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Reinhardt P, Ahmadli U, Uysal E, Shrestha BK, Schucht P, Hakim A, Ermiş E. Single versus multiple fraction stereotactic radiosurgery for medium-sized brain metastases (4-14 cc in volume): reducing or fractionating the radiosurgery dose? Front Oncol 2024; 14:1333245. [PMID: 39193387 PMCID: PMC11347337 DOI: 10.3389/fonc.2024.1333245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 07/24/2024] [Indexed: 08/29/2024] Open
Abstract
Background and purpose Stereotactic radiosurgery (SRS) of brain metastases (BM) and resection cavities is a widely used and effective treatment modality. Based on target lesion size and anatomical location, single fraction SRS (SF-SRS) or multiple fraction SRS (MF-SRS) are applied. Current clinical recommendations conditionally recommend either reduced dose SF-SRS or MF-SRS for medium-sized BM (2-2.9 cm in diameter). Despite excellent local control rates, SRS carries the risk of radionecrosis (RN). The purpose of this study was to assess the 12-months local control (LC) rate and 12-months RN rate of this specific patient population. Materials and methods This single-center retrospective study included 54 patients with medium-sized intact BM (n=28) or resection cavities (n=30) treated with either SF-SRS or MF-SRS. Follow-up MRI was used to determine LC and RN using a modification of the "Brain Tumor Reporting and Data System" (BT-RADS) scoring system. Results The 12-month LC rate following treatment of intact BM was 66.7% for SF-SRS and 60.0% for MF-SRS (p=1.000). For resection cavities, the 12-month LC rate was 92.9%% after SF-SRS and 46.2% after MF-SRS (p=0.013). For intact BM, RN rate was 17.6% for SF-SRS and 20.0% for MF-SRS (p=1.000). For resection cavities, RN rate was 28.6% for SF-SRS and 20.0% for MF-SRS (p=1.000). Conclusion Patients with intact BM showed no statistically significant differences in 12-months LC and RN rate following SF-SRS or MF-SRS. In patients with resection cavities the 12-months LC rate was significantly better following SF-SRS, with no increase in the RNFS.
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Affiliation(s)
- Philipp Reinhardt
- Department of Radiation Oncology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Uzeyir Ahmadli
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Emre Uysal
- Department of Radiation Oncology, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Türkiye
| | - Binaya Kumar Shrestha
- Department of Radiation Oncology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Philippe Schucht
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Arsany Hakim
- Department of Radiation Oncology, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Türkiye
| | - Ekin Ermiş
- Department of Radiation Oncology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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Pan K, Wang B, Xu X, Liang J, Tang Y, Ma S, Xia B, Zhu L. Hypofractionated stereotactic radiotherapy for brain metastases in lung cancer patients: dose‒response effect and toxicity. Discov Oncol 2024; 15:318. [PMID: 39078419 PMCID: PMC11289209 DOI: 10.1007/s12672-024-01191-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 07/24/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND Lung cancer is a common cause of brain metastases, approximately 40% of patients with lung cancer will develop brain metastases at some point during their disease. Hypofractionated stereotactic radiotherapy (HSRT) has been demonstrated to be effective in controlling limited brain metastases. However, there is still no conclusive on the optimal segmentation of HSRT. The aim of our study was to explore the correlation between the HSRT dosage and its treatment effect and toxicity. METHODS A retrospective analysis was conducted on patients with non-small cell lung cancer (NSCLC) brain metastasis at Hangzhou Cancer Hospital from 1 January 2019 to 1 January 2021. The number of brain metastases did not exceed 10 in all patients and the number of fractions of HSRT was 5. The prescription dose ranges from 25 to 40 Gy. The Kaplan-Meier method was used for estimation of the localised intracranial control rate (iLC). Adverse radiation effects (AREs) were evaluated according to CTCAE 5.0. This study was approved by the Institutional Ethics Review Board of the Hangzhou Cancer Hospital (#73/HZCH-2022). RESULTS Forty eligible patients with a total of 70 brain metastases were included in this study. The 1-year iLC was 76% and 89% in the prescribed dose ≤ 30 Gy and > 30 Gy group, respectively (P < 0.05). For patients treated with HSRT combined with targeted therapy, immunotherapy and chemotherapy, the 1-year iLC was 89%, 100%, and 45%, respectively. No significant associations were observed between the number, maximum diameter, location, and type of pathology of brain metastases. The rate of all-grade AREs was 33%. Two patients who received a total dose of 40 Gy developed grade 3 headache, the rest of the AREs were grade 1-2. CONCLUSIONS Increasing the prescription dose of HSRT improves treatment effect but may also exacerbate the side effects. Systemic therapy might impact the iLC rate, and individualized treatment regimens need to be developed.
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Affiliation(s)
- Kaicheng Pan
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China
| | - Bing Wang
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China
| | - Xiao Xu
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China
| | - Jiafeng Liang
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China
| | - Yi Tang
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China
| | - Shenglin Ma
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China
| | - Bing Xia
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China.
| | - Lucheng Zhu
- Department of Radiotherapy, Hangzhou Cancer Hospital, Hangzhou, China.
- Department of Oncology, Affiliated Hangzhou Cancer Hospital, Zhejiang Chinese Medical University, Hangzhou, China.
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Leng JX, Carpenter DJ, Huang C, Qazi J, Arshad M, Mullikin TC, Reitman ZJ, Kirkpatrick JP, Floyd SR, Fecci PE, Chmura SJ, Hong JC, Salama JK. Determinants of Symptomatic Intracranial Progression After an Initial Stereotactic Radiosurgery Course. Adv Radiat Oncol 2024; 9:101475. [PMID: 38690297 PMCID: PMC11059392 DOI: 10.1016/j.adro.2024.101475] [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: 11/28/2023] [Accepted: 02/04/2024] [Indexed: 05/02/2024] Open
Abstract
Purpose Clinical and imaging surveillance of patients with brain metastases is important after stereotactic radiosurgery (SRS) because many will experience intracranial progression (ITCP) requiring multidisciplinary management. The prognostic significance of neurologic symptoms at the time of ITCP is poorly understood. Methods and Materials This was a multi-institutional, retrospective cohort study from 2015 to 2020, including all patients with brain metastases completing an initial course of SRS. The primary outcome was overall survival (OS) by presence of neurologic symptoms at ITCP. OS, freedom from ITCP (FF-ITCP), and freedom from symptomatic ITCP (FF-SITCP) were assessed via Kaplan-Meier method. Cox proportional hazard models tested parameters impacting FF-ITCP and FF-SITCP. Results Among 1383 patients, median age was 63.4 years, 55% were female, and common primaries were non-small cell lung (49%), breast (15%), and melanoma (9%). At a median follow-up of 8.72 months, asymptomatic and symptomatic ITCP were observed in 504 (36%) and 194 (14%) patients, respectively. The majority of ITCP were distant ITCP (79.5%). OS was worse with SITCP (median, 10.2 vs 17.9 months, P < .001). SITCP was associated with clinical factors including total treatment volume (P = .012), melanoma histology (P = .001), prior whole brain radiation therapy (P = .003), number of brain metastases (P < .001), interval of 1 to 2 years from primary and brain metastasis diagnosis (P = .012), controlled extracranial disease (P = .042), and receipt of pre-SRS chemotherapy (P = .015). Patients who were younger and received post-SRS chemotherapy (P = .001), immunotherapy (P < .001), and targeted or small-molecule inhibitor therapy (P < .026) had better FF-SITCP. Conclusions In this cohort study of patients with brain metastases completing SRS, neurologic symptoms at ITCP is prognostic for OS. This data informs post-SRS surveillance in clinical practice as well as future prospective studies needed in the modern management of brain metastases.
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Affiliation(s)
- Jim X. Leng
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - David J. Carpenter
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
- Department of Radiation Oncology, Wellstar Paulding Hospital, Hiram, Georgia
| | - Christina Huang
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Jamiluddin Qazi
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Muzamil Arshad
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Trey C. Mullikin
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Zachary J. Reitman
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - John P. Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Scott R. Floyd
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Peter E. Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Steven J. Chmura
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Julian C. Hong
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, California
- Joint Program in Computational Precision Health, University of California, San Francisco, California and University of California, Berkeley, California
| | - Joseph K. Salama
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
- Radiation Oncology Clinical Service, Durham VA Health Care System, Durham, North Carolina
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Hahnemann L, Krämer A, Fink C, Jungk C, Thomas M, Christopoulos P, Lischalk J, Meis J, Hörner-Rieber J, Eichkorn T, Deng M, Lang K, Paul A, Meixner E, Weykamp F, Debus J, König L. Fractionated stereotactic radiotherapy of intracranial postoperative cavities after resection of brain metastases - Clinical outcome and prognostic factors. Clin Transl Radiat Oncol 2024; 46:100782. [PMID: 38694237 PMCID: PMC11061678 DOI: 10.1016/j.ctro.2024.100782] [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: 10/21/2023] [Revised: 04/17/2024] [Accepted: 04/20/2024] [Indexed: 05/04/2024] Open
Abstract
Background and Purpose After surgical resection of brain metastases (BM), radiotherapy (RT) is indicated. Postoperative stereotactic radiosurgery (SRS) reduces the risk of local progression and neurocognitive decline compared to whole brain radiotherapy (WBRT). Aside from the optimal dose and fractionation, little is known about the combination of systemic therapy and postoperative fractionated stereotactic radiotherapy (fSRT), especially regarding tumour control and toxicity. Methods In this study, 105 patients receiving postoperative fSRT with 35 Gy in 7 fractions performed with Cyberknife were retrospectively reviewed. Overall survival (OS), local control (LC) and total intracranial brain control (TIBC) were analysed via Kaplan-Meier method. Cox proportional hazards models were used to identify prognostic factors. Results Median follow-up was 20.8 months. One-year TIBC was 61.6% and one-year LC was 98.6%. Median OS was 28.7 (95%-CI: 16.9-40.5) months. In total, local progression (median time not reached) occurred in 2.0% and in 20.4% radiation-induced contrast enhancements (RICE) of the cavity (after median of 14.3 months) were diagnosed. Absence of extracranial metastases was identified as an independent prognostic factor for superior OS (p = <0.001) in multivariate analyses, while a higher Karnofsky performance score (KPS) was predictive for longer OS in univariate analysis (p = 0.041). Leptomeningeal disease (LMD) developed in 13% of patients. Conclusion FSRT after surgical resection of BM is an effective and safe treatment approach with excellent local control and acceptable toxicity. Further prospective randomized trials are needed to establish standardized therapeutic guidelines.
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Affiliation(s)
- L. Hahnemann
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - A. Krämer
- Department of Radiation Oncology, University Hospital of Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - C. Fink
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - C. Jungk
- Department of Neurosurgery, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - M. Thomas
- Department of Thoracic Oncology, Thoraxklinik and National Center for Tumor Diseases at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Germany
| | - P. Christopoulos
- Department of Thoracic Oncology, Thoraxklinik and National Center for Tumor Diseases at Heidelberg University Hospital, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Germany
| | - J.W. Lischalk
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Health at Long Island, New York, NY, USA
| | - J. Meis
- Institute of Medical Biometry, University of Heidelberg, Im Neuenheimer Feld 130, 69120 Heidelberg, Germany
| | - J. Hörner-Rieber
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - T. Eichkorn
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - M. Deng
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - K. Lang
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - A. Paul
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - E. Meixner
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - F. Weykamp
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - J. Debus
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heavy Ion Therapy Center (HIT), Heidelberg University Hospital, Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology (E050), German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - L. König
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
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Vaios EJ, Shenker RF, Hendrickson PG, Wan Z, Niedzwiecki D, Winter SF, Shih HA, Dietrich J, Wang C, Salama AKS, Clarke JM, Allen K, Sperduto P, Mullikin T, Kirkpatrick JP, Floyd SR, Reitman ZJ. Long-Term Intracranial Outcomes With Combination Dual Immune-Checkpoint Blockade and Stereotactic Radiosurgery in Patients With Melanoma and Non-Small Cell Lung Cancer Brain Metastases. Int J Radiat Oncol Biol Phys 2024; 118:1507-1518. [PMID: 38097090 PMCID: PMC11056239 DOI: 10.1016/j.ijrobp.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 10/26/2023] [Accepted: 12/02/2023] [Indexed: 01/18/2024]
Abstract
PURPOSE The intracranial benefit of offering dual immune-checkpoint inhibition (D-ICPI) with ipilimumab and nivolumab to patients with melanoma or non-small cell lung cancer (NSCLC) receiving stereotactic radiosurgery (SRS) for brain metastases (BMs) is unknown. We hypothesized that D-ICPI improves local control compared with SRS alone. METHODS AND MATERIALS Patients with melanoma or NSCLC treated with SRS from 2014 to 2022 were evaluated. Patients were stratified by treatment with D-ICPI, single ICPI (S-ICPI), or SRS alone. Local recurrence, intracranial progression (IP), and overall survival were estimated using competing risk and Kaplan-Meier analyses. IP included both local and distant intracranial recurrence. RESULTS Two hundred eighty-eight patients (44% melanoma, 56% NSCLC) with 1,704 BMs were included. Fifty-three percent of patients had symptomatic BMs. The median follow-up was 58.8 months. Twelve-month local control rates with D-ICPI, S-ICPI, and SRS alone were 94.73% (95% CI, 91.11%-96.90%), 91.74% (95% CI, 89.30%-93.64%), and 88.26% (95% CI, 84.07%-91.41%). On Kaplan-Meier analysis, only D-ICPI was significantly associated with reduced local recurrence (P = .0032). On multivariate Cox regression, D-ICPI (hazard ratio [HR], 0.4003; 95% CI, 0.1781-0.8728; P = .0239) and planning target volume (HR, 1.022; 95% CI, 1.004-1.035; P = .0059) correlated with local control. One hundred seventy-three (60%) patients developed IP. The 12-month cumulative incidence of IP was 41.27% (95% CI, 30.27%-51.92%), 51.86% (95% CI, 42.78%-60.19%), and 57.15% (95% CI, 44.98%-67.59%) after D-ICPI, S-ICPI, and SRS alone. On competing risk analysis, only D-ICPI was significantly associated with reduced IP (P = .0408). On multivariate Cox regression, D-ICPI (HR, 0.595; 95% CI, 0.373-0.951; P = .0300) and presentation with >10 BMs (HR, 2.492; 95% CI, 1.668-3.725; P < .0001) remained significantly correlated with IP. The median overall survival after D-ICPI, S-ICPI, and SRS alone was 26.1 (95% CI, 15.5-40.7), 21.5 (16.5-29.6), and 17.5 (11.3-23.8) months. S-ICPI, fractionation, and histology were not associated with clinical outcomes. There was no difference in hospitalizations or neurologic adverse events between cohorts. CONCLUSIONS The addition of D-ICPI for patients with melanoma and NSCLC undergoing SRS is associated with improved local and intracranial control. This appears to be an effective strategy, including for patients with symptomatic or multiple BMs.
