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Chou CJ, Yang HC, Chang PY, Chen CJ, Wu HM, Lin CF, Lai IC, Peng SJ. Automated identification and quantification of metastatic brain tumors and perilesional edema based on a deep learning neural network. J Neurooncol 2024; 166:167-174. [PMID: 38133789 DOI: 10.1007/s11060-023-04540-y] [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: 09/30/2023] [Accepted: 12/12/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE This paper presents a deep learning model for use in the automated segmentation of metastatic brain tumors and associated perilesional edema. METHODS The model was trained using Gamma Knife surgical data (90 MRI sets from 46 patients), including the initial treatment plan and follow-up images (T1-weighted contrast-enhanced (T1cWI) and T2-weighted images (T2WI)) manually annotated by neurosurgeons to indicate the target tumor and edema regions. A mask region-based convolutional neural network was used to extract brain parenchyma, after which the DeepMedic 3D convolutional neural network was in the segmentation of tumors and edemas. RESULTS Five-fold cross-validation demonstrated the efficacy of the brain parenchyma extraction model, achieving a Dice similarity coefficient of 96.4%. The segmentation models used for metastatic tumors and brain edema achieved Dice similarity coefficients of 71.6% and 85.1%, respectively. This study also presents an intuitive graphical user interface to facilitate the use of these models in clinical analysis. CONCLUSION This paper introduces a deep learning model for the automated segmentation and quantification of brain metastatic tumors and perilesional edema trained using only T1cWI and T2WI. This technique could facilitate further research on metastatic tumors and perilesional edema as well as other intracranial lesions.
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Affiliation(s)
- Chi-Jen Chou
- Division of Neurosurgery, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Huai-Che Yang
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Po-Yao Chang
- Department of Electrical Engineering, National Central University, Taoyuan, Taiwan
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, 22903, USA
| | - Hsiu-Mei Wu
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chun-Fu Lin
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - I-Chun Lai
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
- Department of Heavy Particles & Radiation Oncology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Syu-Jyun Peng
- Professional Master Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, No.250, Wuxing St., Xinyi Dist., Taipei City, 110, Taiwan.
- Clinical Big Data Research Center, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan.
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Kaur M, Cassinelli Petersen G, Jekel L, von Reppert M, Varghese S, Dixe de Oliveira Santo I, Avesta A, Aneja S, Omuro A, Chiang V, Aboian M. PACS-Integrated Tools for Peritumoral Edema Volumetrics Provide Additional Information to RANO-BM-Based Assessment of Lung Cancer Brain Metastases after Stereotactic Radiotherapy: A Pilot Study. Cancers (Basel) 2023; 15:4822. [PMID: 37835516 PMCID: PMC10571649 DOI: 10.3390/cancers15194822] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
Stereotactic radiotherapy (SRT) is the standard of care treatment for brain metastases (METS) today. Nevertheless, there is limited understanding of how posttreatment lesional volumetric changes may assist prediction of lesional outcome. This is partly due to the paucity of volumetric segmentation tools. Edema alone can cause significant clinical symptoms and, therefore, needs independent study along with standard measurements of contrast-enhancing tumors. In this study, we aimed to compare volumetric changes of edema to RANO-BM-based measurements of contrast-enhancing lesion size. Patients with NSCLC METS ≥10 mm on post-contrast T1-weighted image and treated with SRT had measurements for up to seven follow-up scans using a PACS-integrated tool segmenting the peritumoral FLAIR hyperintense volume. Two-dimensional contrast-enhancing and volumetric edema changes were compared by creating treatment response curves. Fifty NSCLC METS were included in the study. The initial median peritumoral edema volume post-SRT relative to pre-SRT baseline was 37% (IQR 8-114%). Most of the lesions with edema volume reduction post-SRT experienced no increase in edema during the study. In over 50% of METS, the pattern of edema volume change was different than the pattern of contrast-enhancing lesion change at different timepoints, which was defined as incongruent. Lesions demonstrating incongruence at the first follow-up were more likely to progress subsequently. Therefore, edema assessment of METS post-SRT provides critical additional information to RANO-BM.
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Affiliation(s)
- Manpreet Kaur
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT 06510, USA; (M.K.); (L.J.)
- Medical Faculty, Ludwig-Maximilians-University of Munich, 80336 Munich, Germany
| | - Gabriel Cassinelli Petersen
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT 06510, USA; (M.K.); (L.J.)
| | - Leon Jekel
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT 06510, USA; (M.K.); (L.J.)
| | - Marc von Reppert
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT 06510, USA; (M.K.); (L.J.)
| | - Sunitha Varghese
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Irene Dixe de Oliveira Santo
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT 06510, USA; (M.K.); (L.J.)
| | - Arman Avesta
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT 06510, USA (S.A.)
| | - Sanjay Aneja
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT 06510, USA (S.A.)
| | - Antonio Omuro
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Veronica Chiang
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT 06510, USA (S.A.)
| | - Mariam Aboian
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT 06510, USA; (M.K.); (L.J.)
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Li L, Feng M, Xu P, Wu YL, Yin J, Huang Y, Tan MY, Jinyi L. Stereotactic radiosurgery with whole brain radiotherapy combined with bevacizumab in the treatment of brain metastases from NSCLC. Int J Neurosci 2023; 133:334-341. [PMID: 33843421 DOI: 10.1080/00207454.2021.1916490] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Non-small cell lung cancer (NSCLC) patients who experience brain metastases are usually associated with poor prognostic outcomes. Whole-brain radiotherapy (WBRT) is one of the standard treatment strategies for NSCLC. It is interesting to combine angiogenesis inhibitors such as bevacizumab with radiation therapy. This study aimed to explore the efficacy and safety of stereotactic radiosurgery (SRS) with WBRT combined with bevacizumab in the treatment of brain metastases. METHODS A total of 21 patients with brain metastases from NSCLC were treated with bevacizumab and WBRT-SRS, while 28 patients were treated with WBRT-SRS only. The bevacizumab average dose was 5-7.5 mg/kg, approximately 2 cycles during radiotherapy. Tumor responses were evaluated every 3 months based on Response Evaluation Criteria in Solid Tumors version 1.1. RESULTS The median follow-up time was 13.5 months (range 2.7-88.4 months). The ORR and DCR of patients who received WBRT-SRS with or without bevacizumab were similar (p = 0.458, p = 0.382). OS(42.63 years VS 25.23 years, p = 0.02)and LPFS (39.53 years VS 23 years, p = 0.047)were better in WBRT-SRS with bevacizumab groups. After radiotherapy and 3 months after radiotherapy, the volume of peritumoral edema was significantly reduced in WBRT-SRS with bevacizumab groups(45.62 ± 24.03 cm3 vs 63.03 ± 25.44 cm3, p = 0.036;8.63 ± 6.87 cm3 vs 15.62 ± 10.58 cm3, p = 0.021). The main adverse reactions were similar in the two groups except for Venous thrombosis with bevacizumab (0 patients vs 5 patients, p = 0.006). CONCLUSION Bevacizumab with radiotherapy improved the overall efficacy and reduced the peritumoral edema of BM from NSCLC.
