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Choi A, Hunting J, Lanier C, Douglas E, Triozzi P, Ruiz J, Benayoun M, White J, Chan M. Treatment Options for Brain Metastases. Curr Treat Options Oncol 2024; 25:1011-1026. [PMID: 39037617 PMCID: PMC11329393 DOI: 10.1007/s11864-024-01195-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 07/23/2024]
Abstract
OPINION STATEMENT Therapies for brain metastasis continue to evolve as the life expectancies for patients have continued to prolong. Novel advances include the use of improved technology for radiation delivery, surgical guidance, and response assessment, along with systemic therapies that can pass through the blood brain barrier. With increasing complexity of treatments and the increased need for salvage treatments, multi-disciplinary management has become significantly more important.
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Affiliation(s)
- Ariel Choi
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - John Hunting
- Department of Medicine (Hematology and Oncology), Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Claire Lanier
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Emily Douglas
- Department of Medicine (Hematology and Oncology), Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Pierre Triozzi
- Department of Medicine (Hematology and Oncology), Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jimmy Ruiz
- Department of Medicine (Hematology and Oncology), Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Marc Benayoun
- Department of Radiology at Wake Forest School of Medicine, Winston‑Salem, NC, USA
| | - Jaclyn White
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
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Ene CI, Abi Faraj C, Beckham TH, Weinberg JS, Andersen CR, Haider AS, Rao G, Ferguson SD, Alvarez-Brenkenridge CA, Kim BYS, Heimberger AB, McCutcheon IE, Prabhu SS, Wang CM, Ghia AJ, McGovern SL, Chung C, McAleer MF, Tom MC, Perni S, Swanson TA, Yeboa DN, Briere TM, Huse JT, Fuller GN, Lang FF, Li J, Suki D, Sawaya RE. Response of treatment-naive brain metastases to stereotactic radiosurgery. Nat Commun 2024; 15:3728. [PMID: 38697991 PMCID: PMC11066027 DOI: 10.1038/s41467-024-47998-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 04/15/2024] [Indexed: 05/05/2024] Open
Abstract
With improvements in survival for patients with metastatic cancer, long-term local control of brain metastases has become an increasingly important clinical priority. While consensus guidelines recommend surgery followed by stereotactic radiosurgery (SRS) for lesions >3 cm, smaller lesions (≤3 cm) treated with SRS alone elicit variable responses. To determine factors influencing this variable response to SRS, we analyzed outcomes of brain metastases ≤3 cm diameter in patients with no prior systemic therapy treated with frame-based single-fraction SRS. Following SRS, 259 out of 1733 (15%) treated lesions demonstrated MRI findings concerning for local treatment failure (LTF), of which 202 /1733 (12%) demonstrated LTF and 54/1733 (3%) had an adverse radiation effect. Multivariate analysis demonstrated tumor size (>1.5 cm) and melanoma histology were associated with higher LTF rates. Our results demonstrate that brain metastases ≤3 cm are not uniformly responsive to SRS and suggest that prospective studies to evaluate the effect of SRS alone or in combination with surgery on brain metastases ≤3 cm matched by tumor size and histology are warranted. These studies will help establish multi-disciplinary treatment guidelines that improve local control while minimizing radiation necrosis during treatment of brain metastasis ≤3 cm.
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Affiliation(s)
- Chibawanye I Ene
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA.
| | - Christina Abi Faraj
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Thomas H Beckham
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey S Weinberg
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Clark R Andersen
- Department of Biostatistics, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Ali S Haider
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Ganesh Rao
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Sherise D Ferguson
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | | | - Betty Y S Kim
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Amy B Heimberger
- Department of Neurological Surgery, Malnati Brain Tumor Institute of the Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ian E McCutcheon
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Sujit S Prabhu
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Chenyang Michael Wang
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Amol J Ghia
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Caroline Chung
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Martin C Tom
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Subha Perni
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Todd A Swanson
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Debra N Yeboa
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Tina M Briere
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Jason T Huse
- Department of Pathology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Gregory N Fuller
- Department of Pathology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Frederick F Lang
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Dima Suki
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Raymond E Sawaya
- Faculty of Medicine and Medical Affairs, American University of Beirut, Beirut, Lebanon
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3
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Gecici NN, Gurses ME, Kaye B, Jimenez NLF, Berke C, Gökalp E, Lu VM, Ivan ME, Komotar RJ, Shah AH. Comparative analysis of bevacizumab and LITT for treating radiation necrosis in previously radiated CNS neoplasms: a systematic review and meta-analysis. J Neurooncol 2024; 168:1-11. [PMID: 38619777 PMCID: PMC11093788 DOI: 10.1007/s11060-024-04650-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 03/15/2024] [Indexed: 04/16/2024]
Abstract
PURPOSE Radiation necrosis (RN) is a local inflammatory reaction that arises in response to radiation injury and may cause significant morbidity. This study aims to evaluate and compare the efficacy of bevacizumab and laser interstitial thermal therapy (LITT) in treating RN in patients with previously radiated central nervous system (CNS) neoplasms. METHODS PubMed, Cochrane, Scopus, and EMBASE databases were screened. Studies of patients with radiation necrosis from primary or secondary brain tumors were included. Indirect meta-analysis with random-effect modeling was performed to compare clinical and radiological outcomes. RESULTS Twenty-four studies were included with 210 patients in the bevacizumab group and 337 patients in the LITT group. Bevacizumab demonstrated symptomatic improvement/stability in 87.7% of cases, radiological improvement/stability in 86.2%, and steroid wean-off in 45%. LITT exhibited symptomatic improvement/stability in 71.2%, radiological improvement/stability in 64.7%, and steroid wean-off in 62.4%. Comparative analysis revealed statistically significant differences favoring bevacizumab in symptomatic improvement/stability (p = 0.02), while no significant differences were observed in radiological improvement/stability (p = 0.27) or steroid wean-off (p = 0.90). The rates of adverse reactions were 11.2% for bevacizumab and 14.9% for LITT (p = 0.66), with the majority being grade 2 or lower (72.2% for bevacizumab and 62.5% for LITT). CONCLUSION Both bevacizumab and LITT exhibited favorable clinical and radiological outcomes in managing RN. Bevacizumab was found to be associated with better symptomatic control compared to LITT. Patient-, diagnosis- and lesion-related factors should be considered when choosing the ideal treatment modality for RN to enhance overall patient outcomes.
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Affiliation(s)
- Neslihan Nisa Gecici
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, 33136, US
| | - Muhammet Enes Gurses
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, 33136, US.
| | - Brandon Kaye
- Dr. Kiran C. Patel College of Allopathic Medicine, Davie, FL, 33326, US
| | | | - Chandler Berke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, 33136, US
| | - Elif Gökalp
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, 33136, US
| | - Victor M Lu
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, 33136, US
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, 33136, US
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, 33136, US
| | - Ashish H Shah
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, 33136, US
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Mayo ZS, Billena C, Suh JH, Lo SS, Chao ST. The dilemma of radiation necrosis from diagnosis to treatment in the management of brain metastases. Neuro Oncol 2024; 26:S56-S65. [PMID: 38437665 PMCID: PMC10911797 DOI: 10.1093/neuonc/noad188] [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] [Indexed: 03/06/2024] Open
Abstract
Radiation therapy with stereotactic radiosurgery (SRS) or whole brain radiation therapy is a mainstay of treatment for patients with brain metastases. The use of SRS in the management of brain metastases is becoming increasingly common and provides excellent local control. Cerebral radiation necrosis (RN) is a late complication of radiation treatment that can be seen months to years following treatment and is often indistinguishable from tumor progression on conventional imaging. In this review article, we explore risk factors associated with the development of radiation necrosis, advanced imaging modalities used to aid in diagnosis, and potential treatment strategies to manage side effects.
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Affiliation(s)
- Zachary S Mayo
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Cole Billena
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - John H Suh
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Samuel T Chao
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio, USA
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5
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Xu D, Hu Z, Wang K, Hu S, Zhou Y, Zhang S, Chen Y, Pan T. Why does HER2-positive breast cancer metastasize to the brain and what can we do about it? Crit Rev Oncol Hematol 2024; 195:104269. [PMID: 38272149 DOI: 10.1016/j.critrevonc.2024.104269] [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: 04/07/2023] [Revised: 12/18/2023] [Accepted: 01/19/2024] [Indexed: 01/27/2024] Open
Abstract
Breast cancer is the most frequent malignancy in women. However, in the middle and late stages, some people develop distant metastases, which considerably lower the quality of life and life expectancy. The brain is one of the sites where metastasis frequently happens. According to epidemiological research, brain metastases occur at a late stage in 30-50% of patients with HER2-positive breast cancer, resulting in a poor prognosis. Additionally, few treatments are available for HER2-positive brain metastatic breast cancer, and the mortality rate is remarkable owing to the complexity of the brain's anatomical structure and physiological function. In this review, we described the stages of the brain metastasis of breast cancer, the relationship between the microenvironment and metastatic cancer cells, and the unique molecular and cellular mechanisms. It involves cancer cells migrating, invading, and adhering to the brain; penetrating the blood-brain barrier; interacting with brain cells; and activating signal pathways once inside the brain. Finally, we reviewed current clinically used treatment approaches for brain metastasis in HER2-positive breast cancer; summarized the traditional treatment, targeted treatment, immunotherapy, and other treatment modalities; compared the benefits and drawbacks of each approach; discussed treatment challenges; and emphasized the importance of identifying potential targets to improve patient survival rates and comprehend brain metastasis in breast cancer.
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Affiliation(s)
- Dongyan Xu
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Zhengfang Hu
- Beijing Tian Tan Hospital, Capital Medical University, Beijing 100050, China
| | - Kaiyue Wang
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Shiyao Hu
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Yunxiang Zhou
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Shizhen Zhang
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Yiding Chen
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Tao Pan
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China.
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Vellayappan B, Lim-Fat MJ, Kotecha R, De Salles A, Fariselli L, Levivier M, Ma L, Paddick I, Pollock BE, Regis J, Sheehan JP, Suh JH, Yomo S, Sahgal A. A Systematic Review Informing the Management of Symptomatic Brain Radiation Necrosis After Stereotactic Radiosurgery and International Stereotactic Radiosurgery Society Recommendations. Int J Radiat Oncol Biol Phys 2024; 118:14-28. [PMID: 37482137 DOI: 10.1016/j.ijrobp.2023.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 07/02/2023] [Accepted: 07/14/2023] [Indexed: 07/25/2023]
Abstract
Radiation necrosis (RN) secondary to stereotactic radiosurgery is a significant cause of morbidity. The optimal management of corticosteroid-refractory brain RN remains unclear. Our objective was to summarize the literature specific to efficacy and toxicity of treatment paradigms for patients with symptomatic corticosteroid-refractory RN and to provide consensus guidelines for grading and management of RN on behalf of the International Stereotactic Radiosurgery Society. A systematic review of articles pertaining to treatment of RN with bevacizumab, laser interstitial thermal therapy (LITT), surgical resection, or hyperbaric oxygen therapy was performed. The primary composite outcome was clinical and/or radiologic stability/improvement (ie, proportion of patients achieving improvement or stability with the given intervention). Proportions of patients achieving the primary outcome were pooled using random weighted-effects analysis but not directly compared between interventions. Twenty-one articles were included, of which only 2 were prospective studies. Thirteen reports were relevant for bevacizumab, 5 for LITT, 5 for surgical resection and 1 for hyperbaric oxygen therapy. Weighted effects analysis revealed that bevacizumab had a pooled symptom improvement/stability rate of 86% (95% CI 77%-92%), pooled T2 imaging improvement/stability rate of 93% (95% CI 87%-98%), and pooled T1 postcontrast improvement/stability rate of 94% (95% CI 87%-98%). Subgroup analysis showed a statistically significant improvement favoring treatment with low-dose (below median, ≤7.5 mg/kg every 3 weeks) versus high-dose bevacizumab with regards to symptom improvement/stability rate (P = .02) but not for radiologic T1 or T2 changes. The pooled T1 postcontrast improvement/stability rate for LITT was 88% (95% CI 82%-93%), and pooled symptom improvement/stability rate for surgery was 89% (95% CI 81%-96%). Toxicity was inconsistently reported but was generally low for all treatment paradigms. Corticosteroid-refractory RN that does not require urgent surgical intervention, with sufficient noninvasive diagnostic testing that favors RN, can be treated medically with bevacizumab in carefully selected patients as a strong recommendation. The role of LITT is evolving as a less invasive image guided surgical modality; however, the overall evidence for each modality is of low quality. Prospective head-to-head comparisons are needed to evaluate the relative efficacy and toxicity profile among treatment approaches.
