with BM as a function of BM number. Survival analyses were performed with Kaplan-Meier analysis as well as univariate and multivariate Cox proportional hazards models. RESULTS Patients with BMs were first categorized as those with 1, 2-4, and 5-10 BMs based on the scheme proposed by Yamamoto et al. (Lancet Oncology 2014). Median overall survival for patients with 1 BM was superior to those with 2-4 BMs (7.1 months vs. 6.4 months, P = 0.009), and survival of patients with 2-4 BMs did not differ from those with 5-10 BMs (6.4 months vs. 6.3 months, P = 0.170). The median survival of patients with >10 BMs was lower than those with 2-10 BMs (6.3 months vs. 5.5 months, P = 0.025). In a multivariate model that accounted for age, Karnofsky Performance Score, systemic disease status, tumor histology, and cumulative intracranial tumor volume, we observed a ∼10% increase in hazard of death when comparing patients with 1 versus 2-10 BMs (P < 0.001) or 10 versus >10 BMs (P < 0.001). When BM number was modeled as a continuous variable rather than using the classification by Yamamoto et al., we observed a step-wise 4% increase in the hazard of death for every increment of 6-7 BM (P < 0.001). CONCLUSIONS The contribution of BM number to overall survival is modest and should be considered as one of the many variables considered in the decision between SRS and whole-brain radiation therapy.
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41
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Ziemer BP, Shiraishi S, Hattangadi-Gluth JA, Sanghvi P, Moore KL. Fully automated, comprehensive knowledge-based planning for stereotactic radiosurgery: Preclinical validation through blinded physician review. Pract Radiat Oncol 2017; 7:e569-e578. [PMID: 28711334 DOI: 10.1016/j.prro.2017.04.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 04/06/2017] [Accepted: 04/14/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE As knowledge-based planning (KBP) attempts to augment and potentially supplant manual treatment planning, it is imperative to ensure any implementation maintains or improves overall plan quality in any disease site. The purpose of this study was to demonstrate the overall quality of KBP-driven automated stereotactic radiosurgery (SRS) treatment planning using blinded physician comparison and determine systematic factors predictive of physician plan preference to guide future KBP refinement. METHODS AND MATERIALS Automated noncoplanar volume modulated arc therapy KBP routines were developed for 199 plans across 3 clinical SRS scenarios: isolated lesions (isolated), lesions closely abutting (<3 cm) organs at risk (involved), and single-isocenter multiple metastases (multimet). Overall plan quality and preference were assessed via blinded review of the plans by two SRS physicians. Quantitative quality metrics were also compared to determine systematic differences in the treatment plans. Multiple parameters were investigated as predictors of KBP plan selection. RESULTS For the isolated, involved, and multimet scenarios, the KBP plans were considered to be superior or equivalent to clinical plans 86.7% (91/105), 81.1% (43/53), and 78.1% (32/41) of the time, respectively. All investigated quality metrics were equivalent or indicated more sparing for all KBP plans. The only nondosimetric predictor was planning target volume in the isolated (P = .02) and involved (P = .05) groups. The dosimetric predictors for the isolated group were gradient measure and heterogeneity index (both P < .01). In the multimet category, the only significant dosimetric predictor was interlesion dose (P = .01). CONCLUSIONS The fully automated KBP SRS plans were equivalent or superior to previously treated plans in 83.4% (166/199) of cases. In clinical implementation, geometric features found to be predictive of KBP performance can be used to identify plans where KBP results might benefit from further refinement, whereas dosimetric predictive features could be used to further refine KBP optimization priorities.
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Affiliation(s)
- Benjamin P Ziemer
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Satomi Shiraishi
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Jona A Hattangadi-Gluth
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Parag Sanghvi
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Kevin Lawrence Moore
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California.