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Affiliation(s)
- Lu Li
- Sichuan Cancer Hospital & Institute, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Mei Feng
- Sichuan Cancer Hospital & Institute, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Peng Xu
- Sichuan Cancer Hospital & Institute, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yi Lin Wu
- School of Clinical Medicine, Chengdu Medical College, Chengdu, China
| | - Jun Yin
- Sichuan Cancer Hospital & Institute, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yecai Huang
- Sichuan Cancer Hospital & Institute, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Ming Yu Tan
- Sichuan Cancer Hospital & Institute, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Lang Jinyi
- Sichuan Cancer Hospital & Institute, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Jung IH, Chang KW, Park SH, Jung HH, Chang JH, Chang JW, Chang WS. Pseudoprogression and peritumoral edema due to intratumoral necrosis after Gamma knife radiosurgery for meningioma. Sci Rep 2022; 12:13663. [PMID: 35953695 PMCID: PMC9372131 DOI: 10.1038/s41598-022-17813-9] [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: 03/04/2022] [Accepted: 08/01/2022] [Indexed: 11/09/2022] Open
Abstract
Peritumoral cerebral edema is reported to be a side effect that can occur after stereotactic radiosurgery. We aimed to determine whether intratumoral necrosis (ITN) is a risk factor for peritumoral edema (PTE) when gamma knife radiosurgery (GKRS) is performed in patients with meningioma. In addition, we propose the concept of pseudoprogression: a temporary volume expansion that can occur after GKRS in the natural course of meningioma with ITN. This retrospective study included 127 patients who underwent GKRS for convexity meningioma between January 2019 and December 2020. Risk factors for PTE and ITN were investigated using logistic regression analysis. Analysis of variance was used to determine whether changes in tumor volume were statistically significant. After GKRS, ITN was observed in 34 (26.8%) patients, and PTE was observed in 10 (7.9%) patients. When postoperative ITN occurred after GKRS, the incidence of postoperative PTE was 18.970-fold (p = 0.009) greater. When a 70% dose volume ≥ 1 cc was used, the possibility of ITN was 5.892-fold (p < 0.001) higher. On average, meningiomas with ITN increased in volume by 128.5% at 6 months after GKRS and then decreased to 94.6% at 12 months. When performing GKRS in meningioma, a 70% dose volume ≥ 1 cc is a risk factor for ITN. At 6 months after GKRS, meningiomas with ITN may experience a transient volume expansion and PTE, which are characteristics of pseudoprogression. These characteristics typically improve at 12 months following GKRS.
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Affiliation(s)
- In-Ho Jung
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea.,Department of Neurosurgery, Brain Tumor Center, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea.,Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Kyung Won Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - So Hee Park
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Hyun Ho Jung
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Brain Tumor Center, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Jin Woo Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Won Seok Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea.
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Liu D, Chen J, Ge H, Hu X, Yang K, Liu Y, Hu G, Luo B, Yan Z, Song K, Xiao C, Zou Y, Zhang W, Liu H. Differentiation of malignant brain tumor types using intratumoral and peritumoral radiomic features. Front Oncol 2022; 12:848846. [PMID: 35965511 PMCID: PMC9366472 DOI: 10.3389/fonc.2022.848846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 06/28/2022] [Indexed: 12/14/2022] Open
Abstract
Tumor infiltration of central nervous system (CNS) malignant tumors may extend beyond visible contrast enhancement. This study explored tumor habitat characteristics in the intratumoral and peritumoral regions to distinguish common malignant brain tumors such as glioblastoma, primary central nervous system lymphoma, and brain metastases. The preoperative MRI data of 200 patients with solitary malignant brain tumors were included from two datasets for training. Quantitative radiomic features from the intratumoral and peritumoral regions were extracted for model training. The performance of the model was evaluated using data (n = 50) from the third clinical center. When combining the intratumoral and peritumoral features, the Adaboost model achieved the best area under the curve (AUC) of 0.91 and accuracy of 76.9% in the test cohort. Based on the optimal features and classifier, the model in the binary classification diagnosis achieves AUC of 0.98 (glioblastoma and lymphoma), 0.86 (lymphoma and metastases), and 0.70 (glioblastoma and metastases) in the test cohort, respectively. In conclusion, quantitative features from non-enhanced peritumoral regions (especially features from the 10-mm margin around the tumor) can provide additional information for the characterization of regional tumoral heterogeneity, which may offer potential value for future individualized assessment of patients with CNS tumors.
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Affiliation(s)
- Dongming Liu
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Jiu Chen
- Institute of Neuropsychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Fourth Clinical College of Nanjing Medical University, Nanjing, China
- Department of Neurosurgery, Institute of Brain Sciences, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Honglin Ge
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Xinhua Hu
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
- Department of Neurosurgery, Institute of Brain Sciences, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Kun Yang
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Yong Liu
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Guanjie Hu
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Bei Luo
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Zhen Yan
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Kun Song
- Department of Pathology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Chaoyong Xiao
- Department of Radiology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Yuanjie Zou
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Wenbin Zhang
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
- Department of Neurosurgery, Institute of Brain Sciences, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Wenbin Zhang, ; Hongyi Liu,
| | - Hongyi Liu
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
- Department of Neurosurgery, Institute of Brain Sciences, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Wenbin Zhang, ; Hongyi Liu,
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Shen CC, Sun MH, Yang MY, You WC, Sheu ML, Chen YJ, Chen YJ, Sheehan J, Pan HC. Outcome of intracerebral cavernoma treated by Gamma Knife radiosurgery based on a double-blind assessment of treatment indication. Radiat Oncol 2021; 16:164. [PMID: 34454542 PMCID: PMC8401103 DOI: 10.1186/s13014-021-01885-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The benefit and the risk profile of Gamma Knife radiosurgery (GKRS) for intracerebral cavernoma remains incompletely defined in part due to the natural history of low incidence of bleeding and spontaneous regression of this vascular malformation. In this study, we retrieved cases from a prospectively collected database to assess the outcome of intracerebral cavernoma treated with GKRS using a double blinded review process for treatment. METHODS From 2003 to 2018, there were 94 cases of cavernoma treated by GKRS in the doubly blinded assessments by two experienced neurological and approved for GKRS treatment. All the patients received GKRS with margin dose of 11-12 (Gray) Gy and afterwards were assessed for neurological outcome, radiologic response, and quality of life. RESULTS The median age of the patients was 48 (15-85) years with median follow up of 77 (26-180) months post SRS. The mean target volume was 1.93 ± 3.45 cc. In those who has pre-SRS epilepsy, 7 of 16 (43.7%) achieved seizure freedom (Engel I/II) and 9 of 16 (56.3%) achieved decreased seizures (Engel III) after SRS. Rebleeding occurred in 2 cases (2.1%) at 13 and 52 months post SRS. The radiologic assessment demonstrated 20 (21.3%) cases of decreased cavernoma volume, 69 (73.4%) were stable, and 5 (7.3%) increased size. Eighty-seven of 94 (92.5%) cases at the last follow up achieve improvement in their quality of life, but 7 cases (7.4%) showed a deterioration. In statistical analysis, the effective seizure control class (Engel I/II) was highly correlated with patient harboring a single lesion (p < 0.05) and deep seated location of the cavernoma (p < 0.01). New neurological deficits were highly correlated with decreased mental (p < 0.001) and physical (p < 0.05) components of quality of life testing, KPS (p < 0.001), deep seated location (p < 0.01), and increased nidus volume (p < 0.05). Quality of life deterioration either in physical component (p < 0.01), mental component (p < 0.01), and KPS (p < 0.05) was highly correlated with increased cavernoma volume. CONCLUSION Low margin dose GKRS for intracerebral cavernoma offers reasonable seizure control and improved quality of life while conferring a low risk of treatment complications including adverse radiation effect.