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Affiliation(s)
- Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore.
| | - Mary Jane Lim-Fat
- Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Antonio De Salles
- Department of Neurosurgery, University of California, Los Angeles, California; HCor Neuroscience, São Paulo, Brazil
| | - Laura Fariselli
- Department of Neurosurgery, Unit of Radiotherapy, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Marc Levivier
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of Southern California, Los Angeles, California
| | - Ian Paddick
- Division Physics, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jean Regis
- Department of Functional Neurosurgery, Aix Marseille University, Timone University Hospital, Marseille, France
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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7
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Bellur S, Khosla AA, Ozair A, Kotecha R, McDermott MW, Ahluwalia MS. Management of Brain Metastases: A Review of Novel Therapies. Semin Neurol 2023; 43:845-858. [PMID: 38011864 DOI: 10.1055/s-0043-1776782] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Brain metastases (BMs) represent the most common intracranial tumors in adults, and most commonly originate from lung, followed by breast, melanoma, kidney, and colorectal cancer. Management of BM is individualized based on the size and number of brain metastases, the extent of extracranial disease, the primary tumor subtype, neurological symptoms, and prior lines of therapy. Until recently, treatment strategies were limited to local therapies, like surgical resection and radiotherapy, the latter in the form of whole-brain radiotherapy or stereotactic radiosurgery. The next generation of local strategies includes laser interstitial thermal therapy, magnetic hyperthermic therapy, post-resection brachytherapy, and focused ultrasound. New targeted therapies and immunotherapies with documented intracranial activity have transformed clinical outcomes. Novel systemic therapies with intracranial utility include new anaplastic lymphoma kinase inhibitors like brigatinib and ensartinib; selective "rearranged during transfection" inhibitors like selpercatinib and pralsetinib; B-raf proto-oncogene inhibitors like encorafenib and vemurafenib; Kirsten rat sarcoma viral oncogene inhibitors like sotorasib and adagrasib; ROS1 gene rearrangement (ROS1) inhibitors, anti-neurotrophic tyrosine receptor kinase agents like larotrectinib and entrectinib; anti-human epidermal growth factor receptor 2/epidermal growth factor receptor exon 20 agent like poziotinib; and antibody-drug conjugates like trastuzumab-emtansine and trastuzumab-deruxtecan. This review highlights the modern multidisciplinary management of BM, emphasizing the integration of systemic and local therapies.
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Affiliation(s)
- Shreyas Bellur
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | | | - Ahmad Ozair
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Rupesh Kotecha
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Michael W McDermott
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida
| | - Manmeet S Ahluwalia
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
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8
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Kutuk T, Tolakanahalli R, Chaswal V, Yarlagadda S, Herrera R, Appel H, La Rosa A, Mishra V, Wieczorek DJJ, McDermott MW, Siomin V, Mehta MP, Odia Y, Gutierrez AN, Kotecha R. Surgically targeted radiation therapy (STaRT) for recurrent brain metastases: Initial clinical experience. Brachytherapy 2023; 22:872-881. [PMID: 37722990 DOI: 10.1016/j.brachy.2023.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/23/2023] [Accepted: 08/01/2023] [Indexed: 09/20/2023]
Abstract
PURPOSE This study evaluates the outcomes of recurrent brain metastasis treated with resection and brachytherapy using a novel Cesium-131 carrier, termed surgically targeted radiation therapy (STaRT), and compares them to the first course of external beam radiotherapy (EBRT). METHODS Consecutive patients who underwent STaRT between August 2020 and June 2022 were included. All patients underwent maximal safe resection with pathologic confirmation of viable disease prior to STaRT to 60 Gy to a 5-mm depth from the surface of the resection cavity. Complications were assessed using CTCAE version 5.0. RESULTS Ten patients with 12 recurrent brain metastases after EBRT (median 15.5 months, range: 4.9-44.7) met the inclusion criteria. The median BED10Gy90% and 95% were 132.2 Gy (113.9-265.1 Gy) and 116.0 Gy (96.8-250.6 Gy), respectively. The median maximum point dose BED10Gy for the target was 1076.0 Gy (range: 120.7-1478.3 Gy). The 6-month and 1-year local control rates were 66.7% and 33.3% for the prior EBRT course; these rates were 100% and 100% for STaRT, respectively (p < 0.001). At a median follow-up of 14.5 months, there was one instance of grade two radiation necrosis. Surgery-attributed complications were observed in two patients including pseudomeningocele and minor headache. CONCLUSIONS STaRT with Cs-131 presents an alternative approach for operable recurrent brain metastases and was associated with superior local control than the first course of EBRT in this series. Our initial clinical experience shows that STaRT is associated with a high local control rate, modest surgical complication rate, and low radiation necrosis risk in the reirradiation setting.
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Affiliation(s)
- Tugce Kutuk
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Ranjini Tolakanahalli
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Vibha Chaswal
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Sreenija Yarlagadda
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Roberto Herrera
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Haley Appel
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Alonso La Rosa
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Vivek Mishra
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - D Jay J Wieczorek
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Michael W McDermott
- Department of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL
| | - Vitaly Siomin
- Department of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Yazmin Odia
- Department of Neuro-oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Alonso N Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL.
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9
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Winter SF, Vaios EJ, Shih HA, Grassberger C, Parsons MW, Gardner MM, Ehret F, Kaul D, Boehmerle W, Endres M, Dietrich J. Mitigating Radiotoxicity in the Central Nervous System: Role of Proton Therapy. Curr Treat Options Oncol 2023; 24:1524-1549. [PMID: 37728819 DOI: 10.1007/s11864-023-01131-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/21/2023]
Abstract
OPINION STATEMENT Central nervous system (CNS) radiotoxicity remains a challenge in neuro-oncology. Dose distribution advantages of protons over photons have prompted increased use of brain-directed proton therapy. While well-recognized among pediatric populations, the benefit of proton therapy among adults with CNS malignancies remains controversial. We herein discuss the role of protons in mitigating late CNS radiotoxicities in adult patients. Despite limited clinical trials, evidence suggests toxicity profile advantages of protons over conventional radiotherapy, including retention of neurocognitive function and brain volume. Modelling studies predict superior dose conformality of protons versus state-of-the-art photon techniques reduces late radiogenic vasculopathies, endocrinopathies, and malignancies. Conversely, potentially higher brain tissue necrosis rates following proton therapy highlight a need to resolve uncertainties surrounding the impact of variable biological effectiveness of protons on dose distribution. Clinical trials comparing best photon and particle-based therapy are underway to establish whether protons substantially improve long-term treatment-related outcomes in adults with CNS malignancies.
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Affiliation(s)
- Sebastian F Winter
- Department of Neurology and MGH Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117, Berlin, Germany.
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Clinician Scientist Program, 10117, Berlin, Germany.
| | - Eugene J Vaios
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael W Parsons
- Department of Psychiatry, Psychology Assessment Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Melissa M Gardner
- Department of Psychiatry, Psychology Assessment Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Felix Ehret
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Clinician Scientist Program, 10117, Berlin, Germany
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Berlin, Germany; German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - David Kaul
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Berlin, Germany; German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Wolfgang Boehmerle
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117, Berlin, Germany
| | - Matthias Endres
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- ExcellenceCluster NeuroCure, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Jorg Dietrich
- Department of Neurology and MGH Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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10
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Cuschieri A, Borg M, Levinskaia E, Zammit C. LITT for biopsy proven radiation necrosis: A qualitative systematic review. J Clin Neurosci 2023; 116:69-78. [PMID: 37639807 DOI: 10.1016/j.jocn.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/18/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION With the widespread use of stereotactic radiosurgery (SRS), post-radiation treatment effects (PTREs) are increasing in prevalence. Radiation necrosis (RN) is a serious PTRE which carries a poor prognosis. Since 2012, laser interstitial thermal therapy (LITT) has been used to treat RN. However, reviews have attempting to generalise the efficacy of LITT against biopsy-proven RN are limited. In this systematic review, patient demographic characteristics and post-LITT clinical outcomes are characterised. METHODS A systematic literature search was conducted in four major databases for cohort studies and case reports published between 2012 and 2022, following the PRISMA 2020 checklist. Data was extracted and descriptively analysed. Quality of reporting was assessed using the PROCESS criteria and reporting bias was evaluated using the ROBINS-I scoring system. RESULTS Eleven studies met our inclusion criteria, with an overall moderate risk of reporting bias being observed. Mean pre-LITT target lesion volume was 6.75 cm3, and was independent of gender, time since SRS, age and number of interventions prior to LITT. DISCUSSION AND CONCLUSION LITT is a versatile treatment option which may be used to treat a vast range of patients with refractory biopsy-proven RN. However, neurosurgeons should exercise caution when selecting patients for LITT due to insufficient data on the treatment's efficacy against biopsy-proven RN. This warrants further studies to unequivocally determine the safety and clinical outcomes.
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Affiliation(s)
- Andrea Cuschieri
- Faculty of Medicine and Surgery, University of Malta, Imsida MSD2080, Malta.
| | - Mariah Borg
- Faculty of Medicine and Surgery, University of Malta, Imsida MSD2080, Malta
| | | | - Christian Zammit
- Faculty of Medicine and Surgery, University of Malta, Imsida MSD2080, Malta
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11
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Demetz M, Mangesius J, Krigers A, Nevinny-Stickel M, Thomé C, Freyschlag CF, Kerschbaumer J. Tumor Location Impacts the Development of Radiation Necrosis in Benign Intracranial Tumors. Cancers (Basel) 2023; 15:4760. [PMID: 37835452 PMCID: PMC10571857 DOI: 10.3390/cancers15194760] [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: 07/31/2023] [Revised: 09/04/2023] [Accepted: 09/13/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Radiation necrosis (RN) is a possible late complication of stereotactic radiosurgery (SRS), but only a few risk factors are known. The aim of this study was to assess tumor location in correlation to the development of radiation necrosis for skull base (SB) and non-skull base tumors. METHODS All patients treated with radiosurgery for benign neoplasms (2004-2020) were retrospectively evaluated. The clinical, imaging and medication data were obtained and the largest axial tumor diameter was determined using MRI scans in T1-weighted imaging with gadolinium. The diagnosis of RN was established using imaging parameters. Patients with tumors located at the skull base were compared to patients with tumors in non-skull base locations. RESULTS 205 patients could be included. Overall, 157 tumors (76.6%) were located at the SB and compared to 48 (23.4%) non-SB tumors. Among SB tumors, the most common were vestibular schwannomas (125 cases) and meningiomas (21 cases). In total, 32 (15.6%) patients developed RN after a median of 10 (IqR 5-12) months. Moreover, 62 patients (30.2%) had already undergone at least one surgical resection. In multivariate Cox regression, SB tumors showed a significantly lower risk of radiation necrosis with a Hazard Ratio (HR) of 0.252, p < 0.001, independently of the applied radiation dose. Furthermore, higher radiation doses had a significant impact on the occurrence of RN (HR 1.372, p = 0.002). CONCLUSIONS The risk for the development of RN for SB tumors appears to be low but should not be underestimated. No difference was found between recurrent tumors and newly diagnosed tumors, which may support the value of radiosurgical treatment for patients with recurrent SB tumors.
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Affiliation(s)
- Matthias Demetz
- Department of Neurosurgery, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Julian Mangesius
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Aleksandrs Krigers
- Department of Neurosurgery, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | | | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Christian F Freyschlag
- Department of Neurosurgery, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Johannes Kerschbaumer
- Department of Neurosurgery, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
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12
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Diehl CD, Giordano FA, Grosu AL, Ille S, Kahl KH, Onken J, Rieken S, Sarria GR, Shiban E, Wagner A, Beck J, Brehmer S, Ganslandt O, Hamed M, Meyer B, Münter M, Raabe A, Rohde V, Schaller K, Schilling D, Schneider M, Sperk E, Thomé C, Vajkoczy P, Vatter H, Combs SE. Opportunities and Alternatives of Modern Radiation Oncology and Surgery for the Management of Resectable Brain Metastases. Cancers (Basel) 2023; 15:3670. [PMID: 37509330 PMCID: PMC10377800 DOI: 10.3390/cancers15143670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Postsurgical radiotherapy (RT) has been early proven to prevent local tumor recurrence, initially performed with whole brain RT (WBRT). Subsequent to disadvantageous cognitive sequalae for the patient and the broad distribution of modern linear accelerators, focal irradiation of the tumor has omitted WBRT in most cases. In many studies, the effectiveness of local RT of the resection cavity, either as single-fraction stereotactic radiosurgery (SRS) or hypo-fractionated stereotactic RT (hFSRT), has been demonstrated to be effective and safe. However, whereas prospective high-level incidence is still lacking on which dose and fractionation scheme is the best choice for the patient, further ablative techniques have come into play. Neoadjuvant SRS (N-SRS) prior to resection combines straightforward target delineation with an accelerated post-surgical phase, allowing an earlier start of systemic treatment or rehabilitation as indicated. In addition, low-energy intraoperative RT (IORT) on the surgical bed has been introduced as another alternative to external beam RT, offering sterilization of the cavity surface with steep dose gradients towards the healthy brain. This consensus paper summarizes current local treatment strategies for resectable brain metastases regarding available data and patient-centered decision-making.