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Affiliation(s)
- Eugene J Vaios
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Rachel F Shenker
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Peter G Hendrickson
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Zihan Wan
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
| | - Donna Niedzwiecki
- Duke Cancer Institute Biostatistics, Duke University Medical Center, Durham, North Carolina
| | - Sebastian F Winter
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jorg Dietrich
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Chunhao Wang
- Departments of Medical Physics, Duke University Medical Center, Durham, North Carolina
| | - April K S Salama
- Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey M Clarke
- Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Karen Allen
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Paul Sperduto
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Trey Mullikin
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - John P Kirkpatrick
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina; Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Scott R Floyd
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Zachary J Reitman
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina; Neurosurgery, Duke University Medical Center, Durham, North Carolina; Pathology, Duke University Medical Center, Durham, North Carolina.
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Palmer JD, Perlow HK, Lehrer EJ, Wardak Z, Soliman H. Novel radiotherapeutic strategies in the management of brain metastases: Challenging the dogma. Neuro Oncol 2024; 26:S46-S55. [PMID: 38437668 PMCID: PMC10911796 DOI: 10.1093/neuonc/noad260] [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
The role of radiation therapy in the management of brain metastasis is evolving. Advancements in machine learning techniques have improved our ability to both detect brain metastasis and our ability to contour substructures of the brain as critical organs at risk. Advanced imaging with PET tracers and magnetic resonance imaging-based artificial intelligence models can now predict tumor control and differentiate tumor progression from radiation necrosis. These advancements will help to optimize dose and fractionation for each patient's lesion based on tumor size, histology, systemic therapy, medical comorbidities/patient genetics, and tumor molecular features. This review will discuss the current state of brain directed radiation for brain metastasis. We will also discuss future directions to improve the precision of stereotactic radiosurgery and optimize whole brain radiation techniques to improve local tumor control and prevent cognitive decline without forming necrosis.
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Affiliation(s)
- Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Haley K Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Eric J Lehrer
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Zabi Wardak
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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La Rosa A, Mittauer KE, Bassiri N, Wieczorek DJJ, Lee YC, Rzepczynski AE, Chuong MD, Kutuk T, McAllister NC, Hall MD, Gutierrez AN, Tolakanahalli R, Mehta MP, Kotecha R. Clinical application of an institutional fractionated stereotactic radiosurgery (FSRS) program for brain metastases delivered with MRIdian Ⓡ BrainTx™. Med Dosim 2024; 49:263-270. [PMID: 38431501 DOI: 10.1016/j.meddos.2024.02.001] [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: 09/21/2023] [Revised: 01/16/2024] [Accepted: 02/07/2024] [Indexed: 03/05/2024]
Abstract
Single-fraction stereotactic radiosurgery (SRS) or fractionated SRS (FSRS) are well established strategies for patients with limited brain metastases. A broad spectrum of modern dedicated platforms are currently available for delivering intracranial SRS/FSRS; however, SRS/FSRS delivered using traditional CT-based platforms relies on the need for diagnostic MR images to be coregistered to planning CT scans for target volume delineation. Additionally, the on-board image guidance on traditional platforms yields limited inter-fraction and intra-fraction real-time visualization of the tumor at the time of treatment delivery. MR Linacs are capable of obtaining treatment planning MR and on-table MR sequences to enable visualization of the targets and organs-at-risk and may subsequently help identify anatomical changes prior to treatment that may invoke the need for on table treatment adaptation. Recently, an MR-guided intracranial package (MRIdian A3i BrainTxTM) was released for intracranial treatment with the ability to perform high-resolution MR sequences using a dedicated brain coil and cranial immobilization system. The objective of this report is to provide, through the experience of our first patient treated, a comprehensive overview of the clinical application of our institutional program for FSRS adaptive delivery using MRIdian's A3i BrainTx system-highlights include reviewing the imaging sequence selection, workflow demonstration, and details in its delivery feasibility in clinical practice, and dosimetric outcomes.
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Affiliation(s)
- Alonso La Rosa
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Kathryn E Mittauer
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Nema Bassiri
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - D Jay J Wieczorek
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Yongsook C Lee
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Amy E Rzepczynski
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Michael D Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Tugce Kutuk
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Nicole C McAllister
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Matthew D Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Alonso N Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Ranjini Tolakanahalli
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.
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Kawahara D, Watanabe Y. A simulation study on the radiation-induced immune response of tumors after single fraction high-dose irradiation. Phys Med 2024; 118:103205. [PMID: 38241939 DOI: 10.1016/j.ejmp.2023.103205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 11/06/2023] [Accepted: 12/28/2023] [Indexed: 01/21/2024] Open
Abstract
PURPOSE We investigated radiation-induced antitumor immunity and its suppression by hypoxia-inducible factor (HIF-1α) for radiosurgery (SRS) using an improved cellular automata (CA) model. METHOD A two-dimensional Cellular Automata (CA) model was employed to simulate the impact of radiation on cancer cell death and subsequent immune responses. Cancer cells died from direct cell death from radiation and indirect cell death due to radiation-induced vascular damage. The model also incorporated radiation-induced immunity and immuno-suppression. It was incorporated into the model assuming that the death of cancer cells generates effector cells, forming complexes with cancer cells, and high radiation doses lead to vascular damage, inducing tumor hypoxia and increasing HIF-1α expression. The model was validated and subjected to sensitivity analysis by evaluating tumor volume changes post-irradiation and exploring the effects and sensitivity of radiation-induced immune responses. RESULTS The ratios of the tumor volume at 360 days post-irradiation and the SRS day (rTV) decreased with a higher PME, a higher Pcomp, and a lower ThHIF. The rTVs were 4.6 and 2.0 for PME = 0.1 and 0.9, 12.0 and 2.2 for Pcomp = 0.1 and 0.9, and 1.5 and 15.3 for ThHIF = 0.1 and 10.0, respectively. CONCLUSIONS By modeling the activation and deactivation of the effectors, the improved CA model showed that the radiation-induced immunogenic cell death in the tumor caused a decrease in the post-irradiation volume by a factor of four for the therapeutic doses relative to non-immune reaction cases. Furthermore, the suppressive effects of HIF-1α induced by hypoxia decreased radiation-induced immune effects by more than 50.
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Affiliation(s)
- Daisuke Kawahara
- Department of Radiation Oncology, Institute of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima City, Hiroshima 734-8551, Japan.
| | - Yoichi Watanabe
- Department of Radiation Oncology, University of Minnesota-Twin Cities, 420 Delaware St. SE, MMC494, Minneapolis, MN 55455, USA
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Gruber I, Weidner K, Treutwein M, Koelbl O. Stereotactic radiosurgery of brain metastases: a retrospective study. Radiat Oncol 2023; 18:202. [PMID: 38115009 PMCID: PMC10731882 DOI: 10.1186/s13014-023-02389-z] [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: 09/30/2023] [Accepted: 12/12/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Single-fraction stereotactic radiosurgery (SRS) is an established standard for radiation therapy of brain metastases although recent developments indicate that multi-fractionated stereotactic radiotherapy (FSRT) results in lower radiation necrosis especially for larger metastases, and the same or even better local control in comparison to SRS. METHODS Seventy-two patients with 111 brain metastases received SRS with a single dose of 18 Gy between September 2014 and December 2021. The dose prescription was either 18 Gy given to the enclosing 80% isodose with a normalization to Dmax = 100% of 22.5 Gy (part I) or 18 Gy = D98, while D0.03 cc of 21.6-22.5 Gy was accepted (part II). The study retrospectively evaluated local progression-free survival (LPFS), response on the first follow-up magnetic resonance imaging (MRI), and radiation necrosis. RESULTS Melanoma brain metastases (n = 44) were the most frequent metastases. The median gross tumor volume (GTV) was 0.30 cm³ (IQR, 0.17-0.61). The median follow-up time of all patients was 50.8 months (IQR, 30.4-64.6). Median LPFS was 23.5 months (95%CI 17.2, 29.8). The overall LPFS rates at 12-, 18-, 24- and 30 months were 65.3%, 56.3%, 46.5%, and 38.8%. Brain metastases with radioresistant histology (melanoma, renal cell cancer, and sarcoma) showed a 12-month LPFS of 60.2%, whereas brain metastases with other histology had a 12-month LPFS of 70.1%. The response of brain metastases on first follow-up MRIs performed after a median time of 47 days (IQR, 40-63) was crucial for long-term local control and survival. Eight brain metastases (7.2%) developed radiation necrosis after a median time of 18.4 months (IQR, 9.4-26.5). In multivariate analyses, a GTV > 0.3 cm³ negatively affected LPFS (HR 2.229, 95%CI 1.172, 4.239). Melanoma, renal cell cancers, and sarcoma had a lower chance of LPFS in comparison to other cancer types (HR 2.330, 95%CI 1.155, 4.699). CONCLUSIONS Our results indicate a reasonable 1-year local control of brain metastases with radiosensitive histology. Radioresistant metastases show a comparatively poor local control. Treatment refinements merit exploration to improve local control of brain metastases. TRIAL REGISTRATION This study is retrospectively registered (ethics approval number 23-3451-104).
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Affiliation(s)
- Isabella Gruber
- Department of Radiation Oncology, University Hospital Regensburg, Franz-Josef-Strauss Allee 11, Regensburg, Bavarian, 93053, Germany.
| | - Karin Weidner
- Department of Radiation Oncology, University Hospital Regensburg, Franz-Josef-Strauss Allee 11, Regensburg, Bavarian, 93053, Germany
| | - Marius Treutwein
- Department of Radiation Oncology, University Hospital Regensburg, Franz-Josef-Strauss Allee 11, Regensburg, Bavarian, 93053, Germany
| | - Oliver Koelbl
- Department of Radiation Oncology, University Hospital Regensburg, Franz-Josef-Strauss Allee 11, Regensburg, Bavarian, 93053, Germany
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10
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Lee J, Kim HJ, Kim WC. CyberKnife-based stereotactic radiosurgery or fractionated stereotactic radiotherapy in older patients with brain metastases from non-small cell lung cancer. Radiat Oncol J 2023; 41:258-266. [PMID: 38185930 PMCID: PMC10772598 DOI: 10.3857/roj.2023.00563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 01/09/2024] Open
Abstract
PURPOSE We analyzed clinical results of CyberKnife (CK)-based stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (FSRT) in older patients (age ≥65 years) affected by brain metastases (BM) from non-small cell lung cancer (NSCLC). MATERIALS AND METHODS Forty-three older patients with 92 BM were treated with CK-based SRS/FSRT at our institution between 2009 and 2019. The end-point was overall survival (OS). Univariate and multivariate analyses were performed to identify the prognostic factors influencing OS. The in-field local control (IFLC) within the SRS/FSRT field was also assessed. RESULTS During a median follow-up period of 18 months, the median OS was 32 months. NSCLC-specific graded prognostic assessment (GPA) (p = 0.027) was an independent significant factor affecting OS in the multivariate analysis. The median IFLC period was 31 months, and the total BM volume (p = 0.025) appeared to be a significant feature of IFLC. No adverse events >grade 2 were reported after SRS/FSRT. CONCLUSION CK-based SRS/FSRT is a safe and efficient option for older patients with BM arising from NSCLC, showing good OS without severe side effects. GPA, which was consisted in age, performance status, extra-cerebral metastasis, and number of BM, seemed to be predictive factors for OS.
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Affiliation(s)
- Jeongshim Lee
- Department of Radiation Oncology, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Hun Jung Kim
- Department of Radiation Oncology, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Woo Chul Kim
- Department of Radiation Oncology, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
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11
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Alzate JD, Mashiach E, Berger A, Bernstein K, Mullen R, Nigris Vasconcellos FD, Qu T, Silverman JS, Donahue BR, Cooper BT, Sulman EP, Golfinos JG, Kondziolka D. Low-Dose Radiosurgery for Brain Metastases in the Era of Modern Systemic Therapy. Neurosurgery 2023; 93:1112-1120. [PMID: 37326435 DOI: 10.1227/neu.0000000000002556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/17/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Dose selection for brain metastases stereotactic radiosurgery (SRS) classically has been based on tumor diameter with a reduction of dose in the settings of prior brain irradiation, larger tumor volumes, and critical brain location. However, retrospective series have shown local control rates to be suboptimal with reduced doses. We hypothesized that lower doses could be effective for specific tumor biologies with concomitant systemic therapies. This study aims to report the local control (LC) and toxicity when using low-dose SRS in the era of modern systemic therapy. METHODS We reviewed 102 patients with 688 tumors managed between 2014 and 2021 who had low-margin dose radiosurgery, defined as ≤14 Gy. Tumor control was correlated with demographic, clinical, and dosimetric data. RESULTS The main primary cancer types were lung in 48 (47.1%), breast in 31 (30.4%), melanoma in 8 (7.8%), and others in 15 patients (11.7%). The median tumor volume was 0.037cc (0.002-26.31 cm 3 ), and the median margin dose was 14 Gy (range 10-14). The local failure (LF) cumulative incidence at 1 and 2 years was 6% and 12%, respectively. On competing risk regression analysis, larger volume, melanoma histology, and margin dose were predictors of LF. The 1-year and 2-year cumulative incidence of adverse radiation effects (ARE: an adverse imaging-defined response includes increased enhancement and peritumoral edema) was 0.8% and 2%. CONCLUSION It is feasible to achieve acceptable LC in BMs with low-dose SRS. Volume, melanoma histology, and margin dose seem to be predictors for LF. The value of a low-dose approach may be in the management of patients with higher numbers of small or adjacent tumors with a history of whole brain radio therapy or multiple SRS sessions and in tumors in critical locations with the aim of LC and preservation of neurological function.