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Affiliation(s)
- Chiung-Chyi Shen
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan.,Basic Medical Education Center, Central Taiwan University of Science and Technology, Taichung, Taiwan
| | - Ming Hsi Sun
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Meng-Yin Yang
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Weir-Chiang You
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Meei-Ling Sheu
- Institute of Biomedical Science, National Chung-Hsin University, Taichung, Taiwan
| | - Yen-Ju Chen
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ying Ju Chen
- College of Humanities and Social Sciences, Providence University, Taichung, Taiwan
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Hung-Chuan Pan
- Department of Medical Research and Neurosurgery, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec.4, Taichung, 40705, Taiwan. .,Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan.
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Muhsen BA, Joshi KC, Lee BS, Thapa B, Borghei-Razavi H, Jia X, Barnett GH, Chao ST, Mohammadi AM, Suh JH, Vogelbaum MA, Angelov L. The effect of Gamma Knife radiosurgery on large posterior fossa metastases and the associated mass effect from peritumoral edema. J Neurosurg 2021; 134:466-474. [PMID: 31978879 DOI: 10.3171/2019.11.jns191485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 11/12/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gamma Knife radiosurgery (GKRS) as monotherapy is an option for the treatment of large (≥ 2 cm) posterior fossa brain metastases (LPFMs). However, there is concern regarding possible posttreatment increase in peritumoral edema (PTE) and associated compression of the fourth ventricle. This study evaluated the effects and safety of GKRS on tumor and PTE control in LPFM. METHODS The authors performed a single-center retrospective review of 49 patients with 51 LPFMs treated with GKRS. Patients with at least 1 clinical and radiological follow-up visit were included. Tumor, PTE, and fourth ventricle volumetric measurements were used to assess efficacy and safety. Overall survival was a secondary outcome. RESULTS Fifty-one lesions in 49 consecutive patients were identified; 57.1% of patients were male. At the time of GKRS, the median age was 61.5 years, and the median Karnofsky Performance Status score was 90. The median number of LPFMs and overall brain metastases were 1 and 2, respectively. The median overall tumor, PTE, and fourth ventricle volumes at diagnosis were 4.96 cm3 (range 1.4-21.1 cm3), 14.98 cm3 (range 0.6-71.8 cm3), and 1.23 cm3 (range 0.3-3.2 cm3), respectively, and the median lesion diameter was 2.6 cm (range 2.0-5.07 cm). The median follow-up time was 7.3 months (range 1.6-57.2 months). At the first follow-up, 2 months posttreatment, the median tumor volume decreased by 58.66% (range -96.95% to +48.69%, p < 0.001), median PTE decreased by 78.10% (range -99.92% to +198.35%, p < 0.001), and the fourth ventricle increased by 24.97% (range -37.96% to +545.6%, p < 0.001). The local control rate at first follow-up was 98.1%. The median OS was 8.36 months. No patient required surgical intervention, external ventricular drainage, or shunting between treatment and first follow-up. However, 1 patient required a ventriculoperitoneal shunt at 23 months from treatment. Posttreatment, 65.30% received our general steroid taper, 6.12% received no steroids, and 28.58% required prolonged steroid treatment. CONCLUSIONS In this retrospective analysis, patients with LPFMs treated with GKRS had a statistically significant posttreatment reduction in tumor size and PTE and marked opening of the fourth ventricle (all p < 0.001). This study demonstrates that GKRS is well tolerated and can be considered in the management of select cases of LPFMs, especially in patients who are poor surgical candidates.
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Affiliation(s)
- Baha'eddin A Muhsen
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
| | - Krishna C Joshi
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
| | - Bryan S Lee
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland
| | - Bicky Thapa
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
| | - Hamid Borghei-Razavi
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
| | - Xuefei Jia
- 2Quantitative Health Sciences, Taussig Cancer Institute, Cleveland Clinic, Cleveland
| | - Gene H Barnett
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
| | - Samuel T Chao
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
- 4Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alireza M Mohammadi
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
| | - John H Suh
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
- 4Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Vogelbaum
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
| | - Lilyana Angelov
- 1Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland; and
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8
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Oldenburger E, Oldenburger F, Coolbrandt A, Isebaert S, Neyens I, Sevenants A, Van Audenhove C, Haustermans K. The use of patient reported outcome measures (PROMs) in palliative radiotherapy: A topical review. Radiother Oncol 2020; 149:94-103. [DOI: 10.1016/j.radonc.2020.04.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/24/2020] [Accepted: 04/24/2020] [Indexed: 01/11/2023]
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9
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Verhaak E, Gehring K, Hanssens PEJ, Aaronson NK, Sitskoorn MM. Health-related quality of life in adult patients with brain metastases after stereotactic radiosurgery: a systematic, narrative review. Support Care Cancer 2020; 28:473-484. [PMID: 31792879 PMCID: PMC6954134 DOI: 10.1007/s00520-019-05136-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 10/16/2019] [Indexed: 01/03/2023]
Abstract
PURPOSE A growing number of patients with brain metastases (BM) are being treated with stereotactic radiosurgery (SRS), and the importance of evaluating the impact of SRS on the health-related quality of life (HRQoL) in these patients has been increasingly acknowledged. This systematic review summarizes the current knowledge about the HRQoL of patients with BM after SRS. METHODS We searched EMBASE, Medline Ovid, Web-of-Science, the Cochrane Database, PsycINFO Ovid, and Google Scholar up to November 15, 2018. Studies in patients with BM in which HRQoL was assessed before and after SRS and analyzed over time were included. Studies including populations of several types of brain cancer and/or several types of treatments were included if the results for patients with BM and treatment with SRS alone were described separately. RESULTS Out of 3638 published articles, 9 studies met the eligibility criteria and were included. In 4 out of 7 studies on group results, overall HRQoL of patients with BM remained stable after SRS. In small study samples of longer-term survivors, overall HRQoL remained stable up to 12 months post-SRS. Contradictory results were reported for physical and general/global HRQoL, which might be explained by the different questionnaires that were used. CONCLUSIONS In general, SRS does not have significant negative effects on patients' overall HRQoL over time. Future research is needed to analyze different aspects of HRQoL, differences in individual changes in HRQoL after SRS, and factors that influence these changes. These studies should take into account several methodological issues as discussed in this review.