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Affiliation(s)
- Christian D Diehl
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 80336 München, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Anca-L Grosu
- Department of Radiation Oncology, University Medical Center, Medical Faculty, 79106 Freiburg, Germany
| | - Sebastian Ille
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Klaus-Henning Kahl
- Department of Radiation Oncology, University Medical Center Augsburg, 86156 Augsburg, Germany
| | - Julia Onken
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
- Berlin Institute of Health, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- German Cancer Consortium (DKTK), Partner Site Berlin, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, 37075 Göttingen, Germany
- Comprehensive Cancer Center Niedersachsen (CCC-N), 37075 Göttingen, Germany
| | - Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, 53127 Bonn, Germany
| | - Ehab Shiban
- Department of Neurosurgery, University Medical Center Augsburg, 86156 Augsburg, Germany
| | - Arthur Wagner
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Jürgen Beck
- Department of Neurosurgery, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Stefanie Brehmer
- Department of Neurosurgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Oliver Ganslandt
- Neurosurgical Clinic, Klinikum Stuttgart, 70174 Stuttgart, Germany
| | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Faculty of Medicine, Technical University of Munich, 81675 München, Germany
| | - Marc Münter
- Department of Radiation Oncology, Klinikum Stuttgart Katharinenhospital, 70174 Stuttgart, Germany
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Veit Rohde
- Department of Neurosurgery, Universitätsmedizin Göttingen, 37075 Göttingen, Germany
| | - Karl Schaller
- Department of Neurosurgery, University of Geneva Medical Center & Faculty of Medicine, 1211 Geneva, Switzerland
| | - Daniela Schilling
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Elena Sperk
- Mannheim Cancer Center, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), Klinikum rechts der Isar, 81675 München, Germany
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, 85764 Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, 80336 München, Germany
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13
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Soffietti R, Pellerino A, Bruno F, Mauro A, Rudà R. Neurotoxicity from Old and New Radiation Treatments for Brain Tumors. Int J Mol Sci 2023; 24:10669. [PMID: 37445846 DOI: 10.3390/ijms241310669] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/18/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
Research regarding the mechanisms of brain damage following radiation treatments for brain tumors has increased over the years, thus providing a deeper insight into the pathobiological mechanisms and suggesting new approaches to minimize this damage. This review has discussed the different factors that are known to influence the risk of damage to the brain (mainly cognitive disturbances) from radiation. These include patient and tumor characteristics, the use of whole-brain radiotherapy versus particle therapy (protons, carbon ions), and stereotactic radiotherapy in various modalities. Additionally, biological mechanisms behind neuroprotection have been elucidated.
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Affiliation(s)
- Riccardo Soffietti
- Division of Neuro-Oncology, Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science University Hospital, 10126 Turin, Italy
| | - Alessia Pellerino
- Division of Neuro-Oncology, Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science University Hospital, 10126 Turin, Italy
| | - Francesco Bruno
- Division of Neuro-Oncology, Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science University Hospital, 10126 Turin, Italy
| | - Alessandro Mauro
- Department of Neuroscience "Rita Levi Montalcini", University of Turin and City of Health and Science University Hospital, 10126 Turin, Italy
- I.R.C.C.S. Istituto Auxologico Italiano, Division of Neurology and Neuro-Rehabilitation, San Giuseppe Hospital, 28824 Piancavallo, Italy
| | - Roberta Rudà
- Division of Neuro-Oncology, Department of Neuroscience "Rita Levi Montalcini", University and City of Health and Science University Hospital, 10126 Turin, Italy
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14
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Merenzon MA, Levy AS, Bhatia S, Rivera C, Morell AA, Semonche A, Daggubati LC, Luther E, Komotar RJ, Shah AH, Ivan ME. Towards the definition of progressive disease in brain metastasis treated with laser ablation: an evidence-based study. J Neurooncol 2023:10.1007/s11060-023-04360-0. [PMID: 37306886 DOI: 10.1007/s11060-023-04360-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/31/2023] [Indexed: 06/13/2023]
Abstract
PURPOSE The postoperative period after laser interstitial thermal therapy (LITT) is marked by a temporary increase in volume, which can impact the accuracy of radiographic assessment. The current criteria for progressive disease (PD) suggest that a 20% increase in size of brain metastasis (BM) assessed in 6-12 weeks intervals should be considered as local progression (LP). However, there is no agreement on how LP should be defined in this context. In this study, we aimed to statistically analyze which tumor volume variations were associated with LP. METHODS We analyzed 40 BM that underwent LITT between 2013 and 2022. For this study, LP was defined following radiographic features. A ROC curve was generated to evaluate volume change as a predictor of LP and find the optimal cutoff point. A logistic regression analysis and Kaplan Meier curves were performed to assess the impact of various clinical variables on LP. RESULTS Out of 40 lesions, 12 (30%) had LP. An increase in volume of 25.6% from baseline within 120-180 days after LITT presented a 70% sensitivity and 88.9% specificity for predicting LP (AUC: 0.78, p = 0.041). The multivariate analysis showed a 25% increase in volume between 120 and 180 days as a negative predictive factor (p = 0.02). Volumetric changes within 60-90 days after LITT did not predict LP (AUC: 0.57; p = 0.61). CONCLUSION Volume changes within the first 120 days after the procedure are not independent indicators of LP of metastatic brain lesions treated with LITT.
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Affiliation(s)
- Martin A Merenzon
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace 2nd Floor, (D4-6), Miami, FL, 33136, USA.
| | - Adam S Levy
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace 2nd Floor, (D4-6), Miami, FL, 33136, USA
| | - Shovan Bhatia
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace 2nd Floor, (D4-6), Miami, FL, 33136, USA
| | - Cameron Rivera
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace 2nd Floor, (D4-6), Miami, FL, 33136, USA
| | - Alexis A Morell
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace 2nd Floor, (D4-6), Miami, FL, 33136, USA
| | - Alexa Semonche
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace 2nd Floor, (D4-6), Miami, FL, 33136, USA
- Department of Neurosurgery, University of California, San Francisco, School of Medicine, 533 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Lekhaj C Daggubati
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace 2nd Floor, (D4-6), Miami, FL, 33136, USA
| | - Evan Luther
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace 2nd Floor, (D4-6), Miami, FL, 33136, USA
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace 2nd Floor, (D4-6), Miami, FL, 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL, 33136, USA
| | - Ashish H Shah
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace 2nd Floor, (D4-6), Miami, FL, 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL, 33136, USA
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 1095 NW 14th Terrace 2nd Floor, (D4-6), Miami, FL, 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL, 33136, USA
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15
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Baskaran AB, Buerki RA, Khan OH, Gondi V, Stupp R, Lukas RV, Villaflor VM. Building Team Medicine in the Management of CNS Metastases. J Clin Med 2023; 12:3901. [PMID: 37373596 DOI: 10.3390/jcm12123901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/30/2023] [Accepted: 06/03/2023] [Indexed: 06/29/2023] Open
Abstract
CNS metastases are often terminal for cancer patients and occur at an approximately 10-fold higher rate than primary CNS tumors. The incidence of these tumors is approximately 70,000-400,000 cases annually in the US. Advances that have occurred over the past two decades have led to more personalized treatment approaches. Newer surgical and radiation techniques, as well as targeted and immune therapies, have enanled patient to live longer, thus increasing the risk for the development of CNS, brain, and leptomeningeal metastases (BM and LM). Patients who develop CNS metastases have often been heavily treated, and options for future treatment could best be addressed by multidisciplinary teams. Studies have indicated that patients with brain metastases have improved survival outcomes when cared for in high-volume academic institutions using multidisciplinary teams. This manuscript discusses a multidisciplinary approach for both parenchymal brain metastases as well as leptomeningeal metastases implemented in three academic institutions. Additionally, with the increasing development of healthcare systems, we discuss optimizing the management of CNS metastases across healthcare systems and integrating basic and translational science into our clinical care to further improve outcomes. This paper summarizes the existing therapeutic approaches to the treatment of BM and LM and discusses novel and emerging approaches to optimizing access to neuro-oncologic care while simultaneously integrating multidisciplinary teams in the care of patients with BM and LM.
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Affiliation(s)
- Archit B Baskaran
- Department of Neurology, The University of Chicago, Chicago, IL 60637, USA
| | - Robin A Buerki
- Health System Clinician of Neurology (Neuro-Oncology), Northwestern Medicine Regional Medical Group, Warrenville, IL 60555, USA
| | - Osaama H Khan
- Surgical Neuro-Oncology, Northwestern Medicine Central DuPage Hospital, Winfield, IL 60190, USA
| | - Vinai Gondi
- Department of Radiation Oncology, Nothwestern Medicine West Region, Lou & Jean Malnati Brain Tumor Institute, Northwestern University, Warrenville, IL 60555, USA
| | - Roger Stupp
- Neuro-Oncology Division, Neurological Surgery, Medicine (Hematology and Oncology), Neurology, Department of Neurology, Lou & Jean Malnati Brain Tumor Institute Northwestern University, Chicago, IL 60611, USA
| | - Rimas V Lukas
- Neuro-Oncology Division, Department of Neurology, Lou & Jean Malnati Brain Tumor Institute, Northwestern University, Chicago, IL 60611, USA
| | - Victoria M Villaflor
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA
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16
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Levy AS, Merenzon MA, Eatz T, Morell AA, Eichberg DG, Bloom MJ, Shah AH, Komotar RJ, Ivan ME. Development of an enhanced recovery protocol after laser ablation surgery protocol: a preliminary analysis. Neurooncol Pract 2023; 10:281-290. [PMID: 37188164 PMCID: PMC10180378 DOI: 10.1093/nop/npad007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background Enhanced recovery after surgery (ERAS) programs are a model of care that aim to improve patient outcomes, reduce complications, and facilitate recovery while reducing healthcare-associated costs and admission length. While such programs have been developed in other surgical subspecialties, there have yet to be guidelines published specifically for laser interstitial thermal therapy (LITT). Here we describe the first multidisciplinary ERAS preliminary protocol for LITT for the treatment of brain tumors. Methods Between the years 2013 and 2021, 184 adult patients consecutively treated with LITT at our single institution were retrospectively analyzed. During this time, a series of pre, intra, and postoperative adjustments were made to the admission course and surgical/anesthesia workflow with the goal of improving recovery and admission length. Results The mean age at surgery was 60.7 years with a median preoperative Karnofsky performance score of 90 ± 13. Lesions were most commonly metastases (50%) and high-grade gliomas (37%). The mean length of stay was 2.4 days, with the average patient being discharged 1.2 days after surgery. There was an overall readmission rate of 8.7% with a LITT-specific readmission rate of 2.2%. Three of 184 patients required repeat intervention in the perioperative period, and there was one perioperative mortality. Conclusions This preliminary study shows the proposed LITT ERAS protocol to be a safe means of discharging patients on postoperative day 1 while preserving outcomes. Although future prospective work is needed to validate this protocol, results show the ERAS approach to be promising for LITT.
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Affiliation(s)
- Adam S Levy
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, Florida, 33136, USA
| | - Martin A Merenzon
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, Florida, 33136, USA
| | - Tiffany Eatz
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, Florida, 33136, USA
| | - Alexis A Morell
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, Florida, 33136, USA
| | - Daniel G Eichberg
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, Florida, 33136, USA
| | - Marc J Bloom
- Department of Anesthesiology, University of Miami Health System, Miami, Florida, USA
| | - Ashish H Shah
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, Florida, 33136, USA
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, Florida, 33136, USA
- Sylvester Cancer Center, University of Miami Health System, Miami, Florida, USA
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, Florida, 33136, USA
- Sylvester Cancer Center, University of Miami Health System, Miami, Florida, USA
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17
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Peña-Pino I, Chen CC. Stereotactic Radiosurgery as Treatment for Brain Metastases: An Update. Asian J Neurosurg 2023; 18:246-257. [PMID: 37397044 PMCID: PMC10310446 DOI: 10.1055/s-0043-1769754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
Stereotactic radiosurgery (SRS) is a mainstay treatment option for brain metastasis (BM). While guidelines for SRS use have been outlined by professional societies, consideration of these guidelines should be weighed in the context of emerging literature, novel technology platforms, and contemporary treatment paradigms. Here, we review recent advances in prognostic scale development for SRS-treated BM patients and survival outcomes as a function of the number of BM and cumulative intracranial tumor volume. Focus is placed on the role of stereotactic laser thermal ablation in the management of BM that recur after SRS and the management of radiation necrosis. Neoadjuvant SRS prior to surgical resection as a means of minimizing leptomeningeal spread is also discussed.