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Affiliation(s)
- Juan Diego Alzate
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | - Elad Mashiach
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | - Assaf Berger
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - Reed Mullen
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | | | - Tanxia Qu
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - Joshua S Silverman
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - Bernadine R Donahue
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - Benjamin T Cooper
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - Erik P Sulman
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , New York , USA
| | - John G Golfinos
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
| | - Douglas Kondziolka
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , New York , USA
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12
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Buszek SM, Tran B, Long JP, Luo D, Suki D, Li J, Ferguson S, Chung C. Postoperative Management of Recurrence After Radiosurgery and Surgical Resection for Brain Metastases and Predicting Benefit From Adjuvant Radiation. Pract Radiat Oncol 2023; 13:e499-e503. [PMID: 37295724 DOI: 10.1016/j.prro.2023.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/01/2023] [Accepted: 05/21/2023] [Indexed: 06/12/2023]
Abstract
Stereotactic radiosurgery (SRS) is often used as upfront treatment for brain metastases. Progression or radionecrosis after SRS is common and can prompt resection. However, postoperative management strategies after resection for SRS failure vary widely, and no standard practice has been established. In this approved study, we retrospectively reviewed patients who received SRS for a brain metastasis followed by resection of the same lesion. We extracted patient-, disease-, and treatment-related variables and information on disease-related outcomes. Univariate and multivariate analyses of clinicopathologic variables were used to create a model to predict factors associated with local failure (LF). A total of 225 patients with brain metastases treated with SRS from 2009 to 2017 followed by surgical resection were identified. Overall, 65% of cases had gross total resection (GTR) on postoperative imaging review. Twenty-one patients (9.3%) received adjuvant radiation therapy to the surgical cavity, and 204 (90.7%) were observed. Of these 204 patients, 118 had GTR with evidence of tumor within the pathology specimen. With a median follow-up of 13 months after resection, 47 patients (40%) developed LF after surgery. After salvage resection of a brain metastasis initially treated with SRS, the observed LF rate was 40% among those who had a GTR and evidence of tumor on pathologic examination. This LF rate is sufficiently high that adjuvant radiation to the surgical bed after salvage resection should be considered in these cases when there is tumor in the pathology, even after a GTR.
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Affiliation(s)
- Samantha M Buszek
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Benjamin Tran
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - James P Long
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Dershan Luo
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Dima Suki
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sherise Ferguson
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Caroline Chung
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
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13
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Bander ED, El Ahmadieh TY, Chen J, Reiner AS, Brown S, Giantini-Larsen AM, Young RJ, Beal K, Imber BS, Pike LRG, Brennan CW, Tabar V, Panageas KS, Moss NS. Outcomes Following Early Postoperative Adjuvant Radiosurgery for Brain Metastases. JAMA Netw Open 2023; 6:e2340654. [PMID: 37906192 PMCID: PMC10618851 DOI: 10.1001/jamanetworkopen.2023.40654] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/19/2023] [Indexed: 11/02/2023] Open
Abstract
Importance Adjuvant stereotactic radiosurgery (SRS) enhances the local control of resected brain metastases (BrM). However, the risks of local failure (LF) and potential for posttreatment adverse radiation effects (PTRE) after early postoperative adjuvant SRS have not yet been established. Objective To evaluate whether adjuvant SRS delivered within a median of 14 days after surgery is associated with improved LF without a concomitant increase in PTRE. Design, Setting, and Participants This prospective cohort study examines a clinical workflow (RapidRT) that was implemented from 2019 to 2022 to deliver SRS to surgical patients within a median of 14 days, ensuring all patients were treated within 30 days postoperatively. This prospective cohort was compared with a historical cohort (StanRT) of patients with BrM resected between 2013 and 2019 to assess the association of the RapidRT workflow with LF and PTRE. The 2 cohorts were combined to identify optimal SRS timing, with a median follow-up of 3.3 years for survivors. Exposure Timing of adjuvant SRS (14, 21, and 30 days postoperatively). Main Outcomes and Measures LF and PTRE, according to modified Response Assessment in Neuro-Oncology Brain Metastases criteria. Results There were 438 patients (265 [60.5%] female patients; 23 [5.3%] Asian, 27 [6.2%] Black, and 364 [83.1%] White patients) with a mean (SD) age of 62 (13) years; 377 were in the StanRT cohort and 61 in the RapidRT cohort. LF and PTRE rates at 1 year were not significantly different between RapidRT and StanRT cohorts. Timing of SRS was associated with radiographic PTRE. Patients receiving radiation within 14 days had the highest 1-year PTRE rate (18.08%; 95% CI, 8.31%-30.86%), and patients receiving radiation between 22 and 30 days had the lowest 1-year PTRE rate (4.10%; 95% CI, 1.52%-8.73%; P = .03). LF rates were highest for patients receiving radiation more than 30 days from surgery (10.65%; 95% CI, 6.90%-15.32%) but comparable for patients receiving radiation within 14 days, between 15 and 21 days, and between 22 and 30 days (≤14 days: 5.12%; 95% CI, 0.86%-15.60%; 15 to ≤21 days: 3.21%; 95% CI, 0.59%-9.99%; 22 to ≤30 days: 6.58%; 95% CI, 3.06%-11.94%; P = .20). Conclusions and Relevance In this cohort study of adjuvant SRS timing following surgical resection of BrM, the optimal timing for adjuvant SRS appears to be within 22 to 30 days following surgery. The findings of this study suggest that this timing allows for a balanced approach that minimizes the risks associated with LF and PTRE.
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Affiliation(s)
- Evan D. Bander
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical College, New York
| | - Tarek Y. El Ahmadieh
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Neurosurgery, Loma Linda University Health, Loma Linda, California
| | - Justin Chen
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne S. Reiner
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Samantha Brown
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alexandra M. Giantini-Larsen
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical College, New York
| | - Robert J. Young
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kathryn Beal
- Department of Radiation Oncology and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Brandon S. Imber
- Department of Radiation Oncology and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Luke R. G. Pike
- Department of Radiation Oncology and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cameron W. Brennan
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Viviane Tabar
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katherine S. Panageas
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nelson S. Moss
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
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14
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Khaledi N, Khan R, Gräfe JL. Historical Progress of Stereotactic Radiation Surgery. J Med Phys 2023; 48:312-327. [PMID: 38223793 PMCID: PMC10783188 DOI: 10.4103/jmp.jmp_62_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 09/24/2023] [Accepted: 09/27/2023] [Indexed: 01/16/2024] Open
Abstract
Radiosurgery and stereotactic radiotherapy have established themselves as precise and accurate areas of radiation oncology for the treatment of brain and extracranial lesions. Along with the evolution of other methods of radiotherapy, this type of treatment has been associated with significant advances in terms of a variety of modalities and techniques to improve the accuracy and efficacy of treatment. This paper provides a comprehensive overview of the progress in stereotactic radiosurgery (SRS) over several decades, and includes a review of various articles and research papers, commencing with the emergence of stereotactic techniques in radiotherapy. Key clinical aspects of SRS, such as fixation methods, radiobiology considerations, quality assurance practices, and treatment planning strategies, are presented. In addition, the review highlights the technological advancements in treatment modalities, encompassing the transition from cobalt-based systems to linear accelerator-based modalities. By addressing these topics, this study aims to offer insights into the advancements that have shaped the field of SRS, that have ultimately enhanced the accuracy and effectiveness of treatment.
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Affiliation(s)
- Navid Khaledi
- Department of Medical Physics, Cancer Care Manitoba, Winnipeg, MB, Canada
| | - Rao Khan
- Department of Physics, Toronto Metropolitan University, Toronto, ON, Canada
- Department of Physics and Astronomy and Department of Radiation Oncology, Howard University, Washington, District of Columbia, USA
| | - James L. Gräfe
- Department of Physics, Toronto Metropolitan University, Toronto, ON, Canada
- Cancer Care Program, Dr. H. Bliss Murphy Cancer Center. 300 Prince Philip Drive St. John’s, NL, Canada
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15
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Jablonska PA, Galán N, Barranco J, Leon S, Robledano R, Echeveste JI, Calvo A, Aristu J, Serrano D. Presence of Activated (Phosphorylated) STAT3 in Radiation Necrosis Following Stereotactic Radiosurgery for Brain Metastases. Int J Mol Sci 2023; 24:14219. [PMID: 37762522 PMCID: PMC10532304 DOI: 10.3390/ijms241814219] [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: 07/29/2023] [Revised: 08/31/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
Brain radiation necrosis (RN) is a subacute or late adverse event following radiotherapy, involving an exacerbated inflammatory response of the brain tissue. The risk of symptomatic RN associated with stereotactic radiosurgery (SRS) as part of the treatment of brain metastases (BMs) has been a subject of recent investigation. The activation of the signal transducer and activator of transcription 3 (STAT3) was shown in reactive astrocytes (RA) associated with BMs. Given that the pathophysiological mechanisms behind RN are not fully understood, we sought to investigate the role of STAT3 among other inflammatory markers in RN development. A mouse model of RN using clinical LINAC-based SRS was designed to induce brain necrosis with the administration of 50 Gy in a single fraction to the left hemisphere using a circular collimator of 5 mm diameter. Immunohistochemistry and multiplex staining for CD4, CD8, CD68, GFAP, and STAT3 were performed. For validation, eleven patients with BMs treated with SRS who developed symptomatic RN and required surgery were identified to perform staining for CD68, GFAP, and STAT3. In the mouse model, the RN and perinecrotic areas showed significantly higher staining for F4/80+ and GFAP+ cells, with a high infiltration of CD4 and CD8 T-lymphocytes, when compared to the non-irradiated cerebral hemisphere. A high number of GFAP+pSTAT3+ and F4/80+pSTAT3+ cells was found in the RN areas and the rest of the irradiated hemisphere. The analysis of human brain specimens showed that astrocytes and microglia were actively phosphorylating STAT3 in the areas of RN and gliosis. Phosphorylated STAT3 is highly expressed in the microglia and RA pertaining to the areas of brain RN. Targeting STAT3 via inhibition represents a promising strategy to ameliorate symptomatic RN in BM patients undergoing SRS.
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Affiliation(s)
- Paola Anna Jablonska
- Department of Radiation Oncology, Clinica Universidad de Navarra, 31008 Pamplona, Spain
| | - Nuria Galán
- IDISNA and Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain (A.C.); (D.S.)
| | - Jennifer Barranco
- IDISNA and Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain (A.C.); (D.S.)
| | - Sergio Leon
- IDISNA and Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain (A.C.); (D.S.)
- Department of Pathological Anatomy, Clinica Universidad de Navarra, 31008 Pamplona, Spain
| | - Ramón Robledano
- Department of Pathological Anatomy, Clinica Universidad de Navarra, 31008 Pamplona, Spain
| | - José Ignacio Echeveste
- Department of Pathological Anatomy, Clinica Universidad de Navarra, 31008 Pamplona, Spain
| | - Alfonso Calvo
- IDISNA and Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain (A.C.); (D.S.)
- Department of Pathology, Anatomy and Physiology, School of Medicine, University of Navarra, 31008 Pamplona, Spain
- CIBERONC, ISCIII, 28029 Madrid, Spain
| | - Javier Aristu
- Department of Radiation Oncology and Proton Therapy Unit, Clinica Universidad de Navarra, 28027 Madrid, Spain;
| | - Diego Serrano
- IDISNA and Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain (A.C.); (D.S.)
- Department of Pathology, Anatomy and Physiology, School of Medicine, University of Navarra, 31008 Pamplona, Spain
- CIBERONC, ISCIII, 28029 Madrid, Spain
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16
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Kowalchuk RO, Niranjan A, Hess J, Antonios JP, Zhang MY, Braunstein S, Ross RB, Pikis S, Deibert CP, Lee CC, Yang HC, Langlois AM, Mathieu D, Peker S, Samanci Y, Rusthoven CG, Chiang V, Wei Z, Lunsford LD, Trifiletti DM, Sheehan JP. Stereotactic radiosurgery and local control of brain metastases from triple-negative breast cancer. J Neurosurg 2023; 138:1608-1614. [PMID: 36433878 DOI: 10.3171/2022.10.jns221900] [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: 08/16/2022] [Accepted: 10/18/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) is an effective treatment for intracranial metastatic disease, but its role in triple-negative breast cancer requires further study. Herein, the authors report overall survival (OS) and local tumor control in a multiinstitutional cohort with triple-negative breast cancer metastases treated with SRS. METHODS Patients treated from 2010 to 2019 at 9 institutions were included in this retrospective study if they had biopsy-proven triple-negative breast cancer with intracranial metastatic lesions treated with SRS. Patients were excluded if they had undergone prior SRS, whole-brain radiation therapy, or resection of the metastatic lesions. A retrospective chart review was conducted to determine OS, local control, and treatment efficacy. RESULTS Sixty-eight patients with 315 treated lesions were assessed. Patients had a median Karnofsky Performance Status of 80 (IQR 70-90) and age of 57 years (IQR 48-67 years). Most treated patients had 5 or fewer intracranial lesions, with 34% of patients having a single lesion. Treated lesions were small, having a median volume owf 0.11 cm3 (IQR 0.03-0.60 cm3). Patients were treated with a median margin dose of 18 Gy (IQR 18-20 Gy) to the median 71% isodose line (IQR 50%-84%). Overall, patients had a 1-year OS of 43% and 2-year OS of 20%. Most patients (88%) were followed until death, by which time local tumor progression had occurred in only 7% of cases. Furthermore, 76% of the lesions demonstrated regression. Tumor volume was correlated with local tumor progression (p = 0.012). SRS was very well tolerated, and only 3 patients (5%) developed symptomatic radiation necrosis. CONCLUSIONS SRS is a safe and efficacious treatment for well-selected patients with triple-negative breast cancer, especially for those with a favorable performance status and small- to moderate-volume metastatic lesions.