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Affiliation(s)
- Eline Verhaak
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Warandelaan 2, 5037 AB, Tilburg, The Netherlands
| | - Karin Gehring
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands.
- Department of Cognitive Neuropsychology, Tilburg University, Warandelaan 2, 5037 AB, Tilburg, The Netherlands.
| | - Patrick E J Hanssens
- Gamma Knife Center, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
| | - Neil K Aaronson
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Margriet M Sitskoorn
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Warandelaan 2, 5037 AB, Tilburg, The Netherlands
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10
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Sheehan JP, Grills I, Chiang VL, Dong H, Berg A, Warnick RE, Kondziolka D, Kavanagh B. Quality of life outcomes for brain metastasis patients treated with stereotactic radiosurgery: pre-procedural predictive factors from a prospective national registry. J Neurosurg 2019; 131:1848-1854. [PMID: 30579284 DOI: 10.3171/2018.8.jns181599] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/03/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) is increasingly used for the treatment of brain metastasis. To date, most studies have focused on survival, radiological response, or surrogate quality endpoints such as Karnofsky Performance Scale status or neurocognitive indices. The current study prospectively evaluated pre-procedural factors impacting quality of life in brain metastasis patients undergoing SRS. METHODS Using a national, cloud-based platform, patients undergoing SRS for brain metastasis were accrued to the registry. Quality of life prior to SRS was assessed using the 5-level EQ-5D (EQ5D-L) validated tool; additionally, patient and treatment attributes were collected. Patient quality of life was assessed as part of routine follow-up after SRS. Factors predicting a difference in the aggregate EQ5D-L score or the subscores were evaluated. Pre-SRS covariates impacting changes in EQ5D-L were statistically evaluated. Statistical analyses were conducted using multivariate linear regression models. RESULTS EQ5D-L results were available for 116 patients. EQ5D-L improvement (average of 0.387) was noted in patients treated with earlier SRS (p = 0.000175). Worsening overall EQ5D-L (average of 0.052 per lesion) was associated with an increased number of brain metastases at the time of initial presentation (p = 0.0399). Male sex predicted a risk of worsening (average of 0.347) of the pain and discomfort subscore at last follow-up (p = 0.004205). Baseline subscores of pain/discomfort were not correlated with pain/discomfort subscores at follow-up (p = 0.604), whereas baseline subscores of anxiety/depression were strongly positively correlated with the anxiety/depression follow-up subscores (p = 0.0039). CONCLUSIONS After SRS, quality of life was likely to improve in patients treated early with SRS and worsen in those with a greater number of brain metastases. Sex differences appear to exist regarding pain and discomfort worsening after SRS. Those with high levels of anxiety and depression at SRS may benefit from medical treatment as this particular quality of life factor generally remains unchanged after SRS.
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Affiliation(s)
- Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Inga Grills
- 5Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Veronica L Chiang
- 3Department of Neurological Surgery, Yale University, New Haven, Connecticut
| | - Huamei Dong
- 2Penn State Medical Center, Hershey, Pennsylvania
| | - Arthur Berg
- 2Penn State Medical Center, Hershey, Pennsylvania
| | | | - Douglas Kondziolka
- 4Department of Neurological Surgery, New York University, New York, New York
| | - Brian Kavanagh
- 6Department of Radiation Oncology, University of Colorado, Denver, Colorado; and
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11
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Fu M, Han F, Feng C, Chen T, Feng X. Based on arterial spin labeling helps to differentiate high-grade gliomas from brain solitary metastasis: A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e15580. [PMID: 31083237 PMCID: PMC6531209 DOI: 10.1097/md.0000000000015580] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND We first introduced this meta-analysis was to assess the accuracy of arterial spin labeling (ASL) in the differentiating high-grade gliomas (HGG) from brain solitary metastases (BSM). METHODS The PubMed, Web of Knowledge, and Cochrane Libraries and China National Knowledge Infrastructure databases were searched up to August 31, 2018. The pooled weighted sensitivity and specificity, summary receiver operating characteristic curve (SROC), sensitivity analysis, and threshold effect analysis were performed on Stata version 12.0 and Meta-Disc version 1.4. Deeks' funnel plot asymmetry test was performed to assess publication bias. RESULTS Of 5 eligible articles, of the 346 lesions from 346 patients, 274 were HGG, and 72 were BSM. The forest pooled sensitivity of 0.88 (95% confidence interval [CI]: 0.65, 0.96) and specificity of 0.85 (95% CI: 0.74, 0.92) of ASL were reported in this meta-analysis. The pooled area under the curve of SROC was 0.92 (95% CI: 0.89, 0.94). Sensitivity analysis demonstrated that the pooled estimates were reliable. No evident publication bias was obtained (P = .38). CONCLUSION The parameters derived from ASL with high accuracy in differentiating HGG from BSM. However, results must be interpreted with caution due to the small sample size considered. Large sample prospective studies were necessary to assess and confirm its clinical value.
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Affiliation(s)
- Min Fu
- Department of Radiology, The First Hospital of Qinhuangdao, Hebei
| | - Fang Han
- Department of Radiology, Affiliated Zhongshan Hospital of DaLian University, Dalian, Liaoning
| | - Changchao Feng
- Department of Radiology, The First Hospital of Qinhuangdao, Hebei
| | - Tao Chen
- Department of Radiology, Xiang Yang Central Hospital, Xiangyang, Hubei
| | - Xiaobo Feng
- Department of Ultrasound, Jin Zhong Hospital of Traditional Chinese Medicine, China
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12
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Diao K, Bian SX, Routman DM, Yu C, Kim PE, Wagle NA, Wong MK, Zada G, Chang EL. Combination ipilimumab and radiosurgery for brain metastases: tumor, edema, and adverse radiation effects. J Neurosurg 2018; 129:1397-1406. [PMID: 29303446 PMCID: PMC7469982 DOI: 10.3171/2017.7.jns171286] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 07/14/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVETumor and edema volume changes of brain metastases after stereotactic radiosurgery (SRS) and ipilimumab are not well described, and there is concern regarding the safety of combination treatment. The authors evaluated tumor, edema, and adverse radiation-induced changes after SRS with and without ipilimumab and identified associated risk factors.METHODSThis single-institution retrospective study included 72 patients with melanoma brain metastases treated consecutively with upfront SRS from 2006 to 2015. Concurrent ipilimumab was defined as ipilimumab treatment within 4 weeks of SRS. At baseline and during each follow-up, tumor and edema were measured in 3 orthogonal planes. The (length × width × height/2) formula was used to estimate tumor and edema volumes and was validated in the present study for estimation of edema volume. Tumor and edema volume changes from baseline were compared using the Kruskal-Wallis test. Local failure, lesion hemorrhage, and treatment-related imaging changes (TRICs) were analyzed with the Cox proportional hazards model.RESULTSOf 310 analyzed lesions, 91 were not treated with ipilimumab, 59 were treated with concurrent ipilimumab, and 160 were treated with nonconcurrent ipilimumab. Of 106 randomly selected lesions with measurable peritumoral edema, the mean edema volume by manual contouring was 7.45 cm3 and the mean volume by (length × width × height)/2 formula estimation was 7.79 cm3 with R2 = 0.99 and slope of 1.08 on line of best fit. At 6 months after SRS, the ipilimumab groups had greater tumor (p = 0.001) and edema (p = 0.005) volume reduction than the control group. The concurrent ipilimumab group had the highest rate of lesion response and lowest rate of lesion progression (p = 0.002). Within the concurrent ipilimumab group, SRS dose ≥ 20 Gy was associated with significantly greater median tumor volume reduction at 3 months (p = 0.01) and 6 months (p = 0.02). The concurrent ipilimumab group also had the highest rate of lesion hemorrhage (p = 0.01). Any ipilimumab was associated with higher incidence of symptomatic TRICs (p = 0.005). The overall incidence of pathologically confirmed radiation necrosis (RN) was 2%. In multivariate analysis, tumor and edema response at 3 months were the strongest predictors of local failure (HR 0.131 and HR 0.125) and lesion hemorrhage (HR 0.225 and HR 0.262). Tumor and edema response at 1.5 months were the strongest predictors of TRICs (HR 0.144 and HR 0.297).CONCLUSIONSThe addition of ipilimumab improved tumor and edema volume reduction but was associated with a higher incidence of lesion hemorrhage and symptomatic TRICs. There may be a radiation dose-response relationship between SRS and ipilimumab when administered concurrently. Early tumor and edema response were excellent predictors of subsequent local failure, lesion hemorrhage, and TRICs. The incidence of pathologically proven RN was low, supporting the relative safety of ipilimumab in radiosurgery treatment.