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Affiliation(s)
- Isabela Peña-Pino
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, Minnesota, United States
| | - Clark C. Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, United States
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Vaios EJ, Winter SF, Shih HA, Dietrich J, Peters KB, Floyd SR, Kirkpatrick JP, Reitman ZJ. Novel Mechanisms and Future Opportunities for the Management of Radiation Necrosis in Patients Treated for Brain Metastases in the Era of Immunotherapy. Cancers (Basel) 2023; 15:2432. [PMID: 37173897 PMCID: PMC10177360 DOI: 10.3390/cancers15092432] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/12/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023] Open
Abstract
Radiation necrosis, also known as treatment-induced necrosis, has emerged as an important adverse effect following stereotactic radiotherapy (SRS) for brain metastases. The improved survival of patients with brain metastases and increased use of combined systemic therapy and SRS have contributed to a growing incidence of necrosis. The cyclic GMP-AMP (cGAMP) synthase (cGAS) and stimulator of interferon genes (STING) pathway (cGAS-STING) represents a key biological mechanism linking radiation-induced DNA damage to pro-inflammatory effects and innate immunity. By recognizing cytosolic double-stranded DNA, cGAS induces a signaling cascade that results in the upregulation of type 1 interferons and dendritic cell activation. This pathway could play a key role in the pathogenesis of necrosis and provides attractive targets for therapeutic development. Immunotherapy and other novel systemic agents may potentiate activation of cGAS-STING signaling following radiotherapy and increase necrosis risk. Advancements in dosimetric strategies, novel imaging modalities, artificial intelligence, and circulating biomarkers could improve the management of necrosis. This review provides new insights into the pathophysiology of necrosis and synthesizes our current understanding regarding the diagnosis, risk factors, and management options of necrosis while highlighting novel avenues for discovery.
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Affiliation(s)
- Eugene J. Vaios
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
| | - Sebastian F. Winter
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Helen A. Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jorg Dietrich
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Katherine B. Peters
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Scott R. Floyd
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
| | - John P. Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Zachary J. Reitman
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
- Department of Pathology, Duke University Medical Center, Durham, NC 27710, USA
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Matsui JK, Perlow HK, Upadhyay R, McCalla A, Raval RR, Thomas EM, Blakaj DM, Beyer SJ, Palmer JD. Advances in Radiotherapy for Brain Metastases. Surg Oncol Clin N Am 2023; 32:569-586. [PMID: 37182993 DOI: 10.1016/j.soc.2023.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Radiotherapy remains a cornerstone treatment of brain metastases. With new treatment advances, patients with brain metastases are living longer, and finding solutions for mitigating treatment-related neurotoxicity and improving quality of life is important. Historically, whole-brain radiation therapy (WBRT) was widely used but treatment options such as hippocampal sparing WBRT and stereotactic radiosurgery (SRS) have emerged as promising alternatives. Herein, we discuss the recent advances in radiotherapy for brain metastases including the sparing of critical structures that may improve long-term neurocognitive outcomes (eg, hippocampus, fornix) that may improve long-term neurocognitive outcome, evidence supporting preoperative and fractionated-SRS, and treatment strategies for managing radiation necrosis.
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20
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Xue Z, Guan X, Yuan L, Kang P, Zhang C, Li D, Jia G, Jia W. Laser interstitial thermal therapy in the treatment of brain metastases: the relationship between changes in postoperative magnetic resonance imaging characteristics and tumor recurrence. Acta Neurochir (Wien) 2023; 165:1379-1387. [PMID: 36823478 DOI: 10.1007/s00701-023-05504-x] [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: 11/22/2022] [Accepted: 01/24/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Laser interstitial thermal therapy (LITT) has been used to treat brain metastases (BMs) in several countries, and its safety and effectiveness have been confirmed. In most cases, magnetic resonance imaging (MRI) reveals an increase in tumor volume with an enhanced margin after LITT. However, little is known about the relationship between this MRI change and tumor recurrence. OBJECTIVE We report the first case series of BMs treated by LITT in China to evaluate the clinical characteristics and predictive factors of tumor recurrence. MATERIAL AND METHODS Patients with less than four brain metastatic lesions and a Karnofsky performance status (KPS) > 70 were eligible for study inclusion. Standard LITT procedures were performed, and a follow-up MRI was performed to analyze the radiographic changes, especially the volume ratio of the enhanced margin and the whole lesion on MRI at 30 days postoperatively. All the volume-related data were delineated and calculated using 3D Slicer software. Related predictors were also collected to evaluate the correlation with local tumor control. RESULTS Eighteen patients with nineteen lesions were enrolled for treatment and follow-up. Primary tumor histology included pulmonary carcinoma (n = 11) and breast cancer (n = 4). On average, the tumor size measured 3.01 cm3 (range, 0.40-7.40 cm3), the total ablation time was 13.58 min (range, 2.88-37.15 min), and the complete ablation rate was 92.4% (range, 29.2-100%). Comparing 3s0-day follow-up MRI results with preoperative MRI findings, 18 lesions showed a 2.28-fold (range, 1.21-4.88) volume increase; all the lesions displayed an enhanced component with a volume ratio of 42.35% (range, 10.14-100%). Five patients experienced tumor recurrence, and the local tumor control rates at 90 days and 180 days of follow-up were 68.4% and 66.7%, respectively. Univariate analysis indicated that the primary tumor, ablation rate, and enhanced volume ratio (EVR) > 40% in the 30-day MRI were associated with tumor recurrence, whereas multivariate analysis showed that only EVR > 40% was a predictive factor of local control. CONCLUSION LITT is a minimally invasive method used to ablate brain metastases which can be used as the first-line treatment for BM patients under certain indications. After LITT, most tumors showed volume enlargement on the 30-day MRI scan, and EVR > 40% on the 30-day MRI may indicate late tumor recurrence.
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Affiliation(s)
- Zhan Xue
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan Xilu, Beijing, 10070, People's Republic of China
| | - Xiudong Guan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan Xilu, Beijing, 10070, People's Republic of China
| | - Linhao Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan Xilu, Beijing, 10070, People's Republic of China
| | - Peng Kang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan Xilu, Beijing, 10070, People's Republic of China
| | - Chuanbao Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan Xilu, Beijing, 10070, People's Republic of China
| | - Deling Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan Xilu, Beijing, 10070, People's Republic of China
| | - Guijun Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan Xilu, Beijing, 10070, People's Republic of China
| | - Wang Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119 Nansihuan Xilu, Beijing, 10070, People's Republic of China.
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Spacca B, Di Maurizio M, Grandoni M, Tempesti S, Genitori L. Laser interstitial thermal therapy (LITT) for pediatric patients affected by intracranial tumors. Front Neurol 2023; 14:1120286. [PMID: 37153686 PMCID: PMC10157164 DOI: 10.3389/fneur.2023.1120286] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/16/2023] [Indexed: 05/10/2023] Open
Abstract
Introduction The surgical treatment of brain tumors has evolved over time, offering different strategies tailored to patients and their specific lesions. Among these strategies, Laser Interstitial Thermal Therapy (LITT) is one of the most recent advances in pediatric neurooncological surgery, and its results and evolution are still under assessment. Methods We retrospectively analyzed data from six pediatric patients with deep-seated brain tumors treated with LITT at a single center between November 2019 and June 2022. A total of four patients underwent a stereotaxic biopsy during the same operating session. The indications and preparation for LITT, technical issues, clinical and radiological follow-up, impact on quality of life, and oncological treatment are discussed. Results The mean patient age eight years (ranging from 2 to 11 years). The lesion was thalamic in four patients, thalamo-peduncular in one, and occipital posterior periventricular in one. In total, two patients had been previously diagnosed with low-grade glioma (LGG). Biopsies revealed LGG in two patients, ganglioglioma grade I in one, and diffuse high-grade glioma (HGG) in one. Postoperatively, two patients presented with transient motor deficits. The mean follow-up period was 17 months (ranging from 5 to 32 months). Radiological follow-up showed a progressive reduction of the tumor in patients with LGG. Conclusion Laser interstitial thermal therapy is a promising, minimally invasive treatment for deep-seated tumors in children. The results of lesion reduction appear to be relevant in LGGs and continue over time. It can be used as an alternative treatment for tumors located at sites that are difficult to access surgically or where other standard treatment options have failed.
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Affiliation(s)
- Barbara Spacca
- Neurosurgery Unit, Meyer Children’s Hospital IRCCS, Florence, Italy
- *Correspondence: Barbara Spacca,
| | | | - Manuela Grandoni
- Neurosurgery Unit, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Sara Tempesti
- Radiology Unit, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Lorenzo Genitori
- Neurosurgery Unit, Meyer Children’s Hospital IRCCS, Florence, Italy
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Yudkoff C, Mahtabfar A, Piper K, Judy K. Safety and efficacy of salvage therapy with laser interstitial thermal therapy for malignant meningioma refractory to cesium-131 brachytherapy: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22379. [PMID: 36471578 PMCID: PMC9724005 DOI: 10.3171/case22379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/07/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anaplastic meningioma are rare, cancerous tumors of the central nervous system that often require multimodal therapy for tumor control. Both laser interstitial thermal therapy (LITT) and brachytherapy with implanted cesium-131 metallic seeds have demonstrated efficacy in the treatment of recurrent and resistant anaplastic meningioma; however, their safety as a dual therapy has never been reported. OBSERVATIONS In this report, the authors present a case of a 53-year-old female who received LITT in combination with brachytherapy after surgical and radiation treatment options had been exhausted. The authors discuss the unique safety concern of thermal injury with this treatment combination and demonstrate their method for the safe administration of these treatments together. Furthermore, the authors provide a review of the literature on LITT as an emerging therapy for anaplastic meningioma. LESSONS The use of LITT in combination with brachytherapy remains an option for salvage therapy in patients with recurrent meningioma that provides durable local control of tumor.
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Schwalb AM, Srinivasan ES, Fecci PE. Commentary: Laser Interstitial Thermal Therapy for First-Line Treatment of Surgically Accessible Recurrent Glioblastoma: Outcomes Compared With a Surgical Cohort. Neurosurgery 2022; 91:e160-e163. [PMID: 36377926 PMCID: PMC9632939 DOI: 10.1227/neu.0000000000002184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 08/15/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Allison M. Schwalb
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ethan S. Srinivasan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Peter E. Fecci
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA;,Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
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24
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Scherschinski L, Jubran JH, Shaftel KA, Furey CG, Farhadi DS, Benner D, Hendricks BK, Smith KA. Magnetic Resonance-Guided Laser Interstitial Thermal Therapy for Management of Low-Grade Gliomas and Radiation Necrosis: A Single-Institution Case Series. Brain Sci 2022; 12:brainsci12121627. [PMID: 36552087 PMCID: PMC9775146 DOI: 10.3390/brainsci12121627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/10/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Laser interstitial thermal therapy (LITT) has emerged as a minimally invasive treatment modality for ablation of low-grade glioma (LGG) and radiation necrosis (RN). OBJECTIVE To evaluate the efficacy, safety, and survival outcomes of patients with radiographically presumed recurrent or newly diagnosed LGG and RN treated with LITT. METHODS The neuro-oncological database of a quaternary center was reviewed for all patients who underwent LITT for management of LGG between 1 January 2013 and 31 December 2020. Clinical data including demographics, lesion characteristics, and clinical and radiographic outcomes were collected. Kaplan-Meier analyses comprised overall survival (OS) and progression-free survival (PFS). RESULTS Nine patients (7 men, 2 women; mean [SD] age 50 [16] years) were included. Patients underwent LITT at a mean (SD) of 11.6 (8.5) years after diagnosis. Two (22%) patients had new lesions on radiographic imaging without prior treatment. In the other 7 patients, all (78%) had surgical resection, 6 (67%) had intensity-modulated radiation therapy and chemotherapy, respectively, and 4 (44%) had stereotactic radiosurgery. Two (22%) patients had lesions that were wild-type IDH1 status. Volumetric assessment of preoperative T1-weighted contrast-enhancing and T2-weighted fluid-attenuated inversion recovery (FLAIR) sequences yielded mean (SD) lesion volumes of 4.1 (6.5) cm3 and 26.7 (27.9) cm3, respectively. Three (33%) patients had evidence of radiographic progression after LITT. The pooled median (IQR) PFS for the cohort was 52 (56) months, median (IQR) OS after diagnosis was 183 (72) months, and median (IQR) OS after LITT was 52 (60) months. At the time of the study, 2 (22%) patients were deceased. CONCLUSIONS LITT is a safe and effective treatment option for management of LGG and RN, however, there may be increased risk of permanent complications with treatment of deep-seated subcortical lesions.