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Affiliation(s)
- Roman O Kowalchuk
- 1Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Ajay Niranjan
- 2Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Judith Hess
- 3Department of Neurosurgery, Yale New Haven Hospital, New Haven, Connecticut
| | - Joseph P Antonios
- 3Department of Neurosurgery, Yale New Haven Hospital, New Haven, Connecticut
| | - Michael Y Zhang
- 4Department of Radiation Oncology, University of California, San Francisco, California
| | - Steve Braunstein
- 4Department of Radiation Oncology, University of California, San Francisco, California
| | - Richard B Ross
- 5Department of Radiation Oncology, University of Colorado, Boulder, Colorado
| | - Stylianos Pikis
- 6Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | | | - Cheng-Chia Lee
- 8Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- 9National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Huai-Che Yang
- 8Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- 9National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Anne-Marie Langlois
- 10Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Québec, Canada
| | - David Mathieu
- 10Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Québec, Canada
| | - Selcuk Peker
- 11Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey; and
| | - Yavuz Samanci
- 11Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey; and
| | - Chad G Rusthoven
- 5Department of Radiation Oncology, University of Colorado, Boulder, Colorado
| | - Veronica Chiang
- 3Department of Neurosurgery, Yale New Haven Hospital, New Haven, Connecticut
| | - Zhishuo Wei
- 2Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- 2Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Jason P Sheehan
- 6Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
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Kornhuber C, Ensminger S, Hübsch P, Janich M, Leucht CA, Vordermark D, Dietzel CT. Feasibility of a simultaneously integrated boost concept for hypofractionated stereotactic radiotherapy of unresected brain metastases. Radiat Oncol 2023; 18:88. [PMID: 37217934 DOI: 10.1186/s13014-023-02266-9] [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: 01/07/2023] [Accepted: 04/17/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND In stereotactic radiotherapy, dose is prescribed to an isodose surrounding the planning target volume (PTV). However, the desired dose inhomogeneity inside the PTV leaves the specific dose distribution to the gross tumor volume (GTV) unspecified. A simultaneously integrated boost (SIB) to the GTV could solve this shortcoming. In a retrospective planning study with 20 unresected brain metastases, a SIB approach was tested against the classical prescription. METHODS For all metastases, the GTV was isotropically enlarged by 3 mm to a PTV. Two plans were generated, one according to the classical 80% concept with 5 times 7 Gy prescribed (on D2%) to the 80% PTV surrounding isodose (with D98%(PTV) ≥ 35 Gy), and the other one following a SIB concept with 5 times 8.5 Gy average GTV dose and with D98%(PTV) ≥ 35 Gy as additional requirement. Plan pairs were compared in terms of homogeneity inside GTV, high dose in PTV rim around GTV, and dose conformity and gradients around PTV using Wilcoxon matched pairs signed rank test. RESULTS The SIB concept was superior to the classical 80% concept concerning dose homogeneity inside GTV: Heterogeneity index of GTV was in the SIB concept (median 0.0513, range 0.0397-0.0757) significantly (p = 0.001) lower than in the 80% concept (median 0.0894, range 0.0447-0.1872). Dose gradients around PTV were not inferior. The other examined measures were comparable. CONCLUSION Our stereotactic SIB concept better defines the dose distribution inside PTV and can be considered for clinical use.
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Affiliation(s)
- Christine Kornhuber
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany.
| | - Stephan Ensminger
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Patrick Hübsch
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Martin Janich
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Chris Andre Leucht
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Dirk Vordermark
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Christian T Dietzel
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
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18
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Hudson WH, Olson JJ, Sudmeier LJ. Immune microenvironment remodeling after radiation of a progressing brain metastasis. Cell Rep Med 2023:101054. [PMID: 37209684 DOI: 10.1016/j.xcrm.2023.101054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 02/02/2023] [Accepted: 04/27/2023] [Indexed: 05/22/2023]
Abstract
Radiation is commonly used in the treatment of many cancers. However, its effects on anti-tumor immune responses are incompletely understood. Here, we present a detailed immunological analysis of two tumors from a patient with multiple non-small cell lung cancer metastases to the brain. One tumor was resected without treatment; the second was irradiated to a total dose of 30 Gy and resected following further progression. Comprehensive single-cell analysis reveals a substantially reduced immune cell fraction in the irradiated tumor, including the depletion of tissue-resident macrophages and infiltration of pro-inflammatory monocytes. Despite the presence of similar somatic mutations in both tumors, radiation is associated with the depletion of exhausted, tumor-resident T cell clones and their replacement by circulating clones unlikely to contribute to tumor-specific immunity. These results provide insight into the local effects of radiation on anti-tumor immunity and raise important considerations for the combination of radiation and immunotherapy.
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Affiliation(s)
- William H Hudson
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX 77030, USA; Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX 77030, USA; Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Jeffrey J Olson
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA; Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Lisa J Sudmeier
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30322, USA; Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA.
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19
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Čehobašić A, Paladino J, Kaučić H, Mišir-Krpan A, Leipold V, Mlinarić M, Kosmina D, Mack A, Schwarz D, Divošević S, Alerić I. Comparison of 116 Radiosurgery Treatment Plans for Multi-Leaf and Cone Collimator on a Varian Edge Linac: Are Cones Superior in the Daily Routine? Life (Basel) 2023; 13:life13041020. [PMID: 37109549 PMCID: PMC10146576 DOI: 10.3390/life13041020] [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: 03/21/2023] [Revised: 04/07/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
Delivering focused radiation doses via linear accelerators is a crucial component of stereotactic radiosurgery (SRS) for brain metastases. The Varian Edge linear accelerator provides highly conformal radiation therapy through a high-definition multi-leaf collimator (HD120 MLC) and conical collimator (CC). HD120 MLC adapts to the shape of the target volume using movable tungsten leaves, while CC has a block of conical shape (cones). CC in SRS treatments of small brain metastases is preferred due to its mechanical stability and steeper dose fall-off, potentially sparing organs at risk (OARs) and the brain better than HD120 MLC. This study aims to determine if CC offers significant advantages over HD120 MLC for SRS treatments. For 116 metastatic lesions, CC and HD120 MLC treatment plans were created in Varian Eclipse TPS and compared based on various dose parameters, robustness tests, and QA measurements. The results indicate that CC provides no significant advantages over HD120 MLC, except for slight, clinically insignificant benefits in brain sparing and dose fall-off for the smallest lesions. HD120 MLC outperforms CC in almost every aspect, making it a better choice for irradiating brain metastases with 0.1 cm3 or higher volumes.
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Affiliation(s)
- Adlan Čehobašić
- Specijalna Bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia
- Medicinski Fakultet Osijek, Sveučilište Josipa Jurja Strossmayera u Osijeku, Josipa Huttlera 4, 31000 Osijek, Croatia
| | - Josip Paladino
- Specijalna Bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia
| | - Hrvoje Kaučić
- Specijalna Bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia
| | - Ana Mišir-Krpan
- Specijalna Bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia
- Medicinski Fakultet, Sveučilište u Zagrebu, Šalata 3, 10000 Zagreb, Croatia
| | - Vanda Leipold
- Specijalna Bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia
- Medicinski Fakultet Osijek, Sveučilište Josipa Jurja Strossmayera u Osijeku, Josipa Huttlera 4, 31000 Osijek, Croatia
| | - Mihaela Mlinarić
- Specijalna Bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia
| | - Domagoj Kosmina
- Specijalna Bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia
| | - Andreas Mack
- Swiss NeuroRadiosurgery Center, Bürglistrasse 29, 8002 Zürich, Switzerland
| | - Dragan Schwarz
- Specijalna Bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia
- Medicinski Fakultet, Sveučilišta u Rijeci, Braće Branchetta 20/1, 51000 Rijeka, Croatia
- Fakultet za Dentalnu Medicinu i Zdravstvo Osijek, Sveučilište Josipa Jurja Strossmayera u Osijeku, Crkvena Ulica 21, 31000 Osijek, Croatia
| | - Sunčana Divošević
- Specijalna Bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia
| | - Ivana Alerić
- Specijalna Bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia
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20
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Shiue K, Sahgal A, Lo SS. Precision Radiation for Brain Metastases With a Focus on Hypofractionated Stereotactic Radiosurgery. Semin Radiat Oncol 2023; 33:114-128. [PMID: 36990629 DOI: 10.1016/j.semradonc.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
There are multiple published randomized controlled trials supporting single-fraction stereotactic radiosurgery (SF-SRS) for patients presenting with 1 to 4 brain metastases, with the benefit of minimizing radiation-induced neurocognitive sequelae as compared to whole brain radiotherapy . More recently, the dogma of SF-SRS as the only means of delivering an SRS treatment has been challenged by hypofractionated SRS (HF-SRS). The ability to deliver 25-35 Gy in 3-5 HF-SRS fractions is a direct consequence of the evolution of radiation technologies to allow image guidance, specialized treatment planning, robotic delivery and/or patient positioning corrections in all 6 degrees-of-freedom, and frameless head immobilization. The intent is to mitigate the potentially devastating complication of radiation necrosis and improve rates of local control for larger metastases. This narrative review provides an overview of outcomes specific to HF-SRS in addition to the more recent developments of staged SRS, preoperative SRS, and hippocampal avoidance-whole brain radiotherapy with simultaneous integrated boost.
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21
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Yan M, Lee M, Myrehaug S, Tseng CL, Detsky J, Chen H, Das S, Yeboah C, Lipsman N, Costa LD, Holden L, Heyn C, Maralani P, Ruschin M, Sahgal A, Soliman H. Hypofractionated stereotactic radiosurgery (HSRS) as a salvage treatment for brain metastases failing prior stereotactic radiosurgery (SRS). J Neurooncol 2023; 162:119-128. [PMID: 36914878 DOI: 10.1007/s11060-023-04265-y] [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: 01/20/2023] [Accepted: 02/09/2023] [Indexed: 03/14/2023]
Abstract
INTRODUCTION Various treatment options exist to salvage stereotactic radiosurgery (SRS) failures for brain metastases, including repeat SRS and hypofractionated SRS (HSRS). Our objective was to report outcomes specific to salvage HSRS for brain metastases that failed prior HSRS/SRS. METHODS Patients treated with HSRS to salvage local failures (LF) following initial HSRS/SRS, between July 2010 and April 2020, were retrospectively reviewed. The primary outcomes were the rates of LF, radiation necrosis (RN), and symptomatic radiation necrosis (SRN). Univariable (UVA) and multivariable (MVA) analyses using competing risk regression were performed to identify predictive factors for each endpoint. RESULTS 120 Metastases in 91 patients were identified. The median clinical follow up was 13.4 months (range 1.1-111.1), and the median interval between SRS courses was 13.1 months (range 3.0-56.5). 115 metastases were salvaged with 20-35 Gy in 5 fractions and the remaining five with a total dose ranging from 20 to 24 Gy in 3-fractions. 67 targets (56%) were postoperative cavities. The median re-treatment target volume and biological effective dose (BED10) was 9.5 cc and 37.5 Gy, respectively. The 6- and 12- month LF rates were 18.9% and 27.7%, for RN 13% and 15.6%, and for SRN were 6.1% and 7.0%, respectively. MVA identified larger re-irradiation volume (hazard ratio [HR] 1.02, p = 0.04) and shorter interval between radiosurgery courses (HR 0.93, p < 0.001) as predictors of LF. Treatment of an intact target was associated with a higher risk of RN (HR 2.29, p = 0.04). CONCLUSION Salvage HSRS results in high local control rates and toxicity rates that compare favorably to those single fraction SRS re-irradiation experiences reported in the literature.
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Affiliation(s)
- Michael Yan
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Minha Lee
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Sunit Das
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Collins Yeboah
- Department of Medical Physics, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Leodante Da Costa
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Lori Holden
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Chinthaka Heyn
- Division of Radiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Pejman Maralani
- Division of Radiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Mark Ruschin
- Department of Medical Physics, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada.
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22
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Lolli J, Tessari F, Berti F, Fusella M, Fiorentin D, Bimbatti D, Basso U, Busato F. Impressive reduction of brain metastasis radionecrosis after cabozantinib therapy in metastatic renal carcinoma: A case report and review of the literature. Front Oncol 2023; 13:1136300. [PMID: 36959812 PMCID: PMC10028179 DOI: 10.3389/fonc.2023.1136300] [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: 01/02/2023] [Accepted: 02/20/2023] [Indexed: 03/09/2023] Open
Abstract
Introduction Radionecrosis is a consequence of SRS (stereotactic radiosurgery) for brain metastases in 34% of cases, and if symptomatic (8%-16%), it requires therapy with corticosteroids and bevacizumab and, less frequently, surgery. Oncological indications are increasing and appropriate stereotactic adapted LINACs (linear accelerators) are becoming more widely available worldwide. Efforts are being made to treat brain radionecrosis in order to relieve symptoms and spare the use of active therapies. Case presentation Herein, we describe a 65-year-old female patient presenting with brain radionecrosis 6 months after stereotactic radiotherapy for two brain metastatic lesions. Being symptomatic with headache and slow cognitive-motor function, the patient received corticosteroids. Because of later lung progression, the patient took cabozantinib. An impressive reduction of the two brain radionecrosis areas was seen at the brain MRI 2 months after the initiation of the angiogenic drug. Discussion The high incidence of radionecrosis (2/2 treated lesions) can be interpreted by the combination of SRS and previous ipilimumab that is associated with increased risk of radionecrosis. The molecular mechanisms of brain radionecrosis, and its exact duration in time, are poorly understood. We hypothesize that the antiangiogenic effect of cabozantinib may have had a strong effect in reducing brain radionecrosis areas. Conclusion In this clinical case, cabozantinib is associated with a fast and significant volume reduction of brain radionecrosis appearing after SRS and concomitant immunotherapy. This drug seems to show, like bevacizumab, clinical implications not only for its efficacy in systemic disease control but also in reducing brain radionecrosis. More research is needed to evaluate all molecular mechanisms of brain radionecrosis and their interaction with systemic therapies like third-generation TKIs.