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Affiliation(s)
- Kevin Diao
- Harvard Medical School, Boston, Massachusetts
- Department of Radiation Oncology, Keck School of Medicine
of USC, Los Angeles, California
| | - Shelly X. Bian
- Department of Radiation Oncology, Keck School of Medicine
of USC, Los Angeles, California
| | - David M. Routman
- Department of Radiation Oncology, Keck School of Medicine
of USC, Los Angeles, California
| | - Cheng Yu
- Department of Radiation Oncology, Keck School of Medicine
of USC, Los Angeles, California
| | - Paul E. Kim
- Department of Radiology, Keck School of Medicine of USC,
Los Angeles, California
| | - Naveed A. Wagle
- Department of Clinical Neurology, Keck School of Medicine
of USC, Los Angeles, California
| | - Michael K. Wong
- Department of Medical Oncology, Keck School of Medicine of
USC, Los Angeles, California
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine
of USC, Los Angeles, California
| | - Eric L. Chang
- Department of Radiation Oncology, Keck School of Medicine
of USC, Los Angeles, California
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13
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Outcome of partially irradiated recurrent nonfunctioning pituitary macroadenoma by gamma knife radiosurgery. J Neurooncol 2018; 139:767-775. [DOI: 10.1007/s11060-018-2925-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 06/05/2018] [Indexed: 10/14/2022]
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14
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Skeie BS, Eide GE, Flatebø M, Heggdal JI, Larsen E, Bragstad S, Pedersen PH, Enger PØ. Quality of life is maintained using Gamma Knife radiosurgery: a prospective study of a brain metastases patient cohort. J Neurosurg 2017; 126:708-725. [DOI: 10.3171/2015.10.jns15801] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE
Gamma Knife radiosurgery (GKRS) is increasingly used in the management of brain metastases (BMs), but few studies have evaluated how GKRS impacts quality of life (QOL). The aim of this study was to monitor QOL as the primary end point following GKRS in a patient cohort with BM.
METHODS
The study included 97 consecutive patients with 1–6 BMs treated with GKRS between May 2010 and September 2011. QOL was assessed at baseline and at 1, 3, 6, 9, and 12 months postoperatively using the Functional Assessment of Cancer Therapy–Brain (FACT-BR) questionnaire with the brain cancer subscale (BRCS) questionnaire. Factors predicting QOL were identified by mixed linear regression analyses. Local control and toxicity were evaluated according to Response Evaluation Criteria in Solid Tumors (RECIST) and the European Organisation for Research and Treatment/Radiation Therapy Oncology Group (EORTC/RTOG) criteria of late effects, respectively.
RESULTS
Compliance was high from baseline (97%) to 12-month follow-up (78%). Mean BRCS scores remained high during follow-up: they improved in 66% of patients and remained unchanged in 6% at 9 months. Local control (p = 0.018), improved symptoms (p = 0.005), and stable extracerebral disease (p = 0.001) correlated with high QOL-BRCS score. High baseline recursive partitioning analysis class predicted improved QOL (p = 0.031), whereas high Karnofsky Performance Scale score (p = 0.017), asymptomatic BMs (p = 0.001), and no cognitive deficits (p = 0.033) or seizures (p = 0.040) predicted high, stable QOL-BRCS during the 12-month follow-up.
CONCLUSIONS
QOL remained stable for up to 12 months following GKRS for the total cohort. High QOL was reported if local control occurred, cerebral symptoms improved/stabilized, or the need for steroids declined, which all reflected successful GKRS. Conversely, low QOL accompanied progression of intra- and extracerebral disease. Based on the study findings, GKRS appears to be a safe and effective treatment option for patients with BMs.
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Affiliation(s)
| | - Geir Egil Eide
- 5Global Public Health and Primary Care, University of Bergen, Norway
- 6Centre for Clinical Research, Haukeland University Hospital; and
| | | | | | | | | | | | - Per Øyvind Enger
- Departments of 1Neurosurgery and
- 3Biomedicine, Oncomatrix Research Lab, and
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15
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Miller JA, Kotecha R, Barnett GH, Suh JH, Angelov L, Murphy ES, Vogelbaum MA, Mohammadi A, Chao ST. Quality of Life following Stereotactic Radiosurgery for Single and Multiple Brain Metastases. Neurosurgery 2017; 81:147-155. [DOI: 10.1093/neuros/nyw166] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 12/25/2016] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND: Given the neurological morbidity and poor prognosis associated with brain metastases, it is critical to deliver appropriate therapy while remaining mindful of patient quality of life (QOL). For many patients, stereotactic radiosurgery (SRS) effectively controls intracranial disease, but QOL outcomes have not been characterized.
OBJECTIVE: To determine the effect of number of brain metastases upon QOL preservation following SRS.
METHODS: The EuroQol 5 Dimensions questionnaire (EQ-5D) and Patient Health Questionnaire 9 instruments were prospectively collected from a cohort of patients undergoing SRS for brain metastasis between 2008 and 2015. These instruments served as measures of overall QOL and depression. QOL deterioration exceeding the minimum clinically important difference was considered failure. Freedom from 12-month EQ-5D index failure was the primary outcome.
RESULTS: One hundred and twenty-two SRS treatments (67 patients, 421 lesions) were eligible for inclusion. Intracranial failure (local or distant) occurred following 61% of treatments. Among 421 lesions, 8% progressed locally. Median follow-up was 12 months.