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Affiliation(s)
- Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
- Department of Neurosurgery, Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany
- Correspondence: ; Tel.: +1-602-693-5883
| | - Jubran H. Jubran
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Kelly A. Shaftel
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Charuta G. Furey
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Dara S. Farhadi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Dimitri Benner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Benjamin K. Hendricks
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Kris A. Smith
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
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25
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Odia Y, Gutierrez AN, Kotecha R. Surgically targeted radiation therapy (STaRT) trials for brain neoplasms: A comprehensive review. Neuro Oncol 2022; 24:S16-S24. [PMID: 36322100 PMCID: PMC9629486 DOI: 10.1093/neuonc/noac130] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The mainstays of radiation therapy include external beam radiation therapy (EBRT) and internally implanted radiation, or brachytherapy (BT), all with distinct benefits and risks in terms of local or distant tumor control and normal brain toxicities, respectively. GammaTile® Surgically Targeted Radiation Therapy (STaRT) attempts to limit the drawbacks of other BT paradigms via a permanently implanted, bioresorbable, conformable, collagen tile containing four uniform intensity radiation sources, thus preventing deleterious direct contact with the brain and optimizing interseed spacing to homogenous radiation exposure. The safety and feasibility of GammaTile® STaRT therapy was established by multiple clinical trials encompassing the spectrum of primary and secondary brain neoplasms, both recurrent and newly-diagnosed. Implantable GT tiles were FDA approved in 2018 for use in recurrent intracranial neoplasms, expanded to newly-diagnosed malignant intracranial neoplasms by 2020. The current spectrum of trials focuses on better defining the relative efficacy and safety of non-GT standard-of-care radiation strategies for intracranial brain neoplasm. We summarize the key design and eligibility criteria for open and future trials of GT therapy, including registries and randomized trials for newly-diagnosed and recurrent brain metastases as well as recurrent and newly-diagnosed glioblastoma in combination with approved therapies.
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Affiliation(s)
- Yazmin Odia
- Corresponding Author: Yazmin Odia, MD MS FAAN, Chief of Neuro-Oncology, MCI, BHSF, Associate Faculty, HWCOM, FIU, 8900 North Kendall Drive, Miami, FL 33176, USA ()
| | - Alonso N Gutierrez
- Department of Radiation-Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Rupesh Kotecha
- Department of Radiation-Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA,Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
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26
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Wu A, Wu JY, Lim M. Updates in intraoperative strategies for enhancing intra-axial brain tumor control. Neuro Oncol 2022; 24:S33-S41. [PMID: 36322098 PMCID: PMC9629479 DOI: 10.1093/neuonc/noac170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
To ensure excellent postoperative clinical outcomes while preserving critical neurologic function, neurosurgeons who manage patients with intra-axial brain tumors can use intraoperative technologies and tools to achieve maximal safe resection. Neurosurgical oncology revolves around safe and optimal extent of resection, which further dictates subsequent treatment regimens and patient outcomes. Various methods can be adapted for treating both primary and secondary intra-axial brain lesions. We present a review of recent advances and published research centered on different innovative tools and techniques, including fluorescence-guided surgery, new methods of drug delivery, and minimally invasive procedural options.
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Affiliation(s)
- Adela Wu
- Department of Neurosurgery, Stanford Health Care, Stanford, California, USA
| | | | - Michael Lim
- Department of Neurosurgery, Stanford Health Care, Stanford, California, USA
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Schupper AJ, Chanenchuk T, Racanelli A, Price G, Hadjipanayis CG. Laser hyperthermia: Past, present, and future. Neuro Oncol 2022; 24:S42-S51. [PMID: 36322099 PMCID: PMC9629480 DOI: 10.1093/neuonc/noac208] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Magnetic resonance imaging-guided laser interstitial thermal therapy (LITT) is an ablative procedure using heat from a laser to provide cytoreduction in tissue. It is a minimally invasive procedure that has been used in intracranial pathologies such as high-grade gliomas, metastatic lesions, epilepsy, and other lesions. While LITT may offer a more acceptable complication profile compared to open surgery, the role of laser therapy for intracranial lesions in current treatment paradigms continues to evolve. This review will focus on the background and application of LITT, the current evidence for its use, and future directions for the technology.
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Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Tori Chanenchuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Anna Racanelli
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Gabrielle Price
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Constantinos G Hadjipanayis
- Department of Neurosurgery, Icahn School of Medicine, Mount Sinai Downtown Union Square, Mount Sinai Health System, New York, New York, USA
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28
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Aizer AA, Lamba N, Ahluwalia MS, Aldape K, Boire A, Brastianos PK, Brown PD, Camidge DR, Chiang VL, Davies MA, Hu LS, Huang RY, Kaufmann T, Kumthekar P, Lam K, Lee EQ, Lin NU, Mehta M, Parsons M, Reardon DA, Sheehan J, Soffietti R, Tawbi H, Weller M, Wen PY. Brain metastases: A Society for Neuro-Oncology (SNO) consensus review on current management and future directions. Neuro Oncol 2022; 24:1613-1646. [PMID: 35762249 PMCID: PMC9527527 DOI: 10.1093/neuonc/noac118] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Brain metastases occur commonly in patients with advanced solid malignancies. Yet, less is known about brain metastases than cancer-related entities of similar incidence. Advances in oncologic care have heightened the importance of intracranial management. Here, in this consensus review supported by the Society for Neuro-Oncology (SNO), we review the landscape of brain metastases with particular attention to management approaches and ongoing efforts with potential to shape future paradigms of care. Each coauthor carried an area of expertise within the field of brain metastases and initially composed, edited, or reviewed their specific subsection of interest. After each subsection was accordingly written, multiple drafts of the manuscript were circulated to the entire list of authors for group discussion and feedback. The hope is that the these consensus guidelines will accelerate progress in the understanding and management of patients with brain metastases, and highlight key areas in need of further exploration that will lead to dedicated trials and other research investigations designed to advance the field.
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Affiliation(s)
- Ayal A Aizer
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Nayan Lamba
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Radiation Oncology Program, Boston, Massachusetts, USA
| | | | - Kenneth Aldape
- Laboratory of Pathology, National Cancer Institute, Bethesda, Maryland, USA
| | - Adrienne Boire
- Department of Neurology, Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Priscilla K Brastianos
- Departments of Neuro-Oncology and Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - D Ross Camidge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Veronica L Chiang
- Departments of Neurosurgery and Radiation Oncology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael A Davies
- Department of Melanoma Medical Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Leland S Hu
- Department of Radiology, Neuroradiology Division, Mayo Clinic, Phoenix, Arizona, USA
| | - Raymond Y Huang
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | | | - Priya Kumthekar
- Department of Neurology at The Feinberg School of Medicine at Northwestern University and The Malnati Brain Tumor Institute at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois, USA
| | - Keng Lam
- Department of Neurology, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, California, USA
| | - Eudocia Q Lee
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Minesh Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida, USA
| | - Michael Parsons
- Departments of Oncology and Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David A Reardon
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Riccardo Soffietti
- Division of Neuro-Oncology, Department of Neuroscience Rita Levi Montalcini, University of Turin, Turin, Italy
| | - Hussein Tawbi
- Department of Melanoma Medical Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Patrick Y Wen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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29
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Damante MA, Wang JL, Elder JB. Surgical Management of Recurrent Brain Metastasis: A Systematic Review of Laser Interstitial Thermal Therapy. Cancers (Basel) 2022; 14:cancers14184367. [PMID: 36139527 PMCID: PMC9496803 DOI: 10.3390/cancers14184367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 11/16/2022] Open
Abstract
The incidence of recurrent metastatic brain tumors is increasing due to advances in local therapy, including surgical and radiosurgical management, as well as improved systemic disease control. The management of recurrent brain metastases was previously limited to open resection and/or irradiation. In recent years, laser interstitial thermal therapy (LITT) has become a promising treatment modality. As systemic and intracranial disease burden increases in a patient, patients may no longer be candidates for surgical resection. LITT offers a relatively minimally invasive option for patients that cannot tolerate or do not want open surgery, as well as an option for accessing deep-seated tumors that may be difficult to access via craniotomy. This manuscript aims to critically review the available data regarding the use of LITT for recurrent intracranial brain metastasis. Ten of seventy-two studies met the criteria for review. Generally, the available literature suggests that LITT is a safe and feasible option for the treatment of recurrent brain metastases involving supratentorial and cortical brain, as well as posterior fossa and deep-seated locations. Among all studies, only one directly compared craniotomy to LITT in the setting of recurrent brain metastasis. Prospective studies are needed to better elucidate the role of LITT in the management of recurrent brain metastases.
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Quality of Life and Cognitive Function Evaluations and Interventions for Patients with Brain Metastases in the Radiation Oncology Clinic. Cancers (Basel) 2022; 14:cancers14174301. [PMID: 36077835 PMCID: PMC9454858 DOI: 10.3390/cancers14174301] [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: 06/29/2022] [Revised: 08/22/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Brain metastases (BMs) are the most common brain malignancy and are projected to increase in incidence over the coming decades. Historically, brain metastasis studies have focused on improving survival outcomes, but recently, the importance of evaluating health-related quality of life (HRQOL) and cognitive function has gained recognition. Although there is a myriad of validated HRQOL and cognitive assessments available in the radiation oncology clinic, there is an urgent need to identify tools tailored to patients with BMs and to adopt a uniform set of tests that measure HRQOL and cognition. This review presents various assessments for measuring HRQOL and cognitive function, current recommendations to improve standardization, and treatments known to preserve HRQOL and cognitive function. Abstract Brain metastases (BMs) account for a disproportionately high percentage of cancer morbidity and mortality. Historically, studies have focused on improving survival outcomes, and recent radiation oncology clinical trials have incorporated HRQOL and cognitive assessments. We are now equipped with a battery of assessments in the radiation oncology clinic, but there is a lack of consensus regarding how to incorporate them in modern clinical practice. Herein, we present validated assessments for BM patients, current recommendations for future clinical studies, and treatment advances that have improved HRQOL and cognitive outcomes for BM patients.
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Muir M, Traylor JI, Gadot R, Patel R, Prabhu SS. Repeat laser interstitial thermal therapy for recurrent primary and metastatic intracranial tumors. Surg Neurol Int 2022; 13:311. [PMID: 35928321 PMCID: PMC9345120 DOI: 10.25259/sni_418_2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/22/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Repeat craniotomy in patients with primary and metastatic brain tumors carries significant morbidity and can delay adjuvant treatments. Repeat laser interstitial thermal therapy (LITT) for recurrent disease has been described and could benefit patients with limited cytoreductive options. We aim to describe the indications, safety, and efficacy of repeat LITT for recurrent primary and metastatic intracranial tumors. Methods: Patients undergoing repeat ablations for the same lesion were included in the study. We retrospectively analyzed 13 patients treated with 29 total LITT ablations. Results: Eleven patients were treated for glioblastoma (GBM), while two had brain metastases. Eleven patients had LITT performed only 2 times, while three patients underwent three total iterations of LITT for disease recurrence. Median length of stay after the 1st ablation was 2 days, while the median length of stay after the 2nd ablation was 1 day. The median time to resuming adjuvant treatments after the 1st LITT was 11 days. The median time to resuming adjuvant treatments after the 2nd LITT was 28 days. Four patients after the 1st and 2nd LITT sustained deficits persisting through 30-day follow-up. The median progression-free survival among the GBM patients from the first ablation was 6.0 months, 3.2 months from the 2nd ablation, and 2.1 months from the 3rd ablation. Conclusion: Recurrent tumors, especially GBM, can be safely treated using repeat LITT when surgery cannot be effectively performed. Our results indicate that patients tolerate the procedure well and have a meaningful survival given the salvage nature of the procedure.
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Affiliation(s)
- Matthew Muir
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, United States
| | - Jeffrey I. Traylor
- Department of Neurological Surgery, UT Southwestern, Dallas, United States
| | - Ron Gadot
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
| | - Rajan Patel
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
| | - Sujit S. Prabhu
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, United States
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Grabowski MM, Srinivasan ES, Vaios EJ, Sankey EW, Otvos B, Krivosheya D, Scott A, Olufawo M, Ma J, Fomchenko EI, Herndon JE, Kim AH, Chiang VL, Chen CC, Leuthardt EC, Barnett GH, Kirkpatrick JP, Mohammadi AM, Fecci PE. Combination Laser Interstitial Thermal Therapy Plus Stereotactic Radiotherapy (SRT) Increases Time to Progression for Biopsy-Proven Recurrent Brain Metastases. Neurooncol Adv 2022; 4:vdac086. [PMID: 35795470 PMCID: PMC9248774 DOI: 10.1093/noajnl/vdac086] [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] [Indexed: 11/12/2022] Open
Abstract
Background Improved survival for patients with brain metastases has been accompanied by a rise in tumor recurrence after stereotactic radiotherapy (SRT). Laser interstitial thermal therapy (LITT) has emerged as an effective treatment for SRT failures as an alternative to open resection or repeat SRT. We aimed to evaluate the efficacy of LITT followed by SRT (LITT+SRT) in recurrent brain metastases. Methods A multicenter, retrospective study was performed of patients who underwent treatment for biopsy-proven brain metastasis recurrence after SRT at an academic medical center. Patients were stratified by “planned LITT+SRT” versus “LITT alone” versus “repeat SRT alone.” Index lesion progression was determined by modified Response Assessment in Neuro-Oncology Brain Metastases (RANO-BM) criteria. Results Fifty-five patients met inclusion criteria, with a median follow-up of 7.3 months (range: 1.0–30.5), age of 60 years (range: 37–86), Karnofsky Performance Status (KPS) of 80 (range: 60–100), and pre-LITT/biopsy contrast-enhancing volume of 5.7 cc (range: 0.7–19.4). Thirty-eight percent of patients underwent LITT+SRT, 45% LITT alone, and 16% SRT alone. Median time to index lesion progression (29.8, 7.5, and 3.7 months [P = .022]) was significantly improved with LITT+SRT. When controlling for age in a multivariate analysis, patients treated with LITT+SRT remained significantly less likely to have index lesion progression (P = .004). Conclusions These data suggest that LITT+SRT is superior to LITT or repeat SRT alone for treatment of biopsy-proven brain metastasis recurrence after SRT failure. Prospective trials are warranted to validate the efficacy of using combination LITT+SRT for treatment of recurrent brain metastases.