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Affiliation(s)
- Jacopo Lolli
- Radiotherapy Unit, Veneto Institute of Oncology IOV – IRCCS, Padua, Italy
| | - Francesca Tessari
- Radiotherapy Unit, Veneto Institute of Oncology IOV – IRCCS, Padua, Italy
| | - Franco Berti
- Radiotherapy Unit, Veneto Institute of Oncology IOV – IRCCS, Padua, Italy
| | - Marco Fusella
- Radiotherapy Unit, Veneto Institute of Oncology IOV – IRCCS, Padua, Italy
- Department of Radiation Oncology, Abano Terme Hospital, Padua, Italy
| | - Davide Fiorentin
- Radiotherapy Unit, Veneto Institute of Oncology IOV – IRCCS, Padua, Italy
- Department of Radiation Oncology, Abano Terme Hospital, Padua, Italy
| | - Davide Bimbatti
- Medical Oncology 1, Veneto Institute of Oncology IOV-IRCSS, Padua, Italy
| | - Umberto Basso
- Medical Oncology 1, Veneto Institute of Oncology IOV-IRCSS, Padua, Italy
| | - Fabio Busato
- Radiotherapy Unit, Veneto Institute of Oncology IOV – IRCCS, Padua, Italy
- Department of Radiation Oncology, Abano Terme Hospital, Padua, Italy
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23
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Kotecha R, Suh JH, Mehta MP. Editorial: Effects of radiation therapies on brain metastases. Front Oncol 2023; 13:1196143. [PMID: 37124499 PMCID: PMC10133675 DOI: 10.3389/fonc.2023.1196143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 04/04/2023] [Indexed: 05/02/2023] Open
Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, United States
- *Correspondence: Rupesh Kotecha,
| | - John H. Suh
- Deparment of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, United States
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
| | - Minesh P. Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, United States
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24
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Vetlova ER, Banov SM, Golanov AV, Pronin IN, Antipina NA, Galkin MV. [Results of hypofractionated stereotactic radiotherapy for resected and intact large brain metastases]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:67-75. [PMID: 38054229 DOI: 10.17116/neiro20238706167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
Post-resection or isolated hypofractionated stereotactic radiotherapy (HF-SRT) is a therapeutic option for large brain metastases (>2 cm, LBMs). OBJECTIVE To compare the results of post-resection or isolated HF-SRT in patients with LBMs. MATERIAL AND METHODS A prospective study included 115 patients with 129 intact LBMs and 133 patients with 149 resected LBMs who underwent HF-SRT. Median baseline focal size was 22.5 and 28 mm, median target volume - 8.3 and 23.7 cm3, respectively. RESULTS Median follow-up was 13.9 months, median overall survival - 19.1 months. After 12 months, local recurrences developed in 17 and 31% of patients, respectively (p=0.0078). Local recurrence after 12 months developed in 23% of patients with residual tumor in postoperative cavity compared to 16% of patients after total resection (p=0.0073). After 12 months, incidence of leptomeningeal progression was 27 and 11%, respectively (p=0.033), incidence of symptomatic radiation-induced necrosis - 4 and 23%, respectively (p=0.0006). CONCLUSION Post-resection HF-SRT demonstrated better local control and less severe symptomatic radiation-induced necrosis compared to patients with intact LBMs. Incidence of leptomeningeal progression is significantly higher after resection of LBMs.
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Affiliation(s)
- E R Vetlova
- Burdenko Neurosurgical Center, Moscow, Russia
| | - S M Banov
- Burdenko Neurosurgical Center, Moscow, Russia
| | - A V Golanov
- Burdenko Neurosurgical Center, Moscow, Russia
- Russian Medical Academy of Continuing Professional Education, Moscow, Russia
| | - I N Pronin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - M V Galkin
- Burdenko Neurosurgical Center, Moscow, Russia
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25
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Carpenter DJ, Fairchild AT, Adamson JD, Fecci PE, Sampson JH, Herndon JE, Torok JA, Mullikin TC, Kim GJ, Reitman ZJ, Kirkpatrick JP, Floyd SR. Outcomes in Patients with Intact and Resected Brain Metastasis Treated with 5-Fraction Stereotactic Radiosurgery. Adv Radiat Oncol 2022; 8:101166. [PMID: 36845614 PMCID: PMC9943776 DOI: 10.1016/j.adro.2022.101166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022] Open
Abstract
Purpose Hypofractionated stereotactic radiosurgery (HF-SRS) with or without surgical resection is potentially a preferred treatment for larger or symptomatic brain metastases (BMs). Herein, we report clinical outcomes and predictive factors following HF-SRS. Methods and Materials Patients undergoing HF-SRS for intact (iHF-SRS) or resected (rHF-SRS) BMs from 2008 to 2018 were retrospectively identified. Linear accelerator-based image-guided HF-SRS consisted of 5 fractions at 5, 5.5, or 6 Gy per fraction. Time to local progression (LP), time to distant brain progression (DBP), and overall survival (OS) were calculated. Cox models assessed effect of clinical factors on OS. Fine and Gray's cumulative incidence model for competing events examined effect of factors on LP and DBP. The occurrence of leptomeningeal disease (LMD) was determined. Logistic regression examined predictors of LMD. Results Among 445 patients, median age was 63.5 years; 87% had Karnofsky performance status ≥70. Fifty-three % of patients underwent surgical resection, and 75% received 5 Gy per fraction. Patients with resected BMs had higher Karnofsky performance status (90-100, 41 vs 30%), less extracranial disease (absent, 25 vs 13%), and fewer BMs (multiple, 32 vs 67%). Median diameter of the dominant BM was 3.0 cm (interquartile range, 1.8-3.6 cm) for intact BMs and 4.6 cm (interquartile range, 3.9-5.5 cm) for resected BMs. Median OS was 5.1 months (95% confidence interval [CI], 4.3-6.0) following iHF-SRS and 12.8 months (95% CI, 10.8-16.2) following rHF-SRS (P < .01). Cumulative LP incidence was 14.5% at 18 months (95% CI, 11.4-18.0%), significantly associated with greater total GTV (hazard ratio, 1.12; 95% CI, 1.05-1.20) following iFR-SRS, and with recurrent versus newly diagnosed BMs across all patients (hazard ratio, 2.28; 95% CI, 1.01-5.15). Cumulative DBP incidence was significantly greater following rHF-SRS than iHF-SRS (P = .01), with respective 24-month rates of 50.0 (95% CI, 43.3-56.3) and 35.7% (95% CI, 29.2-42.2). LMD (57 events total; 33% nodular, 67% diffuse) was observed in 17.1% of rHF-SRS and 8.1% of iHF-SRS cases (odds ratio, 2.46; 95% CI, 1.34-4.53). Any radionecrosis and grade 2+ radionecrosis events were observed in 14 and 8% of cases, respectively. Conclusions HF-SRS demonstrated favorable rates of LC and radionecrosis in postoperative and intact settings. Corresponding LMD and RN rates were comparable to those of other studies.
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Affiliation(s)
- David J. Carpenter
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina,Corresponding author: Scott Floyd, MD, PhD
| | | | - Justus D. Adamson
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Peter E. Fecci
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - John H. Sampson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - James E. Herndon
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Jordan A. Torok
- Department of Radiation Oncology, St. Clair Hospital Cancer Center, Pittsburgh, Pennsylvania
| | - Trey C. Mullikin
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Grace J. Kim
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Zachary J. Reitman
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - John P. Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina,Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Scott R. Floyd
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
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Foster RD, Moeller BJ, Robinson M, Bright M, Ruiz JL, Hampton CJ, Heinzerling JH. Dosimetric Analysis of Intra-Fraction Motion Detected by Surface-Guided Radiation Therapy During Linac Stereotactic Radiosurgery. Adv Radiat Oncol 2022; 8:101151. [PMID: 36691448 PMCID: PMC9860342 DOI: 10.1016/j.adro.2022.101151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 12/14/2022] [Indexed: 12/28/2022] Open
Abstract
Purpose Stereotactic radiosurgery (SRS) immobilization with an open face mask is more comfortable and less invasive than frame based, but concerns about intrafraction motion must be addressed. Surface-guided radiation therapy (SGRT) is an attractive option for intrafraction patient monitoring because it is continuous, has submillimeter accuracy, and uses no ionizing radiation. The purpose of this study was to investigate the dosimetric consequences of uncorrected intrafraction patient motion detected during frameless linac-based SRS. Methods and Materials Fifty-five SRS patients were monitored during treatment using SGRT between January 1, 2017, and September 30, 2020. If SGRT detected motion >1 mm, imaging was repeated and the necessary shifts were made before continuing treatment. For the 25 patients with intrafraction 3-dimensional vector shifts of ≥1 mm, we moved the isocenter in the planning system using the translational shifts from the repeat imaging and recalculated the plans to determine the dosimetric effect of the shifts. Planning target volume (PTV) coverage, minimum gross tumor volume (GTV) dose (relative and absolute), and normal brain V12 were evaluated. Wilcoxon signed rank tests were used to compare planned and simulated dosimetric parameters and median 2 sample tests were used to investigate these differences between cone and multileaf collimator (MLC) plans. Results For simulated plans, V12 increased by a median of 0.01 cc (P = .006) and relative GTV minimum dose and PTV coverage decreased by a median of 15.8% (P < .001) and 10.2 % (P < .001), respectively. Absolute minimum GTV dose was found to be significantly lower in the simulated plans (P < .001). PTV coverage decreased more for simulated cone plans than for simulated MLC plans (11.6% vs 4.7%, P = .011) but median V12 differences were found to be significantly larger for MLC plans (-0.34 cc vs -0.01 cc, P = .011). Differences in GTV minimum dose between cone and MLC plans were not statistically significant. Conclusions SGRT detected clinically meaningful intrafraction motion during frameless SRS, which could lead to large underdoses and increased normal brain dose if uncorrected.
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Affiliation(s)
- Ryan D. Foster
- Levine Cancer Institute, Atrium Health, Concord, North Carolina,Corresponding author: Ryan Foster, PhD
| | - Benjamin J. Moeller
- Levine Cancer Institute, Atrium Health and Southeast Radiation Oncology Group, Charlotte, North Carolina
| | - Myra Robinson
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Megan Bright
- Levine Cancer Institute, Atrium Health, Concord, North Carolina
| | - Justin L. Ruiz
- Levine Cancer Institute, Atrium Health, Concord, North Carolina
| | | | - John H. Heinzerling
- Levine Cancer Institute, Atrium Health and Southeast Radiation Oncology Group, Charlotte, North Carolina
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Muacevic A, Adler JR, Liu K, Sandhu N, Blomain E, Binkley MS, Gephart MH, Chang SD, Li GH, Reddy SA, Soltys SG, Pollom E. Intracranial Control With Combination BRAF and MEK Inhibitor Therapy in Patients With Metastatic Melanoma. Cureus 2022; 14:e31838. [PMID: 36579260 PMCID: PMC9788920 DOI: 10.7759/cureus.31838] [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] [Accepted: 11/22/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose/Objectives Combination BRAF (vemurafenib, dabrafenib, or encorafenib) plus MEK (trametinib, cobimetinib, or binimetinib) inhibitor therapy is now widely used in the treatment of metastatic melanoma. However, data for intracranial response to these drugs are limited. We aimed to evaluate the intracranial efficacy of BRAF plus MEK inhibitors in patients with BRAF-mutant melanoma with brain metastases (BM) and to determine patterns of failure of these new agents to inform optimal integration of local intracranial therapy. Materials and methods We retrospectively reviewed charts of patients with BRAF-mutant melanoma with metastasis to the brain with at least one untreated brain metastasis at the time of initiation of BRAF plus MEK inhibitors at our institution from 2006 to 2020. We collected per-patient and per-lesion data on demographics, treatment modality, and outcomes. The cumulative incidence of local (LF), distant intracranial (DF), and extracranial failure (EF) were calculated with competing risk analysis with death as a competing risk and censored at the last brain MRI follow-up. LF was calculated on a per-lesion basis while DF and EF were calculated on a per-patient basis. DF was defined as any new intracranial lesions. Overall survival (OS) was analyzed using Kaplan-Meier. Logistic regression was used to identify predictors for LF. Results We identified 10 patients with 63 untreated brain metastases. The median age was 50.5 years. The median sum of the diameters of the five largest untreated brain metastases per patient was 20 mm (interquartile range 15-39 mm) and the median diameter for all measurable lesions was 4 mm. Median follow-up time was 9.0 months (range 1.4 months-46.2 months). Median OS was 13.6 months. The one-year cumulative incidence of LF, DF, and EF was 17.1%, 88.6, and 71.4%, respectively. The median time to LF, DF, and EF from the start of BRAF plus MEK inhibitors was 9.0 months, 4.7 months, and 7.0 months, respectively. The larger size of the BM was associated with LF on univariate analysis (odds ratio 1.13 per 1 mm increase in diameter, 95% confidence interval 1.019 to 1.308, p<0.02). Two (20%) patients eventually received stereotactic radiosurgery, and 2 (20%) received whole-brain radiotherapy for intracranial progression. Conclusion Although patients with BRAF-mutant melanoma with BM had fair local control on BRAF plus MEK inhibitors, the competing risk of death and distant intracranial and extracranial progression was high. Patients with larger brain metastases may benefit from local therapy.