All subscores of the EQ-5D instrument expectantly worsened at last follow-up; however, the magnitude of this difference (0.079) did not exceed the EQ-5D index minimum clinically important difference (mean 0.752 vs 0.673, P < .01). Twelve-month EQ-5D index QOL preservation was 79%. Patients with more than 3 brain metastases had a greater rate of EQ-5D index deterioration (hazard ratio 4.14, P < .01) than those with a single metastasis.
CONCLUSIONS: Among patients with brain metastasis, QOL preservation must remain paramount as multimodality therapy continues to improve. In the present investigation, 12-month QOL preservation was 79%. However, patients with more than 3 brain metastases were at significantly greater risk for QOL decline.
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Affiliation(s)
- Jacob A. Miller
- Cleveland Clinic Lerner College of Medi-cine, Cleveland Clinic, Cleveland, Ohio
| | - Rupesh Kotecha
- Department of Radiation Oncology, Tau-ssig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gene H. Barnett
- Department of Neu-rosurgery, Cleveland Clinic, Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - John H. Suh
- Department of Radiation Oncology, Tau-ssig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Lilyana Angelov
- Department of Neu-rosurgery, Cleveland Clinic, Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Erin S. Murphy
- Department of Radiation Oncology, Tau-ssig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Michael A. Vogelbaum
- Department of Neu-rosurgery, Cleveland Clinic, Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Alireza Mohammadi
- Department of Neu-rosurgery, Cleveland Clinic, Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Samuel T. Chao
- Department of Radiation Oncology, Tau-ssig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
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16
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Shimony N, Shofty B, Harosh CB, Sitt R, Ram Z, Grossman R. Surgical Resection of Cerebral Metastases Leads to Faster Resolution of Peritumoral Edema than Stereotactic Radiosurgery: A Volumetric Analysis. Ann Surg Oncol 2016; 24:1392-1398. [PMID: 27896517 DOI: 10.1245/s10434-016-5709-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Surgical resection and stereotactic radiosurgery (SRS) are well-established treatment options for selected patients with oligo-brain metastases (BMs). The dynamics of edema resolution with each treatment method have not been well characterized. METHODS Of 389 patients treated for BMs between 2012 and 2014, this study retrospectively identified 107 patients (150 metastases) who underwent either surgery or SRS as a single treatment method for BMs. The two groups of patients were matched for clinical parameters. Volumetric assessments of the tumor and associated edema were performed before treatment and then 2-3 months after treatment. RESULTS In this study, 76 surgical cases were compared with 74 cases treated with SRS. The volume of the tumor and surrounding edema was significantly greater in the surgery group than in the SRS group. However, resolution of edema was significantly more rapid in the surgical group (p < 0.0001), accompanied by faster weaning from steroids. After a matching process based on the propensity of a patient to receive SRS, a subgroup cohort was analyzed (mean maximal diameter: 21 mm in the surgical group vs 20.8 mm in the SRS group; p = 0.9). At diagnosis, edema volume, but not tumor volume, was significantly greater in the surgical group. The resolution of edema 2-3 months after treatment was better in the surgical group than in the SRS group (89.6% vs 71.1% of baseline, respectively; p = 0.09), although this difference did not reach the level of significance. CONCLUSIONS Resolution of tumor-associated edema in BMs suitable for either surgery or SRS was significantly faster after surgical resection than after SRS. Accordingly, when both treatment options are suitable, surgery appears to induce faster resolution of the edema.
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Affiliation(s)
- Nir Shimony
- Department of Neurosurgery, Affiliated to the Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Ben Shofty
- Department of Neurosurgery, Affiliated to the Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Carmit Ben Harosh
- Department of Neurosurgery, Affiliated to the Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Razi Sitt
- Department of Neurosurgery, Affiliated to the Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Affiliated to the Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Rachel Grossman
- Department of Neurosurgery, Affiliated to the Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel.
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17
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Sheehan JP, Cohen-Inbar O, Ruangkanchanasetr R, Bulent Omay S, Hess J, Chiang V, Iorio-Morin C, Alonso-Basanta M, Mathieu D, Grills IS, Lee JYK, Lee CC, Dade Lunsford L. Post-radiosurgical edema associated with parasagittal and parafalcine meningiomas: a multicenter study. J Neurooncol 2015; 125:317-24. [PMID: 26329323 DOI: 10.1007/s11060-015-1911-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 08/29/2015] [Indexed: 11/29/2022]
Abstract
Stereotactic radiosurgery (SRS) offers a high degree of tumor control for benign meningiomas. However, radiosurgery can occasionally incite edema or exacerbate pre-existing peri-tumoral edema. The current study investigates the incidence, timing, and extent of edema around parasagittal or parafalcine meningiomas following SRS. A retrospective multicenter review was undertaken through participating centers in the International Gamma Knife Research Foundation (previously the North American Gamma Knife Consortium or NAGKC). All included patients had a parafalcine or parasagittal meningioma and a minimum of 6 months follow up. The median follow up was 19.6 months (6-158 months). Extent of new or worsening edema was quantitatively analyzed using volumetric analysis; edema indices were longitudinally computed following radiosurgery. Analysis was performed to identify prognostic factors for new or worsening edema. A cohort of 212 patients comprised of 51.9 % (n = 110) females, 40.1 % upfront SRS and 59.9 % underwent adjuvant SRS for post-surgical residual tumor. The median tumor volume at SRS was 5.2 ml. Venous sinus compression or invasion was demonstrated in 25 % (n = 53). The median marginal dose was 14 Gy (8-20 Gy). Tumor volume control was determined in 77.4 % (n = 164 out of 212 patients). Tumor edema progressed and then regressed in 33 % (n = 70), was stable or regressed in 52.8 % (n = 112), and progressively worsened in 5.2 % (n = 11). Tumor location, tumor volume, venous sinus invasion, margin, and maximal dose were found to be significantly related to post-SRS edema in multivariate analysis. SRS affords a high degree of tumor control for patients with parasagittal or parafalcine meningiomas. Nevertheless, SRS can lead to worsening peritumoral edema in a subset of patients such as those with larger tumors (>10 cc) and venous sinus invasion/compression. Long-term follow up is required to detect and appropriately manage post-SRS edema.