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Affiliation(s)
- Matthew M Grabowski
- Corresponding Author: Matthew M. Grabowski, MD, Cleveland Clinic, 9500 Euclid Ave. S4, Cleveland, OH 44195, USA ()
| | - Ethan S Srinivasan
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Eugene J Vaios
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Eric W Sankey
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Balint Otvos
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic & Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Daria Krivosheya
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic & Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Alex Scott
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael Olufawo
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jun Ma
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Elena I Fomchenko
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - James E Herndon
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Albert H Kim
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Veronica L Chiang
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Eric C Leuthardt
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Gene H Barnett
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic & Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - John P Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina, USA
- Duke Center for Brain and Spine Metastasis, Durham, North Carolina, USA
| | - Alireza M Mohammadi
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic & Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
- Duke Center for Brain and Spine Metastasis, Durham, North Carolina, USA
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Lerner EC, Edwards RM, Wilkinson DS, Fecci PE. Laser ablation: Heating up the anti-tumor response in the intracranial compartment. Adv Drug Deliv Rev 2022; 185:114311. [PMID: 35489652 PMCID: PMC10589123 DOI: 10.1016/j.addr.2022.114311] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 03/29/2022] [Accepted: 04/21/2022] [Indexed: 02/07/2023]
Abstract
Immunotherapies, such as immune checkpoint inhibition (ICI), have had limited success in treating intracranial malignancies. These failures are due partly to the restrictive blood-brain-barrier (BBB), the profound tumor-dependent induction of local and systemic immunosuppression, and immune evasion exhibited by these tumors. Therefore, novel approaches must be explored that aim to overcome these stringent barriers. LITT is an emerging treatment for brain tumors that utilizes thermal ablation to kill tumor cells. LITT provides an additional therapeutic benefit by synergizing with ICI and systemic chemotherapies to strengthen the anti-tumor immune response. This synergistic relationship involves transient disruption of the BBB and local augmentation of immune function, culminating in increased CNS drug penetrance and improved anti-tumor immunity. In this review, we will provide an overview of the challenges facing immunotherapy for brain tumors, and discuss how LITT may synergize with the endogenous anti-tumor response to improve the efficacy of ICI.
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Affiliation(s)
- Emily C Lerner
- Duke Medical School, Duke University Medical Center, Durham, NC, United States
| | - Ryan M Edwards
- Duke Medical School, Duke University Medical Center, Durham, NC, United States
| | - Daniel S Wilkinson
- Preston Robert Tisch Brain Tumor Center at Duke, Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Peter E Fecci
- Preston Robert Tisch Brain Tumor Center at Duke, Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States.
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Brenner AW, Patel AJ. Review of Current Principles of the Diagnosis and Management of Brain Metastases. Front Oncol 2022; 12:857622. [PMID: 35686091 PMCID: PMC9171239 DOI: 10.3389/fonc.2022.857622] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/25/2022] [Indexed: 12/25/2022] Open
Abstract
Brain metastases are the most common intracranial tumors and are increasing in incidence as overall cancer survival improves. Diagnosis of brain metastases involves both clinical examination and magnetic resonance imaging. Treatment may involve a combination of surgery, radiotherapy, and systemic medical therapy depending on the patient's neurologic status, performance status, and overall oncologic burden. Advances in these domains have substantially impacted the management of brain metastases and improved performance status and survival for some patients. Indications for surgery have expanded with improved patient selection, imaging, and intraoperative monitoring. Robust evidence supports the use of whole brain radiotherapy and stereotactic radiosurgery, for both standalone and adjuvant indications, in almost all patients. Lastly, while systemic medical therapy has historically provided little benefit, modern immunotherapeutic agents have demonstrated promise. Current investigation seeks to determine the utility of neoadjuvant radiotherapy and laser interstitial thermal therapy, which have shown benefit in limited studies to date. This article provides a review of the epidemiology, pathology, diagnosis, and treatment of brain metastases and the corresponding supporting evidence.
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Affiliation(s)
| | - Akash J. Patel
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
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35
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Zhang S, Li C, Cao L, Moser MAJ, Zhang W, Qian Z, Zhang B. Modeling and ex vivo experimental validation of liver tissue carbonization with laser ablation. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 217:106697. [PMID: 35180678 DOI: 10.1016/j.cmpb.2022.106697] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/26/2022] [Accepted: 02/08/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The purpose of this study was to model the process of liver tissue carbonization with laser ablation (LA). METHODS A dynamic heat source model was proposed and combined with the light distribution model as well as bioheat transfer model to predict the development of tissue carbonization with laser ablation (LA) using an ex vivo porcine liver tissue model. An ex vivo laser ablation experiment with porcine liver tissues using a custom-made 1064 nm bare fiber was then used to verify the simulation results at 3, 5, and 7 W laser administrations for 5 min. The spatiotemporal temperature distribution was monitored by measuring the temperature changes at three points close the fiber during LA. Both the experiment and simulation of the temperature, tissue carbonization zone, and ablation zone were then compared. RESULTS Four stages were recognized in the development of liver tissue carbonization during LA. The growth of the carbonization zone along the fiber axial and radial directions were different in the four stages. The carbonization zone along the fiber axial direction (L2) grew in the four stages with a sharp increase in the initial period and a minor increase in Stage 4. However, the change in the carbonization zone along the fiber radial direction (D2) increased dramatically (Stage 1) to a long-time plateau (Stages 2 and 3) followed by a slow growth in Stage 4. An acceptable agreement between the computer simulation and ex vivo experiment in the temperature changes at the three points was found at all three testing laser administrations. A similar result was also obtained for the dimensions of coagulation zone and ablation zone between the computer simulation and ex vivo experiment (carbonization zone: 2.99± 0.10 vs. 2.78 mm2, 67.39± 0.09 vs. 63.53 mm2, and 90.53± 0.11 vs. 85.15 mm2; ablation zone: 68.95± 0.28 vs. 65.29 mm2, 182.11± 0.24 vs. 213.81 mm2, and 244.80± 0.06 vs. 251.79 mm2 at 3, 5, and 7 W, respectively). CONCLUSION This study demonstrates that the proposed dynamic heat source model combined with the light distribution model as well as bioheat transfer model can predict the development of liver tissue carbonization with an acceptable accuracy. This study contributes to an improved understanding of the LA process in the treatment of liver tumors.
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Affiliation(s)
- Shiguang Zhang
- Intelligent Energy-based Tumor Ablation Laboratory, School of Mechatronic Engineering and Automation, Shanghai University, Shanghai, 200444, China; School of Mechanical and Power Engineering, East China University of Science and Technology, Shanghai, 200237, China
| | - Chunlei Li
- Shanghai Advanced Research Institute, Chinese Academy of Science, Shanghai, 201024, China
| | - Lin Cao
- Department of Automatic Control and Systems Engineering, the University of Sheffield, Sheffield, UK
| | - Michael A J Moser
- Department of Surgery, University of Saskatchewan, Saskatoon, Canada
| | - Wenjun Zhang
- Department of Mechanical Engineering, University of Saskatchewan, Saskatoon, Canada
| | - Zhiqin Qian
- School of Mechanical and Power Engineering, East China University of Science and Technology, Shanghai, 200237, China.
| | - Bing Zhang
- Intelligent Energy-based Tumor Ablation Laboratory, School of Mechatronic Engineering and Automation, Shanghai University, Shanghai, 200444, China.
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Vaios EJ, Batich KA, Buckley AF, Dunn-Pirio A, Patel MP, Kirkpatrick JP, Goudar R, Peters KB. Resolution of radiation necrosis with bevacizumab following radiation therapy for primary CNS lymphoma. Oncotarget 2022; 13:576-582. [PMID: 35359747 PMCID: PMC8963718 DOI: 10.18632/oncotarget.28222] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/08/2022] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE Radiation necrosis (RN) is a rare but serious adverse effect following treatment with radiation therapy. No standard of care exists for the management of RN, and efforts to prevent and treat RN are limited by a lack of insight into the pathomechanics and molecular drivers of RN. This case series describes the outcomes of treatment with bevacizumab (BV) in two primary CNS lymphoma (PCNSL) patients who developed symptomatic biopsy-proven RN after whole brain radiation (WBRT) with a stereotactic radiosurgery (SRS) boost. OBSERVATIONS Patient 1 is a 52 year-old female with PCNSL treated with WBRT followed by an SRS boost. She developed symptomatic biopsy-proven RN, and initial treatment with tocopherol and pentoxifylline was unsuccessful. A 100% clinical and radiographic response was achieved with 4 cycles of BV. Patient 2, a 48 year-old male with PCNSL, presented with seizures and biopsy-proven RN after radiation therapy. Initial empiric treatment with tocopherol and pentoxifylline was unsuccessful. A 100% clinical and radiographic response was achieved with 3 cycles of BV. CONCLUSIONS AND RELEVANCE Monitoring for RN in patients with PCNSL treated with radiation therapy is warranted. BV is an efficacious treatment and a viable alternative to corticosteroids or surgical intervention.
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Affiliation(s)
- Eugene J. Vaios
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Kristen A. Batich
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, NC, USA
| | - Anne F. Buckley
- Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | | | - Mallika P. Patel
- Department of Pharmacy, Duke University Medical Center, Durham, NC, USA
| | - John P. Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | | | - Katherine B. Peters
- Departments of Neurosurgery and Neurology, Duke University Medical Center, Durham, NC, USA
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Li AY, Gaebe K, Jerzak KJ, Cheema PK, Sahgal A, Das S. Intracranial Metastatic Disease: Present Challenges, Future Opportunities. Front Oncol 2022; 12:855182. [PMID: 35330715 PMCID: PMC8940535 DOI: 10.3389/fonc.2022.855182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/16/2022] [Indexed: 11/13/2022] Open
Abstract
Intracranial metastatic disease (IMD) is a prevalent complication of cancer that significantly limits patient survival and quality of life. Over the past half-century, our understanding of the epidemiology and pathogenesis of IMD has improved and enabled the development of surveillance and treatment algorithms based on prognostic factors and tumor biomolecular characteristics. In addition to advances in surgical resection and radiation therapy, the treatment of IMD has evolved to include monoclonal antibodies and small molecule antagonists of tumor-promoting proteins or endogenous immune checkpoint inhibitors. Moreover, improvements in the sensitivity and specificity of imaging as well as the development of new serological assays to detect brain metastases promise to revolutionize IMD diagnosis. In this review, we will explore current treatment principles in patients with IMD, including the emerging role of targeted and immunotherapy in select primary cancers, and discuss potential areas for further investigation.
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Affiliation(s)
- Alyssa Y Li
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Karolina Gaebe
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Katarzyna J Jerzak
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Oncology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Parneet K Cheema
- Division of Oncology, William Osler Health System, Brampton, ON, Canada
| | - Arjun Sahgal
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Sunit Das
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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38
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Sankey EW, Grabowski MM, Srinivasan ES, Griffin AS, Howell EP, Otvos B, Tsvankin V, Barnett GH, Mohammadi AM, Fecci PE. Time to Steroid Independence After Laser Interstitial Thermal Therapy vs Medical Management for Treatment of Biopsy-Proven Radiation Necrosis Secondary to Stereotactic Radiosurgery for Brain Metastasis. Neurosurgery 2022; 90:684-690. [DOI: 10.1227/neu.0000000000001922] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 12/05/2021] [Indexed: 12/14/2022] Open
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Shahsavari N, Ahmad M, Sekar V, Meola A, Hancock SL, Chang SD, Chiang VL. Synchronous glioblastoma and brain metastases: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21714. [PMID: 36273867 PMCID: PMC9379681 DOI: 10.3171/case21714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/02/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Radiosurgical treatment of brain metastases is usually performed without brain tissue confirmation. While it is extremely rare for glioblastoma to develop concurrently in patients with brain metastases, they can look radiographically similar, and recognition is important because it alters management and prognosis. The synchronous presence of brain metastases and glioblastoma has not been published to date in the literature, making this a rare illustrative case. OBSERVATIONS A 70-year-old female had lung biopsy-proven metastatic lung adenocarcinoma and multiple brain metastases. Her treatment course included initial carboplatin, pemetrexed, and bevacizumab followed by maintenance nivolumab, and she underwent stereotactic radiosurgery to the multiple brain metastases. During interval radiological surveillance, one lesion in the right temporal lobe was noted to slowly progress associated with development of significant perilesional edema causing midline shift despite repeated stereotactic radiosurgical treatments. Biopsy of this lesion revealed glioblastoma, IDH wildtype. LESSONS Glioblastomas and brain metastases have similar radiological features, so the possibility of incorrect diagnosis needs to be considered for all lesions with interval growth poststereotactic radiosurgery. Biopsy and/or resection/laser ablation should be considered prior to reirradiation.