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Open Source Repository and Online Calculator of Prediction Models for Diagnosis and Prognosis in Oncology. Biomedicines 2022; 10:biomedicines10112679. [DOI: 10.3390/biomedicines10112679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/18/2022] [Accepted: 10/20/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: The main aim was to develop a prototype application that would serve as an open-source repository for a curated subset of predictive and prognostic models regarding oncology, and provide a user-friendly interface for the included models to allow online calculation. The focus of the application is on providing physicians and health professionals with patient-specific information regarding treatment plans, survival rates, and side effects for different expected treatments. (2) Methods: The primarily used models were the ones developed by our research group in the past. This selection was completed by a number of models, addressing the same cancer types but focusing on other outcomes that were selected based on a literature search in PubMed and Medline databases. All selected models were publicly available and had been validated TRIPOD (Transparent Reporting of studies on prediction models for Individual Prognosis Or Diagnosis) type 3 or 2b. (3) Results: The open source repository currently incorporates 18 models from different research groups, evaluated on datasets from different countries. Model types included logistic regression, Cox regression, and recursive partition analysis (decision trees). (4) Conclusions: An application was developed to enable physicians to complement their clinical judgment with user-friendly patient-specific predictions using models that have received internal/external validation. Additionally, this platform enables researchers to display their work, enhancing the use and exposure of their models.
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Hui C, Qu V, Wang JY, von Eyben R, Chang YC, Chiang PL, Liang CH, Lu JT, Li G, Hayden-Gephart M, Wakelee H, Neal J, Ramchandran K, Das M, Nagpal S, Soltys S, Myall N, Pollom E. Local control of brain metastases with osimertinib alone in patients with EGFR-mutant non-small cell lung cancer. J Neurooncol 2022; 160:233-240. [PMID: 36227422 DOI: 10.1007/s11060-022-04145-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/21/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE Although osimertinib has excellent intracranial activity in metastatic non-small cell lung cancer (NSCLC) with exon 19 deletion or L858R EGFR alterations, measures of local control of brain metastases are less well-reported. We describe lesion-level outcomes of brain metastases treated with osimertinib alone. METHODS We retrospectively reviewed patients with EGFR-mutant NSCLC with untreated brain metastasis measuring ≥ 5 mm at the time of initiating osimertinib. Cumulative incidence of local recurrence in brain (LRiB) was calculated with death as a competing risk, and univariable and multivariable analyses were conducted to identify factors associated with LRiB. RESULTS We included 284 brain metastases from 37 patients. Median follow-up was 20.1 months. On initial MRI after starting osimertinib, patient-level response was complete response (CR) in 11 (15%), partial response (PR) in 33 (45%), stable disease (SD) in 18 (25%) and progressive disease (PD) in 11 (15%). The 1-year cumulative incidence of LRiB was 14% (95% CI 9.9-17.9) and was significantly different in patients with a CR (0%), PR (4%), and SD (11%; p = 0.02). Uncontrolled primary tumor (adjusted hazard ratio [aHR] 3.78, 95% CI 1.87-7.66; p < 0.001), increasing number of prior systemic therapies (aHR 2.12, 95% CI 1.49-3.04; p < 0.001), and higher ECOG score (aHR 7.8, 95% CI 1.99-31.81; p = 0.003) were associated with LRiB. CONCLUSIONS Although 1-year cumulative incidence of LRiB is < 4% with a CR or PR, 1-year cumulative incidence of LRiB is over 10% for patients with less than a PR to osimertinib on initial MRI. These patients should be followed closely for need for additional treatment such as stereotactic radiosurgery.
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Affiliation(s)
- Caressa Hui
- Department of Radiation Oncology, Stanford University, Palo Alto, CA, USA
| | - Vera Qu
- Department of Radiation Oncology, Stanford University, Palo Alto, CA, USA
| | - Jen-Yeu Wang
- Department of Radiation Oncology, Stanford University, Palo Alto, CA, USA
| | - Rie von Eyben
- Department of Radiation Oncology, Stanford University, Palo Alto, CA, USA
| | | | | | | | | | - Gordon Li
- Department of Neurosurgery, Stanford University, Palo Alto, CA, USA
| | | | - Heather Wakelee
- Department of Medical Oncology, Stanford University, Palo Alto, CA, USA
| | - Joel Neal
- Department of Medical Oncology, Stanford University, Palo Alto, CA, USA
| | | | - Millie Das
- Department of Medical Oncology, Stanford University, Palo Alto, CA, USA
| | - Seema Nagpal
- Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Scott Soltys
- Department of Radiation Oncology, Stanford University, Palo Alto, CA, USA
| | - Nathaniel Myall
- Department of Medical Oncology, Stanford University, Palo Alto, CA, USA. .,Department of Medical Oncology, Stanford University, 300 Pasteur Dr Rm JC007, Stanford, CA, 94305, USA.
| | - Erqi Pollom
- Department of Radiation Oncology, Stanford University, Palo Alto, CA, USA. .,Department of Radiation Oncology, Stanford University, 875 Blake Wilbur Drive, Stanford, CA, 94305, USA.
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Zero Setup Margin Mask versus Frame Immobilization during Gamma Knife ® Icon™ Stereotactic Radiosurgery for Brain Metastases. Cancers (Basel) 2022; 14:cancers14143392. [PMID: 35884453 PMCID: PMC9320023 DOI: 10.3390/cancers14143392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/07/2022] [Accepted: 07/11/2022] [Indexed: 02/01/2023] Open
Abstract
We compared the clinical outcomes of BM treated with mask immobilization with zero-SM (i.e., zero-PTV) to standard zero-SM frame immobilization SRS. Consecutive patients with BM, 0.5−2.0 cm in maximal diameter, treated with single-fraction SRS (22−24 Gy) during March 2019−February 2021 were included. Univariable and multivariable analysis were performed using the Kaplan−Meier method and Cox proportional hazards regression. A total of 150 patients with 453 BM met inclusion criteria. A total of 129 (28.5%) lesions were treated with a zero-SM mask immobilization and 324 (71.5%) with zero-SM frame immobilization. Frame immobilization treatments were associated with a higher proportion of gastrointestinal and fewer breast-cancer metastases (p = 0.024), and a higher number of treated lesions per SRS course (median 7 vs. 3; p < 0.001). With a median follow up of 15 months, there was no difference in FFLF between the mask and frame immobilization groups on univariable (p = 0.29) or multivariable analysis (p = 0.518). Actuarial FFLF at 1 year was 90.5% for mask and 92% for frame immobilization (p = 0.272). Radiation necrosis rates at 1 year were 12.5% for mask and 4.1% for frame immobilization (p = 0.502). For BM 0.5−2.0 cm in maximal diameter treated with single-fraction SRS using 22−24 Gy, mask immobilization with zero SM produces comparable clinical outcomes to frame immobilization. The initial findings support omitting a SM when using mask immobilization with this treatment approach on a Gamma Knife® Icon™.
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Gondi V, Bauman G, Bradfield L, Burri SH, Cabrera AR, Cunningham DA, Eaton BR, Hattangadi-Gluth JA, Kim MM, Kotecha R, Kraemer L, Li J, Nagpal S, Rusthoven CG, Suh JH, Tomé WA, Wang TJC, Zimmer AS, Ziu M, Brown PD. Radiation Therapy for Brain Metastases: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2022; 12:265-282. [PMID: 35534352 DOI: 10.1016/j.prro.2022.02.003] [Citation(s) in RCA: 102] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/07/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE This guideline provides updated evidence-based recommendations addressing recent developments in the management of patients with brain metastases, including advanced radiation therapy techniques such as stereotactic radiosurgery (SRS) and hippocampal avoidance whole brain radiation therapy and the emergence of systemic therapies with central nervous system activity. METHODS The American Society for Radiation Oncology convened a task force to address 4 key questions focused on the radiotherapeutic management of intact and resected brain metastases from nonhematologic solid tumors. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS Strong recommendations are made for SRS for patients with limited brain metastases and Eastern Cooperative Oncology Group performance status 0 to 2. Multidisciplinary discussion with neurosurgery is conditionally recommended to consider surgical resection for all tumors causing mass effect and/or that are greater than 4 cm. For patients with symptomatic brain metastases, upfront local therapy is strongly recommended. For patients with asymptomatic brain metastases eligible for central nervous system-active systemic therapy, multidisciplinary and patient-centered decision-making to determine whether local therapy may be safely deferred is conditionally recommended. For patients with resected brain metastases, SRS is strongly recommended to improve local control. For patients with favorable prognosis and brain metastases receiving whole brain radiation therapy, hippocampal avoidance and memantine are strongly recommended. For patients with poor prognosis, early introduction of palliative care for symptom management and caregiver support are strongly recommended. CONCLUSIONS The task force has proposed recommendations to inform best clinical practices on the use of radiation therapy for brain metastases with strong emphasis on multidisciplinary care.
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Affiliation(s)
- Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center and Proton Center, Warrenville, Illinois.
| | - Glenn Bauman
- Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre & Western University, London, Ontario, Canada
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Stuart H Burri
- Department of Radiation Oncology, Atrium Health, Charlotte, North Carolina
| | - Alvin R Cabrera
- Department of Radiation Oncology, Kaiser Permanente, Seattle, Washington
| | | | - Bree R Eaton
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | | | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | | | - Jing Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Seema Nagpal
- Division of Neuro-oncology, Department of Neurology, Stanford University, Stanford, California
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - John H Suh
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Wolfgang A Tomé
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Tony J C Wang
- Department of Radiation Oncology, Columbia University, New York, New York
| | - Alexandra S Zimmer
- Women's Malignancies Branch, National Institutes of Health/National Cancer Institute, Bethesda, Maryland
| | - Mateo Ziu
- Department of Neurosciences, INOVA Neuroscience and INOVA Schar Cancer Institute, Falls Church, Virginia
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Cui T, Weiner J, Danish S, Chundury A, Ohri N, Yue N, Wang X, Nie K. Evaluation of Biological Effective Dose in Gamma Knife Staged Stereotactic Radiosurgery for Large Brain Metastases. Front Oncol 2022; 12:892139. [PMID: 35847934 PMCID: PMC9280470 DOI: 10.3389/fonc.2022.892139] [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: 03/08/2022] [Accepted: 05/31/2022] [Indexed: 11/16/2022] Open
Abstract
Objective Gamma knife (GK) staged stereotactic radiosurgery (Staged-SRS) has become an effective treatment option for large brain metastases (BMs); however, it has been challenging to evaluate the total dose because of tumor shrinkage between two staged sessions. This study aims to evaluate total biological effective dose (BED) in Staged-SRS, and to compare the BED with those in single-fraction SRS (SF-SRS) and hypo-fractionated SRS (HF-SRS). Methods Patients treated with GK Staged-SRS at a single institution were retrospectively included. The dose delivered in two sessions of Staged-SRS was summed using the deformable image registration. Each patient was replanned for SF-SRS and HF-SRS. The total BEDs were computed using the linear-quadratic model. Tumor BED98% and brain V84Gy2, equivalent to V12Gy in SF-SRS, were compared between SF-SRS, HF-SRS, and Staged-SRS plans with the Wilcoxon test. Results Twelve patients with 24 BMs treated with GK Staged-SRS were identified. We observed significant differences (p < 0.05) in tumor BED98% but comparable brain V84Gy2 (p = 0.677) between the Staged-SRS and SF-SRS plans. No dosimetric advantages of Staged-SRS over HF-SRS were observed. Tumor BED98% in the HF-SRS plans were significantly higher than those in the Staged-SRS plans (p < 0.05). Despite the larger PTVs, brain V84Gy2 in the HF-SRS plans remained lower (p < 0.05). Conclusion We presented an approach to calculate the composite BEDs delivered to both tumor and normal brain tissue in Staged-SRS. Compared to SF-SRS, Staged-SRS delivers a higher dose to tumor but maintains a comparable dose to normal brain tissue. Our results did not show any dosimetric advantages of Staged-SRS over HF-SRS.
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Affiliation(s)
- Taoran Cui
- Rutgers Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States
- *Correspondence: Taoran Cui,
| | - Joseph Weiner
- Rutgers Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States
| | - Shabbar Danish
- Jersey Shore University Medical Center (JSUMC), Neptune, NJ, United States
| | - Anupama Chundury
- Rutgers Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States
| | - Nisha Ohri
- Rutgers Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States
| | - Ning Yue
- Rutgers Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States
| | - Xiao Wang
- Rutgers Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States
| | - Ke Nie
- Rutgers Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States
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Leyrat B, Khalill T, Lemaire JJ, Casile M, Molnar I, Dedieu V, Chassin V, Dupic G, Bellière A, Durando X, Lapeyre M, Verrelle P, Biau J. Local control and radionecrosis of brain metastases from non– small-cell lung cancer treated by hypofractionated stereotactic radiotherapy: Evaluation of predictive factors. Clin Transl Radiat Oncol 2022; 36:1-8. [PMID: 35733828 PMCID: PMC9207219 DOI: 10.1016/j.ctro.2022.05.008] [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: 11/30/2021] [Revised: 05/30/2022] [Accepted: 05/30/2022] [Indexed: 11/26/2022] Open
Abstract
First study on brain metastases 3-fraction SRT from a homogeneous population of NSCLC, according to French MF-SRT recommendations. MF-SRT with 3x7.7 Gy on the 70% isodose line and PTV = GTV + 2 mm leads to high local control rates in this population, with acceptable rates of radionecrosis. GTV Dmin ≥ 27.4 Gy leads to higher local control. Dyslipidemia could be involved in radionecrosis appearance.