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Affiliation(s)
- Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, 22908, USA.
| | - Or Cohen-Inbar
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, 22908, USA
| | | | | | | | | | | | | | - David Mathieu
- Université de Sherbrooke and Centre de recherche du CHUS, Sherbrooke, Canada
| | | | | | - Cheng-Chia Lee
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, 22908, USA
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18
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Sheehan JP, Lee CC, Xu Z, Przybylowski CJ, Melmer PD, Schlesinger D. Edema following Gamma Knife radiosurgery for parasagittal and parafalcine meningiomas. J Neurosurg 2015; 123:1287-93. [PMID: 26115473 DOI: 10.3171/2014.12.jns142159] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Stereotactic radiosurgery (SRS) has been shown to offer a high probability of tumor control for Grade I meningiomas. However, SRS can sometimes incite edema or exacerbate preexisting edema around the targeted meningioma. The current study evaluates the incidence, timing, and degree of edema around parasagittal or parafalcine meningiomas following SRS. METHODS A retrospective review was undertaken of a prospectively maintained database of patients treated with Gamma Knife radiosurgery at the University of Virginia Health System. All patients with WHO Grade I parafalcine or parasagittal meningiomas with at least 6 months of clinical follow-up were identified, resulting in 61 patients included in the study. The median radiographic follow-up was 28 months (range 6-158 months). Rates of new or worsening edema were quantitatively assessed using volumetric analysis; edema indices were computed as a function of time following radiosurgery. Statistical methods were used to identify favorable and unfavorable prognostic factors for new or worsening edema. RESULTS Progression-free survival at 2 and 5 years was 98% and 90%, respectively, according to Kaplan-Meier analysis. After SRS, new peritumoral edema occurred or preexisting edema worsened in 40% of treated meningiomas. The median time to onset of peak edema was 36 months post-SRS. Persistent and progressive edema was associated with 11 tumors, and resection was undertaken for these lesions. However, 20 patients showed initial edema progression followed by regression at a median of 18 months after radiosurgery (range 6-24 months). Initial tumor volume greater than 10 cm3, absence of prior resection, and higher margin dose were significantly (p<0.05) associated with increased risk of new or progressive edema after SRS. CONCLUSIONS Stereotactic radiosurgery offers a high rate of tumor control in patients with parasagittal or parafalcine meningiomas. However, it can lead to worsening peritumoral edema in a minority of patients. Following radiosurgery, transient edema occurs earlier than persistent and progressive edema. Longitudinal follow-up of meningioma patients after SRS is required to detect and appropriately treat transient as well as progressive edema.
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Affiliation(s)
- Jason P Sheehan
- Departments of 1 Neurological Surgery and.,Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia
| | | | - Zhiyuan Xu
- Departments of 1 Neurological Surgery and
| | | | | | - David Schlesinger
- Departments of 1 Neurological Surgery and.,Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia
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19
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Abstract
OBJECTIVE The goal of this study was to investigate the treatment results of Gamma Knife radiosurgery (GKRS) for cystic brain metastases and relevant factors associated with local tumor control. MATERIALS AND METHODS We retrospectively reviewed the clinical, radiological, and dosimetry data of 37 cystic brain metastases of 28 patients who were treated with GKRS. Cyst drainage was performed in 8 large lesions before GKRS to decrease the target volume. The mean target volume was 4.8 (range, 0.3-15.8) cc at the time of GKRS, and the mean prescription dose was 16.6 (range, 13-22) Gy. RESULTS The actuarial median survival time was 17.7 ± 10.2 months, and the primary tumor status was a significant prognostic factor for survival. The actuarial local tumor control rate at 6 and 12 months was 93.1 and 82.3%, respectively. Among the various factors, only prescription dose (>15 Gy) was a significant factor related to local tumor control after multivariate analysis (p = 0.049). Cyst volume or cyst/total tumor volume ratio did not influence local control after GKRS, when the target volume was reduced to about 15 cc after cyst drainage. CONCLUSION According to our results, we suggest that stereotactic radiosurgery should be considered as one of the treatment options for cystic brain metastases, when large tumor volume can be reduced by surgical drainage before radiosurgery, especially for patients with a controlled primary tumor.
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Affiliation(s)
- Sang Ryul Lee
- a Gamma Knife Center, Department of Neurosurgery , Ajou University School of Medicine , Suwon , Korea
| | - Ji Young Oh
- a Gamma Knife Center, Department of Neurosurgery , Ajou University School of Medicine , Suwon , Korea
| | - Se-Hyuk Kim
- a Gamma Knife Center, Department of Neurosurgery , Ajou University School of Medicine , Suwon , Korea
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Radiosurgery for brain metastases and cerebral edema. J Clin Neurosci 2015; 22:535-8. [DOI: 10.1016/j.jocn.2014.08.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 08/03/2014] [Indexed: 11/21/2022]
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21
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Wang Y, Wang E, Pan L, Dai J, Zhang N, Wang X, Liu X, Mei G, Sheng X. A new strategy of CyberKnife treatment system based radiosurgery followed by early use of adjuvant bevacizumab treatment for brain metastasis with extensive cerebral edema. J Neurooncol 2014; 119:369-76. [DOI: 10.1007/s11060-014-1488-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 05/19/2014] [Indexed: 10/25/2022]
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22
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Boggs DH, Simard JM, Steven A, Mehta MP. Potential of glyburide to reduce intracerebral edema in brain metastases. Expert Rev Neurother 2014; 14:379-88. [DOI: 10.1586/14737175.2014.890891] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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23
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Leung A, Lien K, Zeng L, Nguyen J, Caissie A, Culleton S, Holden L, Chow E. The EORTC QLQ-BN20 for assessment of quality of life in patients receiving treatment or prophylaxis for brain metastases: a literature review. Expert Rev Pharmacoecon Outcomes Res 2014; 11:693-700. [DOI: 10.1586/erp.11.66] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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24
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Luther N, Kondziolka D, Kano H, Mousavi SH, Flickinger JC, Lunsford LD. Motor function after stereotactic radiosurgery for brain metastases in the region of the motor cortex. J Neurosurg 2013; 119:683-8. [DOI: 10.3171/2013.6.jns122081] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors sought to better define the clinical response of patients who underwent stereotactic radiosurgery (SRS) for brain metastases located in the region of the motor cortex.
Methods
A retrospective analysis was performed in 2026 patients with brain metastasis who underwent SRS with the Gamma Knife between 2002 and 2012, and multiple factors that affect motor function before and after SRS were evaluated. Ninety-four patients with tumors ≥ 1.5 cm in diameter located in or adjacent to the motor strip were identified, including 2 patients with bilateral motor strip metastases.
Results
Motor function improved after SRS in 30 (31%) of 96 cases, remained stable in 48 (50%), and worsened over time in 18 (19%) instances. Forty-seven patients had no motor weakness prior to radiosurgery; 10 (22%) developed new Grade 3/5–4/5 weakness. Thirty (68%) of 44 patients with ≥ 3/5 pre-SRS weakness improved, 6 (14%) remained stable, and 8 (18%) worsened. Three of 5 patients with < 3/5 pre-SRS motor function improved. Motor deficits prior to SRS did not correlate with a worse outcome; however, worse outcomes were associated with larger tumor volumes. The median tumor volume in patients whose function improved or remained stable was 5.3 cm3, but it was 9.2 cm3 in patients who worsened (p < 0.05). Tumor volumes > 9 cm3 were associated with a higher risk of worsening motor function. Adverse radiation effects occurred in 5 patients.
Conclusions
Most intact patients with brain metastases in or adjacent to motor cortex maintained neurological function after SRS, and most patients with symptomatic motor weakness remained stable or improved. Larger tumor volumes were associated with less satisfactory outcomes.