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Affiliation(s)
| | | | | | | | - Steven L. Hancock
- Radiation Oncology, Stanford University School of Medicine, Palo Alto, California; and
| | | | - Veronica L. Chiang
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
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Tsui DCC, Camidge DR, Rusthoven CG. Managing Central Nervous System Spread of Lung Cancer: The State of the Art. J Clin Oncol 2022; 40:642-660. [PMID: 34985937 DOI: 10.1200/jco.21.01715] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Brain metastases (BrM) are common in both non-small-cell lung cancer and small-cell lung cancer. Substantial progress in BrM management has occurred in the past decade related to advances in both radiation and medical oncology. Recent and ongoing radiation trials have focused on increasing the candidacy for focal therapy of BrM with stereotactic radiosurgery; reducing the toxicity and improving patient selection for whole brain radiotherapy; and, in small-cell lung cancer, evaluating brain magnetic resonance imaging surveillance without prophylactic cranial irradiation, hippocampal avoidance in prophylactic cranial irradiation and whole brain radiotherapy, and the role of upfront stereotactic radiosurgery for BrM. In medical oncology, the development of multiple tyrosine kinase inhibitors with encouraging CNS activity and emerging data on the CNS activity of immune checkpoint inhibitors in some patients have opened the door to novel systemic and multidisciplinary treatment strategies for the management of BrM. Future research will focus on more robust characterizations of the CNS activity of targeted therapy and immunotherapies, as well as optimal integration and patient selection for multidisciplinary strategies involving CNS-active drugs, radiation therapy, and CNS surveillance.
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Affiliation(s)
- David Chun Cheong Tsui
- Division of Medical Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
| | - D Ross Camidge
- Division of Medical Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
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41
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Sabahi M, Bordes SJ, Najera E, Mohammadi AM, Barnett GH, Adada B, Borghei-Razavi H. Laser Interstitial Thermal Therapy for Posterior Fossa Lesions: A Systematic Review and Analysis of Multi-Institutional Outcomes. Cancers (Basel) 2022; 14:cancers14020456. [PMID: 35053618 PMCID: PMC8773929 DOI: 10.3390/cancers14020456] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 12/28/2021] [Accepted: 01/13/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Laser interstitial thermal therapy (LITT) has emerged as a treatment option for deep-seated primary and metastatic brain lesions; however, hardly any data exist regarding LITT for lesions of the posterior fossa. Methods: A quantitative systematic review was performed. Article selection was performed by searching MEDLINE (using PubMed), Scopus, and Cochrane electronic bibliographic databases. Inclusion criteria were studies assessing LITT on posterior fossa tumors. Results: 16 studies comprising 150 patients (76.1% female) with a mean age of 56.47 years between 2014 and 2021 were systematically reviewed for treatment outcomes and efficacy. Morbidity and mortality data could be extracted for 131 of the 150 patients. Death attributed to treatment failure, disease progression, recurrence, or postoperative complications occurred in 6.87% (9/131) of the pooled sample. Procedure-related complications, usually including new neurologic deficits, occurred in approximately 14.5% (19/131) of the pooled sample. Neurologic deficits improved with time in most cases, and 78.6% (103/131) of the pooled sample experienced no complications and progression-free survival at the time of last follow-up. Conclusions: LITT for lesions of the posterior fossa continues to show promising data. Future clinical cohort studies are required to further direct treatment recommendations.
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Affiliation(s)
- Mohammadmahdi Sabahi
- Neurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan 65141, Iran;
| | - Stephen J. Bordes
- Department of Surgery, Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA 70112, USA;
| | - Edinson Najera
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, FL 33331, USA; (E.N.); (B.A.)
| | - Alireza M. Mohammadi
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH 44195, USA; (A.M.M.); (G.H.B.)
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Gene H. Barnett
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH 44195, USA; (A.M.M.); (G.H.B.)
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Badih Adada
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, FL 33331, USA; (E.N.); (B.A.)
| | - Hamid Borghei-Razavi
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, FL 33331, USA; (E.N.); (B.A.)
- Correspondence: ; Tel.: +1-(954)-659-5630
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Stereotactic Laser Ablation (SLA) followed by consolidation stereotactic radiosurgery (cSRS) as treatment for brain metastasis that recurred locally after initial radiosurgery (BMRS): a multi-institutional experience. J Neurooncol 2022; 156:295-306. [PMID: 35001245 DOI: 10.1007/s11060-021-03893-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The optimal treatment paradigm for brain metastasis that recurs locally after initial radiosurgery remains an area of active investigation. Here, we report outcomes for patients with BMRS treated with stereotactic laser ablation (SLA, also known as laser interstitial thermal therapy, LITT) followed by consolidation radiosurgery. METHODS Clinical outcomes of 20 patients with 21 histologically confirmed BMRS treated with SLA followed by consolidation SRS and > 6 months follow-up were collected retrospectively across three participating institutions. RESULTS Consolidation SRS (5 Gy × 5 or 6 Gy × 5) was carried out 16-73 days (median of 26 days) post-SLA in patients with BMRS. There were no new neurological deficits after SLA/cSRS. While 3/21 (14.3%) patients suffered temporary Karnofsky Performance Score (KPS) decline after SLA, no KPS decline was observed after cSRS. There were no 30-day mortalities or wound complications. Two patients required re-admission within 30 days of cSRS (severe headache that resolved with steroid therapy (n = 1) and new onset seizure (n = 1)). With a median follow-up of 228 days (range: 178-1367 days), the local control rate at 6 and 12 months (LC6, LC12) was 100%. All showed diminished FLAIR volume surrounding the SLA/cSRS treated BMRS at the six-month follow-up; none of the patients required steroid for symptoms attributable to these BMRS. These results compare favorably to the available literature for repeat SRS or SLA-only treatment of BMRS. CONCLUSIONS This multi-institutional experience supports further investigations of SLA/cSRS as a treatment strategy for BMRS.
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Mitchell D, Kwon HJ, Kubica PA, Huff WX, O’Regan R, Dey M. Brain metastases: An update on the multi-disciplinary approach of clinical management. Neurochirurgie 2022; 68:69-85. [PMID: 33864773 PMCID: PMC8514593 DOI: 10.1016/j.neuchi.2021.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/16/2021] [Accepted: 04/03/2021] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Brain metastasis (BM) is the most common malignant intracranial neoplasm in adults with over 100,000 new cases annually in the United States and outnumbering primary brain tumors 10:1. OBSERVATIONS The incidence of BM in adult cancer patients ranges from 10-40%, and is increasing with improved surveillance, effective systemic therapy, and an aging population. The overall prognosis of cancer patients is largely dependent on the presence or absence of brain metastasis, and therefore, a timely and accurate diagnosis is crucial for improving long-term outcomes, especially in the current era of significantly improved systemic therapy for many common cancers. BM should be suspected in any cancer patient who develops new neurological deficits or behavioral abnormalities. Gadolinium enhanced MRI is the preferred imaging technique and BM must be distinguished from other pathologies. Large, symptomatic lesion(s) in patients with good functional status are best treated with surgery and stereotactic radiosurgery (SRS). Due to neurocognitive side effects and improved overall survival of cancer patients, whole brain radiotherapy (WBRT) is reserved as salvage therapy for patients with multiple lesions or as palliation. Newer approaches including multi-lesion stereotactic surgery, targeted therapy, and immunotherapy are also being investigated to improve outcomes while preserving quality of life. CONCLUSION With the significant advancements in the systemic treatment for cancer patients, addressing BM effectively is critical for overall survival. In addition to patient's performance status, therapeutic approach should be based on the type of primary tumor and associated molecular profile as well as the size, number, and location of metastatic lesion(s).
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Affiliation(s)
- D Mitchell
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - HJ Kwon
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - PA Kubica
- Department of Neurosurgery, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA
| | - WX Huff
- Department of Neurosurgery, Indiana University School of Medicine, Indiana University Purdue University Indianapolis, IN, USA
| | - R O’Regan
- Department of Medicine/Hematology Oncology, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA
| | - M Dey
- Department of Neurosurgery, University of Wisconsin School of Medicine & Public Health, UW Carbone Cancer Center, Madison, WI, USA,Correspondence Should Be Addressed To: Mahua Dey, MD, University of Wisconsin School of Medicine & Public Health, 600 Highland Ave, Madison, WI 53792; Tel: 317-274-2601;
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Noh T, Juvekar P, Huang R, Lee G, Ogasawara CT, Golby AJ. Biopsy Artifact in Laser Interstitial Thermal Therapy: A Technical Note. Front Oncol 2021; 11:746416. [PMID: 34868945 PMCID: PMC8637457 DOI: 10.3389/fonc.2021.746416] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 10/28/2021] [Indexed: 11/25/2022] Open
Abstract
Purpose The safety and effectiveness of laser interstitial thermal therapy (LITT) relies critically on the ability to continuously monitor the ablation based on real-time temperature mapping using magnetic resonance thermometry (MRT). This technique uses gradient recalled echo (GRE) sequences that are especially sensitive to susceptibility effects from air and blood. LITT for brain tumors is often preceded by a biopsy and is anecdotally associated with artifact during ablation. Thus, we reviewed our experience and describe the qualitative signal dropout that can interfere with ablation. Methods We retrospectively reviewed all LITT cases performed in our intraoperative MRI suite for tumors between 2017 and 2020. We identified a total of 17 LITT cases. Cases were reviewed for age, sex, pathology, presence of artifact, operative technique, and presence of blood/air on post-operative scans. Results We identified six cases that were preceded by biopsy, all six had artifact present during ablation, and all six were noted to have air/blood on their post-operative MRI or CT scans. In two of those cases, the artifactual signal dropout qualitatively interfered with thermal damage thresholds at the borders of the tumor. There was no artifact in the 11 non-biopsy cases and no obvious blood or air was noted on the post-ablation scans. Conclusion Additional consideration should be given to pre-LITT biopsies. The presence of air/blood caused an artifactual signal dropout effect in cases with biopsy that was severe enough to interfere with ablation in a significant number of those cases. Additional studies are needed to identify modifying strategies.
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Affiliation(s)
- Thomas Noh
- Division of Neurosurgery, John A Burns School of Medicine, Honolulu, HI, United States
| | - Parikshit Juvekar
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Raymond Huang
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Gunnar Lee
- Division of Neurosurgery, John A Burns School of Medicine, Honolulu, HI, United States
| | - Christian T Ogasawara
- Division of Neurosurgery, John A Burns School of Medicine, Honolulu, HI, United States
| | - Alexandra J Golby
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
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Srinivasan ES, Grabowski MM, Nahed BV, Barnett GH, Fecci PE. Laser interstitial thermal therapy for brain metastases. Neurooncol Adv 2021; 3:v16-v25. [PMID: 34859229 PMCID: PMC8633752 DOI: 10.1093/noajnl/vdab128] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Laser interstitial thermal therapy (LITT) is a minimally invasive treatment for intracranial lesions entailing thermal ablation via a stereotactically placed laser probe. In metastatic disease, it has shown the most promise in the treatment of radiographically progressive lesions after initial stereotactic radiosurgery, whether due to recurrent metastatic disease or radiation necrosis. LITT has been demonstrated to provide clinical benefit in both cases, as discussed in the review below. With its minimal surgical footprint and short recovery period, LITT is further advantaged for patients who are otherwise high-risk surgical candidates or with lesions in difficult to access locations. Exploration of the current data on its use in metastatic disease will allow for a better understanding of the indications, benefits, and future directions of LITT for these patients.