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42
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Kim W, Sharim J, Tenn S, Kaprealian T, Bordelon Y, Agazaryan N, Pouratian N. Diffusion tractography imaging-guided frameless linear accelerator stereotactic radiosurgical thalamotomy for tremor: case report. J Neurosurg 2017; 128:215-221. [PMID: 28298033 DOI: 10.3171/2016.10.jns161603] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Essential tremor and Parkinson's disease-associated tremor are extremely prevalent within the field of movement disorders. The ventral intermediate (VIM) nucleus of the thalamus has been commonly used as both a neuromodulatory and neuroablative target for the treatment of these forms of tremor. With both deep brain stimulation and Gamma Knife radiosurgery, there is an abundance of literature regarding the surgical planning, targeting, and outcomes of these methodologies. To date, there have been no reports of frameless, linear accelerator (LINAC)-based thalomotomies for tremor. The authors report the case of a patient with tremor-dominant Parkinson's disease, with poor tremor improvement with medication, who was offered LINAC-based thalamotomy. High-resolution 0.9-mm isotropic MR images were obtained, and simulation was performed via CT with 1.5-mm contiguous slices. The VIM thalamic nucleus was determined using diffusion tensor imaging (DTI)-based segmentation on FSL using probabilistic tractography. The supplemental motor and premotor areas were the cortical target masks. The authors centered their isocenter within the region of the DTI-determined target and treated the patient with 140 Gy in a single fraction. The DTI-determined target had coordinates of 14.2 mm lateral and 8.36 mm anterior to the posterior commissure (PC), and 3 mm superior to the anterior commissure (AC)-PC line, which differed by 3.30 mm from the original target determined by anatomical considerations (15.5 mm lateral and 7 mm anterior to the PC, and 0 mm superior to the AC-PC line). There was faint radiographic evidence of lesioning at the 3-month follow-up within the target zone, which continued to consolidate on subsequent scans. The patient experienced continued right upper-extremity resting tremor improvement starting at 10 months until it was completely resolved at 22 months of follow-up. Frameless LINAC-based thalamotomy guided by DTI-based thalamic segmentation is a feasible method for achieving radiosurgical lesions of the VIM thalamus to treat tremor.
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Affiliation(s)
| | - Justin Sharim
- 2David Geffen School of Medicine at UCLA, Los Angeles, California
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43
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Lu AY, Turban JL, Damisah EC, Li J, Alomari AK, Eid T, Vortmeyer AO, Chiang VL. Novel biomarker identification using metabolomic profiling to differentiate radiation necrosis and recurrent tumor following Gamma Knife radiosurgery. J Neurosurg 2016; 127:388-396. [PMID: 27885954 DOI: 10.3171/2016.8.jns161395] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Following an initial response of brain metastases to Gamma Knife radiosurgery, regrowth of the enhancing lesion as detected on MRI may represent either radiation necrosis (a treatment-related inflammatory change) or recurrent tumor. Differentiation of radiation necrosis from tumor is vital for management decision making but remains difficult by imaging alone. In this study, gas chromatography with time-of-flight mass spectrometry (GC-TOF) was used to identify differential metabolite profiles of the 2 tissue types obtained by surgical biopsy to find potential targets for noninvasive imaging. METHODS Specimens of pure radiation necrosis and pure tumor obtained from patient brain biopsies were flash-frozen and validated histologically. These formalin-free tissue samples were then analyzed using GC-TOF. The metabolite profiles of radiation necrosis and tumor samples were compared using multivariate and univariate statistical analysis. Statistical significance was defined as p ≤ 0.05. RESULTS For the metabolic profiling, GC-TOF was performed on 7 samples of radiation necrosis and 7 samples of tumor. Of the 141 metabolites identified, 17 (12.1%) were found to be statistically significantly different between comparison groups. Of these metabolites, 6 were increased in tumor, and 11 were increased in radiation necrosis. An unsupervised hierarchical clustering analysis found that tumor had elevated levels of metabolites associated with energy metabolism, whereas radiation necrosis had elevated levels of metabolites that were fatty acids and antioxidants/cofactors. CONCLUSIONS To the authors' knowledge, this is the first tissue-based metabolomics study of radiation necrosis and tumor. Radiation necrosis and recurrent tumor following Gamma Knife radiosurgery for brain metastases have unique metabolite profiles that may be targeted in the future to develop noninvasive metabolic imaging techniques.
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Affiliation(s)
| | | | | | | | | | - Tore Eid
- Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut
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Alongi F, Fiorentino A, Mancosu P, Navarria P, Giaj Levra N, Mazzola R, Scorsetti M. Stereotactic radiosurgery for intracranial metastases: linac-based and gamma-dedicated unit approach. Expert Rev Anticancer Ther 2016; 16:731-40. [DOI: 10.1080/14737140.2016.1190648] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Filippo Alongi
- Radiation Oncology Department, Sacro Cuore Hospital, Negrar, Italy
| | - Alba Fiorentino
- Radiation Oncology Department, Sacro Cuore Hospital, Negrar, Italy
| | - Pietro Mancosu
- Radiation Oncology Department, Istituto Clinico Humanitas, Milan, Italy
| | - Pierina Navarria
- Radiation Oncology Department, Istituto Clinico Humanitas, Milan, Italy
| | | | - Rosario Mazzola
- Radiation Oncology Department, Sacro Cuore Hospital, Negrar, Italy
| | - Marta Scorsetti
- Radiation Oncology Department, Istituto Clinico Humanitas, Milan, Italy
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