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Affiliation(s)
- Neal Luther
- 1Center for Image-Guided Neurosurgery, Department of Neurological Surgery, and
| | - Douglas Kondziolka
- 1Center for Image-Guided Neurosurgery, Department of Neurological Surgery, and
- 3Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Hideyuki Kano
- 1Center for Image-Guided Neurosurgery, Department of Neurological Surgery, and
| | - Seyed H. Mousavi
- 1Center for Image-Guided Neurosurgery, Department of Neurological Surgery, and
| | - John C. Flickinger
- 2Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - L. Dade Lunsford
- 1Center for Image-Guided Neurosurgery, Department of Neurological Surgery, and
- 2Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
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Xu Z, Elsharkawy M, Schlesinger D, Sheehan J. Gamma Knife Radiosurgery for Resectable Brain Metastasis. World Neurosurg 2013; 80:351-8. [DOI: 10.1016/j.wneu.2012.03.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Revised: 02/02/2012] [Accepted: 03/29/2012] [Indexed: 11/25/2022]
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Stereotactic radiosurgery in the treatment of brain metastases: the current evidence. Cancer Treat Rev 2013; 40:48-59. [PMID: 23810288 DOI: 10.1016/j.ctrv.2013.05.002] [Citation(s) in RCA: 145] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 05/08/2013] [Accepted: 05/08/2013] [Indexed: 11/22/2022]
Abstract
Chemotherapy has made substantial progress in the therapy of systemic cancer, but the pharmacological efficacy is insufficient in the treatment of brain metastases. Fractionated whole brain radiotherapy (WBRT) has been a standard treatment of brain metastases, but provides limited local tumor control and often unsatisfactory clinical results. Stereotactic radiosurgery using Gamma Knife, Linac or Cyberknife has overcome several of these limitations, which has influenced recent treatment recommendations. This present review summarizes the current literature of single session radiosurgery concerning survival and quality of life, specific responses, tumor volumes and numbers, about potential treatment combinations and radioresistant metastases. Gamma Knife and Linac based radiosurgery provide consistent results with a reproducible local tumor control in both single and multiple brain metastases. Ideally minimum doses of ≥18Gy are applied. Reported local control rates were 90-94% for breast cancer metastases and 81-98% for brain metastases of lung cancer. Local tumor control rates after radiosurgery of otherwise radioresistant brain metastases were 73-90% for melanoma and 83-96% for renal cell cancer. Currently, there is a tendency to treat a larger number of brain metastases in a single radiosurgical session, since numerous studies document high local tumor control after radiosurgical treatment of >3 brain metastases. New remote brain metastases are reported in 33-42% after WBRT and in 39-52% after radiosurgery, but while WBRT is generally applied only once, radiosurgery can be used repeatedly for remote recurrences or new metastases after WBRT. Larger metastases (>8-10cc) should be removed surgically, but for smaller metastases Gamma Knife radiosurgery appears to be equally effective as surgical tumor resection (level I evidence). Radiosurgery avoids the impairments in cognition and quality of life that can be a consequence of WBRT (level I evidence). High local efficacy, preservation of cerebral functions, short hospitalization and the option to continue a systemic chemotherapy are factors in favor of a minimally invasive approach with stereotactic radiosurgery.
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Patel TR, McHugh BJ, Bi WL, Minja FJ, Knisely JPS, Chiang VL. A comprehensive review of MR imaging changes following radiosurgery to 500 brain metastases. AJNR Am J Neuroradiol 2011; 32:1885-92. [PMID: 21920854 DOI: 10.3174/ajnr.a2668] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Stereotactic radiosurgery is known to control 85%-95% of intracranial metastatic lesions during a median survival of 6-8 months. However, with the advent of newer systemic cancer therapies, survival is improving; this change mandates a longitudinal quantitative analysis of the radiographic response of brain metastases to radiosurgery. MATERIALS AND METHODS MR imaging of 516 metastases in 120 patients treated with GK-SRS from June 2006 to December 2009 was retrospectively reviewed. Lesion volume at initial treatment and each follow-up was calculated by using the following formula: length × width × height / 2. Volume changes were correlated with patient demographics, histopathology, and radiation treatment variables. RESULTS Thirty-two percent of lesions increased in volume following radiosurgery. Clinically, this translated into 54% of patients having ≥1 of their lesions increase in size. This increase begins at 6 weeks and can last beyond 15 months' post-SRS. Male sex (P = .002), mean voxel dose <37 Gy (P = .009), and initial treatment volume >500 mm(3) (P < .001) are associated with posttreatment increases in tumor size. Median survival following radiosurgery was 9.5 months for patients with all lesions exhibiting stable/decreased volumes, >18.4 months for patients with all lesions exhibiting increased volumes, and 16.4 months for patients with mixed lesional responses. CONCLUSIONS Most metastatic lesions are stable or smaller in size during the first 36 months post-SRS. However, a transient increase in volume is seen in approximately one-third of lesions. Sex, treatment dose, initial lesion size, and histopathology all correlate with variations in lesion volume post-SRS. The longer the patient survives, the more likely an increase in lesion size will be seen on follow-up imaging.
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Affiliation(s)
- T R Patel
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut 06520, USA
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Yang HC, Kano H, Lunsford LD, Niranjan A, Flickinger JC, Kondziolka D. What Factors Predict the Response of Larger Brain Metastases to Radiosurgery? Neurosurgery 2011; 68:682-90; discussion 690. [DOI: 10.1227/neu.0b013e318207a58b] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Approximately 20 to 40% of patients with systemic malignancies develop brain metastases.
OBJECTIVE:
To assess the potential role of stereotactic radiosurgery (SRS) for larger metastatic brain tumors, we reviewed our recent experience.
METHODS:
Between 2004 and 2008, 70 patients with a metastatic brain tumor larger than 3 cm in maximum diameter underwent Gamma knife SRS. Thirty-three patients had received previous whole brain radiation therapy (WBRT) and 37 received only SRS.
RESULTS:
The overall median follow-up was 8.1 months. At the first planned imaging follow-up at 2 months, 29 (41%) tumors had >50% volume reduction, 22 (31%) had 10 to 50% volume reduction, and 19 (28%) were stable or larger. We also evaluated brain edema using MRI T2 images. In 11 patients (16%) the peritumoral edema volume was reduced by more than 50%, in 25 (36%) it was reduced by 10 to 50%, in 21 (30%) it was stable, and in 13 (19%) it was increased. Twenty (36%) discontinued corticosteroids by the time of first imaging follow-up. Because of persistent symptoms, 7 patients (10%) required a craniotomy to remove the tumor. Tumor volume reduction (>50%) was associated with a single metastasis (P = .012), no previous WBRT (P = .002), and a tumor volume <16 cm3 (P = .002). The better peritumoral edema volume reduction (>50%) was associated with a single metastasis (P = .024), no previous WBRT (P = .05), and breast cancer histology (P = .044).
CONCLUSION:
Surgical resection remains the primary approach for larger brain metastases if feasible. Tumor volume is a better indicator than maximum diameter. Tumor volume and edema responded better in patients who underwent SRS alone.
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Affiliation(s)
- Huai-che Yang
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John C Flickinger
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Radiation Oncology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Douglas Kondziolka
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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