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Affiliation(s)
| | - Matthew M Grabowski
- Department of Neurosurgery, Cleveland Clinic & Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Gene H Barnett
- Department of Neurosurgery, Cleveland Clinic & Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Peter E Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
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Wilcox JA, Brown S, Reiner AS, Young RJ, Chen J, Bale TA, Rosenblum MK, Newman WC, Brennan CW, Tabar V, Beal K, Panageas KS, Moss NS. Salvage resection of recurrent previously irradiated brain metastases: tumor control and radiation necrosis dependency on adjuvant re-irradiation. J Neurooncol 2021; 155:277-286. [PMID: 34655373 DOI: 10.1007/s11060-021-03872-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/08/2021] [Indexed: 01/25/2023]
Abstract
PURPOSE The efficacy of salvage resection (SR) of recurrent brain metastases (rBrM) following stereotactic radiosurgery (SRS) is undefined. We sought to describe local recurrence (LR) and radiation necrosis (RN) rates in patients undergoing SR, with or without adjuvant post-salvage radiation therapy (PSRT). METHODS A retrospective cohort study evaluated patients undergoing SR of post-SRS rBrM between 3/2003-2/2020 at an NCI-designated cancer center. Cases with histologically-viable malignancy were stratified by receipt of adjuvant PSRT within 60 days of SR. Clinical outcomes were described using cumulative incidences in the clustered competing-risks setting, competing risks regression, and Kaplan-Meier methodology. RESULTS One-hundred fifty-five rBrM in 135 patients were evaluated. The overall rate of LR was 40.2% (95% CI 34.3-47.2%) at 12 months. Thirty-nine (25.2%) rBrM treated with SR + PSRT trended towards lower 12-month LR versus SR alone [28.8% (95% CI 17.0-48.8%) versus 43.9% (95% CI 36.2-53.4%), p = .07 by multivariate analysis]. SR as re-operation (p = .03) and subtotal resection (p = .01) were independently associated with higher rates of LR. On univariate analysis, tumor size (p = .48), primary malignancy (p = .35), and PSRT technique (p = .43) bore no influence on LR. SR + PSRT was associated with an increased risk of radiographic RN at 12 months versus SR alone [13.4% (95% CI 5.5-32.7%) versus 3.5% (95% CI 1.5-8.0%), p = .02], though the percentage with symptomatic RN remained low (5.1% versus 0.9%, respectively). Median overall survival from SR was 13.4 months (95% CI 10.5-17.7). CONCLUSION In this largest-known series evaluating SR outcomes in histopathologically-confirmed rBrM, we identify a significant LR risk that may be reduced with adjuvant PSRT and with minimal symptomatic RN. Prospective analysis is warranted.
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Affiliation(s)
- Jessica A Wilcox
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Multidisciplinary Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Samantha Brown
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anne S Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert J Young
- Multidisciplinary Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Justin Chen
- Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Tejus A Bale
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marc K Rosenblum
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William C Newman
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Neurosurgery, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Cameron W Brennan
- Multidisciplinary Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Viviane Tabar
- Multidisciplinary Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kathryn Beal
- Multidisciplinary Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katherine S Panageas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nelson S Moss
- Multidisciplinary Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Luther E, Lu VM, Morell AA, Elarjani T, Mansour S, Echeverry N, Gaztanaga W, King H, McCarthy D, Eichberg DG, Shah A, Burks J, Kaur G, Ivan ME, Komotar RJ. Supralesional Ablation Volumes Are Feasible in the Posterior Fossa and May Provide Enhanced Symptomatic Relief. Oper Neurosurg (Hagerstown) 2021; 21:418-425. [PMID: 34528092 DOI: 10.1093/ons/opab332] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/18/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Laser interstitial thermal therapy (LITT) for posterior fossa lesions remains rare as the small size of the infratentorial compartment, proximity to the brainstem, and thickness/angulation of the occipital bone creates barriers to procedural success. Furthermore, evaluation of the effect of ablation volume on outcomes is limited. OBJECTIVE To analyze our institutional experience with LITT in the posterior fossa stratifying perioperative and long-term outcomes by ablation volumes. METHODS Seventeen patients with posterior fossa lesions treated with LITT from 2013 to 2020 were identified. Local progression-free survival (PFS), overall survival, steroid dependence, and edema reduction were evaluated with Kaplan-Meier analysis grouped by ablation volume. Preoperative, postoperative, and last known Karnofsky Performance Status (KPS) were compared using a matched paired t test. RESULTS No differences in pathology, preoperative KPS, or preoperative lesion volume were found between patients with total (100%-200% increase in pre-LITT lesion volume) versus radical (>200% increase in pre-LITT lesion volume) ablations. Patients who underwent radical ablation had a higher postoperative KPS (93 vs 82, P = .02) and higher KPS (94 vs 87, P = .04) and greater reduction in perilesional edema at last follow-up (P = .01). Median follow-up was 80.8 wk. CONCLUSION Despite obvious anatomical challenges, our results demonstrate that radical ablations are both feasible and safe in the posterior fossa. Furthermore, radical ablations may lead to greater decreases in perilesional edema and improved functional status both immediately after surgery and at last follow-up. Thus, LITT should be considered for patients with otherwise unresectable or radioresistant posterior fossa lesions.
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Affiliation(s)
- Evan Luther
- University of Miami Miller School of Medicine, Department of Neurological Surgery, Miami, Florida, USA
| | - Victor M Lu
- University of Miami Miller School of Medicine, Department of Neurological Surgery, Miami, Florida, USA
| | - Alexis A Morell
- University of Miami Miller School of Medicine, Department of Neurological Surgery, Miami, Florida, USA
| | - Turki Elarjani
- University of Miami Miller School of Medicine, Department of Neurological Surgery, Miami, Florida, USA
| | - Samuel Mansour
- Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Nikolas Echeverry
- Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Wendy Gaztanaga
- University of Miami Miller School of Medicine, Department of Neurological Surgery, Miami, Florida, USA
| | - Hunter King
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - David McCarthy
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Daniel G Eichberg
- University of Miami Miller School of Medicine, Department of Neurological Surgery, Miami, Florida, USA
| | - Ashish Shah
- University of Miami Miller School of Medicine, Department of Neurological Surgery, Miami, Florida, USA
| | - Joshua Burks
- University of Miami Miller School of Medicine, Department of Neurological Surgery, Miami, Florida, USA
| | - Gurvinder Kaur
- University of Miami Miller School of Medicine, Department of Neurological Surgery, Miami, Florida, USA
| | - Michael E Ivan
- University of Miami Miller School of Medicine, Department of Neurological Surgery, Miami, Florida, USA.,Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, Florida, USA
| | - Ricardo J Komotar
- University of Miami Miller School of Medicine, Department of Neurological Surgery, Miami, Florida, USA.,Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, Florida, USA
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Lanier CM, Lecompte M, Glenn C, Hughes RT, Isom S, Jenkins W, Cramer CK, Chan M, Tatter SB, Laxton AW. A Single-Institution Retrospective Study of Patients Treated With Laser-Interstitial Thermal Therapy for Radiation Necrosis of the Brain. Cureus 2021; 13:e19967. [PMID: 34984127 PMCID: PMC8714182 DOI: 10.7759/cureus.19967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2021] [Indexed: 11/05/2022] Open
Abstract
Object Laser-interstitial thermal therapy (LITT) has been proposed as an alternative treatment to surgery for radiation necrosis (RN) in patients treated with stereotactic radiosurgery (SRS) for brain metastases. The present study sought to retrospectively analyze LITT outcomes in patients with RN from SRS. Methods This was a single-institution retrospective study of 30 patients treated from 2011-2018 with pathologically-proven RN after SRS for brain metastases (n=28) or proximally treated extracranial lesions treated with external beam radiotherapy (n=2). Same-day biopsy was performed in all cases. Patients were prospectively followed with Functional Assessment of Cancer Therapy - Brain (FACT-Br), EuroQol-5 Dimension (EQ-5D), Hopkins Verbal Learning Test (HVLT) and clinical history and examination. Adjusted means, standard errors and tests comparing visits to pre-LITT were generated. Kaplan-Meier method was used to estimate time overall survival. Competing risk analysis was used to estimate cumulative incidence of LITT failure. Results In our patient population, median time from radiotherapy to LITT was 13.1 months. Median SRS dose and median LITT treatment target volume were 20 Gy (IQR 18-22) and 3.5 cc (IQR 2.2-4.6), respectively. Seventy-seven percent of our patients tapered off steroids within one month. There were only two instances of RN recurrence after LITT, with recurrence defined as recurrence of symptoms after initial improvement. These recurrences occurred at 1.9 and 3.4 months. The three-, six- and nine-month freedom from recurrence rates were 95.7%, 90.9%, and 90.9%. Median survival in our patient population with pathologically confirmed RN treated with LITT was 2.1 years. Regarding the quality of life questionnaires with which some patients were followed as part of different prospective studies, completion rates were 22/30 for FACT-Br, 16/30 for the EQ-5D and 8/30 for HVLT. Quality of life questionnaire results were overall stable from baseline. Mean FACT-Br scores were stable from baseline (17.9, 16.6, 21.4 and 22.8) to three months (18.8, 15.4, 18.4 and 23.4) (p=0.38, 0.53, 0.09 and 0.59). The mean EQ-5D Aggregate score was stable from baseline (7.1) to one month (7.6) (p=0.25). Mean HVLT-R Total Recall was stable from baseline (20.6) to three months (18.4) (p=0.09). There was a statistically significant decrease in mean Karnofsky Performance Scale (KPS) score from baseline (84) to three-month follow-up (75) (p=0.03). Conclusions LITT represents a safe and durably effective treatment option for RN in the brain. Results demonstrate a median survival of 2.1 years from LITT with only two recurrences, both within four months of treatment and salvageable. Patient-reported outcomes showed no severe declines after LITT. Quality of life questionnaires demonstrated stable well-being and functionality from baseline. LITT should be considered for definitive treatment of RN, especially in cases where patients have significant side effects from standards medical therapies such as steroids or if steroids are minimally effective.
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Affiliation(s)
- Claire M Lanier
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Michael Lecompte
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Chase Glenn
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Ryan T Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Scott Isom
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Wendy Jenkins
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, USA
| | - Christina K Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Michael Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, USA
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, USA
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Parsons MW, Peters KB, Floyd SR, Brown P, Wefel JS. Preservation of neurocognitive function in the treatment of brain metastases. Neurooncol Adv 2021; 3:v96-v107. [PMID: 34859237 PMCID: PMC8633744 DOI: 10.1093/noajnl/vdab122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Neurocognitive function (NCF) deficits are common in patients with brain metastases, occurring in up to 90% of cases. NCF deficits may be caused by tumor-related factors and/or treatment for the metastasis, including surgery, radiation therapy, chemotherapy, and immunotherapy. In recent years, strategies to prevent negative impact of treatments and ameliorate cognitive deficits for patients with brain tumors have gained momentum. In this review, we report on research that has established the efficacy of preventative and rehabilitative therapies for NCF deficits in patients with brain metastases. Surgical strategies include the use of laser interstitial thermal therapy and intraoperative mapping. Radiotherapy approaches include focal treatments such as stereotactic radiosurgery and tailored approaches such as hippocampal avoidant whole-brain radiotherapy (WBRT). Pharmacologic options include use of the neuroprotectant memantine to reduce cognitive decline induced by WBRT and incorporation of medications traditionally used for attention and memory problems. Integration of neuropsychology into the care of patients with brain metastases helps characterize cognitive patterns, educate patients and families regarding their management, and guide rehabilitative therapies. These and other strategies will become even more important for long-term survivors of brain metastases as treatment options improve.
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Affiliation(s)
- Michael W Parsons
- Pappas Center for Neuro-Oncology, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Katherine B Peters
- Preston Robert Tisch Brain Tumor Center, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Scott R Floyd
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Paul Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey S Wefel
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Role of Laser Interstitial Thermal Therapy in the Management of Primary and Metastatic Brain Tumors. Curr Treat Options Oncol 2021; 22:108. [PMID: 34687357 DOI: 10.1007/s11864-021-00912-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 10/20/2022]
Abstract
OPINION STATEMENT Laser interstitial thermal therapy (LITT) is a minimally invasive treatment option for brain tumors including glioblastoma, other primary central nervous system (CNS) neoplasms, metastases, and radiation necrosis. LITT employs a fiber optic coupled laser delivery probe stabilized via stereotaxis to deliver thermal energy that induces coagulative necrosis in tumors to achieve effective cytoreduction. LITT complements surgical resection, radiation treatment, tumor treating fields, and systemic therapy, especially in patients who are high risk for surgical resection due to tumor location in eloquent regions or poor functional status. These factors must be balanced with the increased rate of cerebral edema post LITT compared to surgical resection. LITT has also been shown to induce transient disruption of the blood-brain barrier (BBB), especially in the peritumoral region, which allows for enhanced CNS delivery of anti-neoplastic agents, thus greatly expanding the armamentarium against brain tumors to include highly effective anti-neoplastic agents that have poor BBB penetration. In addition, hyperthermia-induced immunogenic cell death is another secondary side effect of LITT that opens up immunotherapy as an attractive adjuvant treatment for brain tumors. Numerous large studies have demonstrated the safety and efficacy of LITT against various CNS tumors and as the literature continues to grow on this novel technique so will its indications.
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