Background The objective of our study was to report predictive factors of local control (LC) and radionecrosis (RN) of brain metastases (BM) of non-small cell lung carcinoma (NSCLC) treated by multifractionated stereotactic radiotherapy (MF-SRT) according to French recommendations. Method From 2012 to 2020, 87 patients with 101 BM were retrospectively included. The median age was 63 years (37–85). GTV was defined using contrast-enhanced T1w MRI and was isotropically extended by 2 mm to form PTV. Mean maximum BM diameter was 24.5 mm (10–46). Patients were treated with dynamic arctherapy from May 2012 to February 2016 and then with VMAT. The total prescribed dose was 23.1 Gy prescribed to the encompassing 70% isodose, in 3 fractions. Results LC rates at 6 months, 1 year and 2 years was 95.7%, 90.7% and 87.9% respectively. In multivariate analysis, high GTV Dmin (HR = 0.822, p = 0.012) was in favor of better LC whereas a large maximum diameter was predictive of poor LC (HR = 1.124, p = 0.02). GTV Dmin of 27.4 Gy was identified as a discriminant threshold of LC. In case of GTV Dmin ≥ 27.4 Gy, LC at 1 year was 95.3% versus 75.1% with GTV Dmin < 27.4 Gy. Cumulative incidence of RN at 6 months, 1 year and 2 years was 6.3%, 15.4% and 18.1%, respectively. In multivariate analysis, only dyslipidemia was predictive of RN (HR = 2.69, p = 0.03). No dosimetric predictive factor of RN was found in our study. Conclusion MF-SRT (3x7.7 Gy on 70% isodose line, with PTV = GTV + 2 mm; according to French recommendations) of BM from NSCLC gives high LC rates with acceptable RN rate. A GTV Dmin of at least 27.4 Gy could be proposed to optimize dosimetric objectives. No dosimetric predictive factors of RN were found in this study. However, dyslipidemia was identified as a potential predictive factor of RN.
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Chang S, Liu G, Zhao L, Zheng W, Yan D, Chen P, Li X, Yang K, Deraniyagala R, Stevens C, Grills I, Chinnaiyan P, Li X, Ding X. Redefine the Role of Spot-Scanning Proton Beam Therapy for the Single Brain Metastasis Stereotactic Radiosurgery. Front Oncol 2022; 12:804036. [PMID: 35664795 PMCID: PMC9160604 DOI: 10.3389/fonc.2022.804036] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 04/14/2022] [Indexed: 12/30/2022] Open
Abstract
Purpose To explore the role of using Pencil Beam Scanning (PBS) proton beam therapy in single lesion brain stereotactic radiosurgery (SRS), we developed and validated a dosimetric in silico model to assist in the selection of an optimal treatment approach among the conventional Volumetric Modulated Arc Therapy (VMAT), Intensity Modulated Proton Therapy (IMPT) and Spot-scanning Proton Arc (SPArc). Material and Methods A patient’s head CT data set was used as an in silico model. A series of targets (volume range from 0.3 cc to 33.03 cc) were inserted in the deep central and peripheral region, simulating targets with different sizes and locations. Three planning groups: IMPT, VMAT, and SPArc were created for dosimetric comparison purposes and a decision tree was built based on this in silico model. Nine patients with single brain metastases were retrospectively selected for validation. Multiple dosimetric metrics were analyzed to assess the plan quality, such as dose Conformity Index (CI) (ratio of the target volume to 100% prescription isodose volume); R50 (ratio of 50% prescription isodose volume to the target volume); V12Gy (volume of brain tissue minus GTV receiving 12 Gy), and mean dose of the normal brain. Normal tissue complication probability (NTCP) of brain radionecrosis (RN) was calculated using the Lyman-Kutcher-Burman (LKB) model and total treatment delivery time was calculated. Six physicians from different institutions participated in the blind survey to evaluate the plan quality and rank their choices. Results The study showed that SPArc has a dosimetric advantage in the V12Gy and R50 with target volumes > 9.00 cc compared to VMAT and IMPT. A significant clinical benefit can be found in deep centrally located lesions larger than 20.00 cc using SPArc because of the superior dose conformity and mean dose reduction in healthy brain tissue. Nine retrospective clinical cases and the blind survey showed good agreement with the in silico dosimetric model and decision tree. Additionally, SPArc significantly reduced the treatment delivery time compared to VMAT (SPArc 184.46 ± 59.51s vs. VMAT: 1574.78 ± 213.65s). Conclusion The study demonstrated the feasibility of using Proton beam therapy for single brain metastasis patients utilizing the SPArc technique. At the current stage of technological development, VMAT remains the current standard modality of choice for single lesion brain SRS. The in silico dosimetric model and decision tree presented here could be used as a practical clinical decision tool to assist the selection of the optimal treatment modality among VMAT, IMPT, and SPArc in centers that have both photon and proton capabilities.
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Affiliation(s)
- Sheng Chang
- Department of Radiation Oncology, Renmin Hospital, Wuhan University, Wuhan, China
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Gang Liu
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lewei Zhao
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Weili Zheng
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Di Yan
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Peter Chen
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Xiangpan Li
- Department of Radiation Oncology, Renmin Hospital, Wuhan University, Wuhan, China
| | - Kunyu Yang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rohan Deraniyagala
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Craig Stevens
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Inga Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Prakash Chinnaiyan
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Xiaoqiang Li
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
- *Correspondence: Xuanfeng Ding,
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Brachytherapy for central nervous system tumors. J Neurooncol 2022; 158:393-403. [PMID: 35546384 DOI: 10.1007/s11060-022-04026-3] [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: 03/14/2022] [Accepted: 04/28/2022] [Indexed: 10/18/2022]
Abstract
Radiation is a mainstay of treatment for central nervous system (CNS) tumors. Brachytherapy involves the placement of a localized/interstitial radiation source into a tumor or resection bed and has distinct advantages that can make it an attractive form of radiation when used in the appropriate setting. However, the data supporting use of brachytherapy is clouded by variability in radiation sources, techniques, delivered doses, and trial designs. The goal of this manuscript is to identify consistent themes, review the highest-level evidence and potential indications for brachytherapy in CNS tumors, as well as highlight avenues for future work. Improved understanding of the underlying biology, indications, complications, and evolving industry-academic collaborations, place brachytherapy on the brink of a resurgence.
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Wei Z, Niranjan A, Abou-Al-Shaar H, Deng H, Albano L, Lunsford LD. A volume matched comparison of survival after radiosurgery in non-small cell lung cancer patients with one versus more than twenty brain metastases. J Neurooncol 2022; 157:417-423. [PMID: 35316437 DOI: 10.1007/s11060-022-03981-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 03/04/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Treatment of patients with a large number of brain metastases using radiosurgery remains controversial. In this study we sought to conduct a volume matched comparison to evaluate the clinical outcome of patients with > 20 brain metastases and compared it with patents with solitary brain tumor form non-small cell lung cancer (NSCLC). METHODS Between 2014 and 2020, 26 NSCLC patients (925 tumors) underwent stereotactic radiosurgery (SRS) for > 20 metastases in a single procedure (median margin dose = 16 Gy, median cumulative tumor volume = 4.52 cc); 56 patients underwent SRS for a single metastasis (median margin dose = 18 Gy, median volume = 4.74 cc). The overall survival (OS), local tumor control (LC), adverse radiation effect (ARE) risk, and incidence of new tumor development were compared. RESULTS No difference in OS was found between patients with > 20 brain metastases (median OS = 15 months) and patients with solitary metastasis (median OS = 12 months; p = 0.3). In the solitary tumor cohort, two of 56 (3.5%) tumors progressed whereas in the > 20 cohort only 3 of 925 (0.3%) tumors showed progression (*p = 0.0013). The rate of new tumor development was significantly higher in patients with > 20 tumors (***p = 0.0001). No significant difference of ARE rate was found (7.5% for > 20 tumors vs. 8.7% for single metastasis). CONCLUSIONS Patients with > 20 tumors showed significantly better LC with similar OS compared to patients with solitary tumors. Current guidelines that restrict the role of SRS to patients with 1-4 tumors should be revised.
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Affiliation(s)
- Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, 15213, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, 15213, USA.
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, 15213, USA
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, 15213, USA
| | - Luigi Albano
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, 15213, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, 15213, USA
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Kim JH, Choi JW, Kong DS, Seol HJ, Nam DH, Ryu JW, Kim ST, Suh YL, Lee JI. Histopathology and surgical outcome of symptomatic treatment-related changes after gamma knife radiosurgery in patients with brain metastases. Sci Rep 2022; 12:3013. [PMID: 35194082 PMCID: PMC8863779 DOI: 10.1038/s41598-022-06881-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 02/07/2022] [Indexed: 01/07/2023] Open
Abstract
A late-onset treatment-related changes (TRCs), which represent radiographic radiation necrosis (RN), frequently occur after stereotactic radiosurgery (SRS) for brain metastases and often need surgical treatment. This study aimed to validate the true pathology and investigate clinical implication of surgically resected TRCs on advanced magnetic resonance imaging (MRI). Retrospective analyses of 86 patients who underwent surgical resection after radiosurgery of brain metastases were performed. Fifty-four patients displayed TRCs on preoperative MRI, comprising pure RN in 19 patients (TRC-RN group) and mixed viable tumor cells in 35 patients (TRC-PD group). Thirty-two patients revealed the consistent diagnosis of progressive disease in both MRI and histopathology (PD-PD group). The TRC-PD group showed larger prescription isodose volume (9.4 cm3) than the TRC-RN (4.06 cm3, p = 0.014) group and a shorter time interval from SRS to preoperative MRI diagnosis (median 4.07 months) than the PD-PD group (median 8.77 months, p = 0.004). Progression-free survival was significantly different among the three groups (p < 0.001), but not between TRC-RN and TRC-PD (post hoc test, p = 1.00), while no difference was observed in overall survival (p = 0.067). Brain metastases featured as TRCs after SRS frequently contained viable tumor cells. However, this histologic heterogeneity had a minor impact on benign local prognosis of TRCs after surgical resection.
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Affiliation(s)
- Jeong-Hwa Kim
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Jung-Won Choi
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Jae-Wook Ryu
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung-Tae Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yeon-Lim Suh
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
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Sarmey N, Kaisman-Elbaz T, Mohammadi AM. Management Strategies for Large Brain Metastases. Front Oncol 2022; 12:827304. [PMID: 35251995 PMCID: PMC8894177 DOI: 10.3389/fonc.2022.827304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Brain metastases represent the most common intracranial neoplasm and pose a significant disease burden on the individual and the healthcare system. Although whole brain radiation therapy was historically a first line approach, subsequent research and technological advancements have resulted in a larger armamentarium of strategies for treatment of these patients. While chemotherapeutic options remain limited, surgical resection and stereotactic radiosurgery, as well as their combination therapies, have shifted the paradigms for managing intracranial metastatic disease. Ultimately, no single treatment is shown to be consistently effective across patient groups in terms of overall survival, local and distant control, neurocognitive function, and performance status. However, close consideration of patient and tumor characteristics may help delineate more favorable treatment strategies for individual patients. Here the authors present a review of the recent literature surrounding surgery, whole brain radiation therapy, stereotactic radiosurgery, and combination approaches.
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Improving on whole-brain radiotherapy in patients with large brain metastases: A planning study to support the AROMA clinical trial. Radiother Oncol 2022; 170:176-183. [PMID: 35182688 DOI: 10.1016/j.radonc.2022.02.011] [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: 10/11/2021] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE To develop a novel dose-escalated volumetric modulated arc therapy (VMAT) strategy for patients with single or multiple large brain metastases which can deliver a higher dose to individual lesions for better local control (LC), and to compare dosimetry between whole brain radiotherapy (WBRT), hippocampal-sparing whole brain radiotherapy (HS-WBRT) and different VMAT-based focal radiotherapy approaches. METHODS AND MATERIALS We identified 20 patients with one to ten brain metastases and at least one lesion larger than 15 cm3 who had received WBRT as part of routine care. For each patient, we designed and evaluated five radiotherapy treatment plans, including WBRT, HS-WBRT and three VMAT dosing models. A dose of 20 Gy in 5 fractions was prescribed to the whole brain or target volumes depending on the plan, with higher doses to smaller lesions and dose-escalated inner planning target volumes (DE-iPTV) in VMAT plans, respectively. Treatment plans were evaluated using the efficiency index, mean dose and D0.1cc to the target volumes and organs at risk. RESULTS Compared with WBRT, VMAT plans achieved a significantly more efficient dose distribution in brain lesions, especially with our DE-iPTV model, while minimising the dose to the normal brain and other organs at risks (OARs) (p < 0.05). CONCLUSIONS VMAT plans obtained higher doses to brain metastases and minimised doses to OARs. Dose-escalated VMAT for larger lesions allows higher radiotherapy doses to be delivered to larger lesions while maintaining safe doses to OARs.
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Kirkpatrick JP. Answering the Big Clinical Questions in Brain Metastasis Management. Front Oncol 2022; 11:834122. [PMID: 35118002 PMCID: PMC8805701 DOI: 10.3389/fonc.2021.834122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/27/2021] [Indexed: 11/30/2022] Open
Abstract
Management of brain metastases is challenging, both because of the historically guarded prognosis and evolving, more efficacious treatment paradigms for metastatic cancer. This perspective addresses several of the important difficult questions that practitioners treating patients with brain tumors face in the clinic. Successfully answering these questions requires knowledge of the clinical evidence, thoughtful discussion of the patient’s goals of care and collaboration in a multi-disciplinary setting.
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Affiliation(s)
- John P. Kirkpatrick
- Department of Radiation Oncology, Duke Cancer Institute, Durham, NC, United States
- Department of Neurosurgery, Duke Cancer Institute, Durham, NC, United States
- *Correspondence: John P. Kirkpatrick,
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Gutiérrez-Valencia E, Kalyvas A, Villafuerte CJ, Millar BA, Laperriere N, Conrad T, Berlin A, Weiss J, Zadeh G, Bernstein M, Kongkham P, Shultz DB. OUP accepted manuscript. Neuro Oncol 2022; 24:1925-1934. [PMID: 35474015 PMCID: PMC9629433 DOI: 10.1093/neuonc/noac106] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We sought to identify variates correlating with overall survival (OS) in patients treated with surgery (S) plus adjuvant stereotactic radiosurgery (SRS) versus definitive SRS for large (>4 cc) brain metastases (BrM). METHODS We used univariate (UVA) and multivariate analyses (MVA) to identify survival correlates among eligible patients identified from a prospective registry and compared definitive SRS to S+ adjuvant SRS cohorts using propensity score-matched analysis (PSMA). Secondary outcomes were measured using the cumulative incidence (CI) method. RESULTS We identified 364 patients; 127 and 237 were treated with S+SRS and definitive SRS, respectively. On UVA, SRS alone [HR1.73 (1.35,2.22) P < .001), BrM quantity [HR 1.13 (1.06-1.22) (P < .001)]; performance status (PS) [HR 2.78 (1.73-4.46) (P < .001)]; extracranial disease (ECD) [HR 1.82 (1.37,2.40) (P < .001)]; and receipt of systemic treatment after BrM therapy, [HR 0.58 (0.46-073) (P < .001)] correlated with OS. On MVA, SRS alone [HR 1.81 (1.19,2.74) (P < .0054)], SRS target volume [HR 1.03 (1.01,1.06) (P < .0042)], and receipt of systemic treatment [HR 0.68 (0.50,0.93) (P < .015)] correlated with OS. When PSMA was used to balance ECD, BrM quantity, PS, and SRS target volume, SRS alone remained correlated with worsened OS [HR 1.62 (1.20-2.19) (P = 0.0015)]. CI of local failure requiring resection at 12 months was 3% versus 7% for S+SRS and SRS cohorts, respectively [(HR 2.04 (0.89-4.69) (P = .091)]. CI of pachymeningeal failure at 12 months was 16% versus 0% for S+SRS and SRS. CONCLUSION SRS target volume, receipt of systemic therapies, and treatment with S+SRS instead of definitive SRS correlated with improved survival in patients with large BrM.
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Affiliation(s)
| | | | - Conrad J Villafuerte
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Barbara-Ann Millar
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Normand Laperriere
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Tatiana Conrad
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jessica Weiss
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, Toronto Western Hospital - University of Toronto, Toronto, ON, Canada
| | - Mark Bernstein
- Division of Neurosurgery, Toronto Western Hospital - University of Toronto, Toronto, ON, Canada
| | | | - David B Shultz
- Corresponding Author: David B. Shultz, MD, PhD, FRCPC, Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, 7th Floor of Ontario Power Generation (OPG) Building, Room 7–401, 700 University Avenue, Toronto, ON M5G 2M9, Canada ()
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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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Roshchina KE, Bekyashev AK, Gasparyan TG, Aleshin VA, Osinov IK, Savateev AN, Khalafyan DA. Modern possibilities of neurosurgical treatment of brain metastases. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:119-125. [PMID: 36252202 DOI: 10.17116/neiro202286051119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Despite significant progress in neuroimaging and introduction of new combined treatments for solid tumors, brain metastases are still adverse factor for overall survival. Brain metastases are diagnosed in 8-10% of patients and associated with extremely poor prognosis. These lesions result focal and general cerebral symptoms. Literature review highlights the current principles of surgical treatment of metastatic brain lesions in patients with solid tumors.
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Affiliation(s)
- K E Roshchina
- Blokhin National Medical Research Center of Oncology, Moscow, Russia
| | - A Kh Bekyashev
- Blokhin National Medical Research Center of Oncology, Moscow, Russia
- Russian Medical Academy for Continuous Professional Education, Moscow, Russia
| | - T G Gasparyan
- Blokhin National Medical Research Center of Oncology, Moscow, Russia
- Scientific Center of Neurology, Moscow, Russia
| | - V A Aleshin
- Blokhin National Medical Research Center of Oncology, Moscow, Russia
| | - I K Osinov
- Burdenko Neurosurgical Center, Moscow, Russia
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Kawahara D, Nagata Y, Watanabe Y. Improved cellular automata model shows that indirect apoptotic cell death due to vascular damage enhances the local control of tumors by single fraction high-dose irradiation. Biomed Phys Eng Express 2021; 8. [PMID: 34920444 DOI: 10.1088/2057-1976/ac4466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/17/2021] [Indexed: 11/11/2022]
Abstract
We investigated the effects of indirect apoptotic cell death due to vascular damage on tumor response to a single large dose with an improved two-dimensional cellular automata model. The tumor growth was simulated by considering the oxygen and nutrients supplied to the tumor through the blood vessels. The cell damage processes were modeled by taking account of the direct cell death and the indirect death due to the radiation-induced vascular damages. The radiation increased the permeation of oxygen and nutrients through the blood vessel or caused the breakdown of the vasculature. The amount of oxygen in cancer cells affected the response of cancer cells to radiation and the tumor growth rate after irradiation. The lack of oxygen led to the apoptotic death of cancer cells. We calculated the tumor control probability (TCP) at different radiation doses, the probability of apoptotic death, the threshold of the oxygen level for indirect apoptotic death, the average oxygen level in cancer cells and the vessel survival probability after radiation damage. Due to the vessel damage, indirect cell death led to a 4% increase in TCP for the dose ranging from 15 Gy to 20 Gy. TCP increased with increasing the probability of apoptotic death and the threshold of the oxygen level for indirect apoptotic death due to increased apoptotic death. The variation of TCP as a function of the average oxygen level exhibited the minimum at the average oxygen level of 2.7%. The apoptosis increased as the average oxygen level decreased, leading to an increasing TCP. On the other hand, the direct radiation damage increased, and the apoptosis decreased for higher average oxygen level, resulting in a higher TCP. We showed by modeling the radiation damage of blood vessels in a 2D CA simulation that the indirect apoptotic death of cancer cells, caused by the reduction of the oxygen level due to vascular damage after high dose irradiation, increased TCP.
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Affiliation(s)
- Daisuke Kawahara
- Department of Radiation Oncology, Institute of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima City, Hiroshima 734-8551, Japan
| | - Yasushi Nagata
- Department of Radiation Oncology, Institute of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima City, Hiroshima 734-8551, Japan
| | - Yoichi Watanabe
- Department of Radiation Oncology, University of Minnesota-Twin Cities, 420 Delaware St. SE, MMC494, Minneapolis, MN, 55455, United States of America
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Loo M, Clavier JB, Attal Khalifa J, Moyal E, Khalifa J. Dose-Response Effect and Dose-Toxicity in Stereotactic Radiotherapy for Brain Metastases: A Review. Cancers (Basel) 2021; 13:cancers13236086. [PMID: 34885193 PMCID: PMC8657210 DOI: 10.3390/cancers13236086] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 11/29/2022] Open
Abstract
Simple Summary Brain metastases are one of the most frequent complications for cancer patients. Stereotactic radiosurgery is considered a cornerstone treatment for patients with limited brain metastases and the ideal dose and fractionation schedule still remain unknown. The aim of this literature review is to discuss the dose-effect relation in brain metastases treated by stereotactic radiosurgery, accounting for fractionation and technical considerations. Abstract For more than two decades, stereotactic radiosurgery has been considered a cornerstone treatment for patients with limited brain metastases. Historically, radiosurgery in a single fraction has been the standard of care but recent technical advances have also enabled the delivery of hypofractionated stereotactic radiotherapy for dedicated situations. Only few studies have investigated the efficacy and toxicity profile of different hypofractionated schedules but, to date, the ideal dose and fractionation schedule still remains unknown. Moreover, the linear-quadratic model is being debated regarding high dose per fraction. Recent studies shown the radiation schedule is a critical factor in the immunomodulatory responses. The aim of this literature review was to discuss the dose–effect relation in brain metastases treated by stereotactic radiosurgery accounting for fractionation and technical considerations. Efficacy and toxicity data were analyzed in the light of recent published data. Only retrospective and heterogeneous data were available. We attempted to present the relevant data with caution. A BED10 of 40 to 50 Gy seems associated with a 12-month local control rate >70%. A BED10 of 50 to 60 Gy seems to achieve a 12-month local control rate at least of 80% at 12 months. In the brain metastases radiosurgery series, for single-fraction schedule, a V12 Gy < 5 to 10 cc was associated to 7.1–22.5% radionecrosis rate. For three-fractions schedule, V18 Gy < 26–30 cc, V21 Gy < 21 cc and V23 Gy < 5–7 cc were associated with about 0–14% radionecrosis rate. For five-fractions schedule, V30 Gy < 10–30 cc, V 28.8 Gy < 3–7 cc and V25 Gy < 16 cc were associated with about 2–14% symptomatic radionecrosis rate. There are still no prospective trials comparing radiosurgery to fractionated stereotactic irradiation.
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Affiliation(s)
- Maxime Loo
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
- Correspondence:
| | - Jean-Baptiste Clavier
- Radiotherapy Department, Strasbourg Europe Cancer Institute (ICANS), 67033 Strasbourg, France;
| | - Justine Attal Khalifa
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
| | - Elisabeth Moyal
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
| | - Jonathan Khalifa
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
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Yusuf M, Rattani A, Gaskins J, Oliver AL, Mandish SF, Burton E, May ME, Williams B, Ding D, Sharma M, Miller D, Woo S. Stereotactic radiosurgery for melanoma brain metastases: dose-size response relationship in the era of immunotherapy. J Neurooncol 2021; 156:163-172. [PMID: 34807342 PMCID: PMC8606626 DOI: 10.1007/s11060-021-03899-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 11/11/2021] [Indexed: 10/26/2022]
Abstract
PURPOSE/OBJECTIVE(S) To determine, for intact melanoma brain metastases (MBM) treated with single-fraction stereotactic radiosurgery (SRS), whether planning parameter peripheral dose per lesion diameter (PDLDm, Gy/mm) and lesion control (LC) differs with versus without immunotherapy (IO). MATERIALS/METHODS We performed a retrospective analysis of patients with intact MBM treated with SRS from 2008 to 2019. Cox-frailty models were constructed to include confounders selected by penalized Cox regression models with a LASSO selector. Interaction effect testing was used to determine whether a significant effect between IO and PDLDm could be demonstrated with respect to LC. RESULTS The study cohort comprised 67 patients with 244 MBMs treated with SRS (30 patients with 122 lesions treated with both SRS and IO) were included. The logarithm of PDLDm was selected as a predictor of LC (HR 0.307, 95% CI 0.098-0.441), adjusting for IO receipt (HR 0.363, 95% CI 0.108-1.224). Interaction effect testing demonstrated a differential effect of PDLDm by IO receipt, with respect to LC (p = 0.048). Twelve-month LC rates for a 7.5 mm lesion receiving SRS (18 Gy) with IO versus without IO were 87.8% (95% CI 69.0-98.3%) versus 79.8% (95% CI 55.1-93.8%) respectively. CONCLUSION PDLDm predicted LC in patients with small MBMs treated with single-fraction SRS. We found a differential effect of dose per lesion size and LC by immunotherapy receipt. Future studies are needed to determine whether lower doses of single-fraction SRS afford similarly effective LC for patients with small MBMs receiving immunotherapy.
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Affiliation(s)
- Mehran Yusuf
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Abbas Rattani
- Department of Radiation Oncology, School of Medicine, University of Louisville Hospital, 529 S. Jackson St, Louisville, KY, 40202, USA.
| | - Jeremy Gaskins
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY, USA
| | | | - Steven F Mandish
- Department of Radiation Oncology, School of Medicine, University of Louisville Hospital, 529 S. Jackson St, Louisville, KY, 40202, USA
| | - Eric Burton
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Michael E May
- Department of Radiation Oncology, School of Medicine, University of Louisville Hospital, 529 S. Jackson St, Louisville, KY, 40202, USA
| | - Brian Williams
- Department of Neurosurgery, University of Louisville Hospital, Louisville, KY, USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville Hospital, Louisville, KY, USA
| | - Mayur Sharma
- Department of Neurosurgery, University of Louisville Hospital, Louisville, KY, USA
| | - Donald Miller
- Department of Medical Oncology, University of Louisville Hospital, Louisville, KY, USA
| | - Shiao Woo
- Department of Radiation Oncology, School of Medicine, University of Louisville Hospital, 529 S. Jackson St, Louisville, KY, 40202, USA
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Benson KRK, Sandhu N, Zhang C, Ko R, Toesca DAS, Lee PE, Von Eyben R, Diehn M, Gensheimer M, Maxim PG, Bush K, Loo BW, Soltys SG, Pollom EL, Chang DT. Local Recurrence Outcomes of Colorectal Cancer Oligometastases Treated With Stereotactic Ablative Radiotherapy. Am J Clin Oncol 2021; 44:559-564. [PMID: 34534143 DOI: 10.1097/coc.0000000000000864] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE The aim of this study was to report local failure (LF) outcomes and associated predictors in patients with oligometastatic colorectal cancer (CRC) treated with stereotactic ablative radiotherapy (SABR). MATERIALS AND METHODS We retrospectively reviewed patients with CRC metastases to the brain, liver, spine, or lung treated with SABR between 2001 and 2016. Time to LF was summarized using cumulative incidence of LF curves with death as a competing risk. RESULTS The analysis included a total of 130 patients and 256 lesions. Of the metastases treated, 129 (50%) were brain, 50 (20%) liver, 49 (19%) spine, and 28 (11%) lung. Median gross tumor volume was 24 mL for liver metastases, 2 mL for brain metastases, 4 mL for spine metastases, and 1 mL for lung metastases. The overall 1, 2, and 3-year cumulative incidence of LF rates were 21.6% (16.5, 27.1), 28.2% (22.3, 34.4), and 31.5% (25.2, 38.0), respectively. LF was highest among the liver metastases (1 y: 26.0%, 2 y: 38.5%), followed by spine (1 y: 25.1%, 2 y: 31.1%), brain (1 y: 20%, 2 y: 25.2%), and lung (1 y: 13.7%, 2 y: insufficient data). Metastases from right-sided primary CRC were significantly more likely to have LF (P=0.0146, HR=2.23). Biologically effective dose>70 Gy, defined using a standard linear quadratic model using α/β ratio of 10 on the individual lesion level, and pre-SABR chemotherapy were also significant predictors of LF (P= 0.0009 and 0.018, respectively). CONCLUSIONS CRC metastases treated with SABR had significantly higher rates of LF if they originated from right-sided primary CRC, compared with left-sided. Liver metastases had the highest rates of LF compared with other metastatic sites. Thus, CRC liver metastases and metastases from right-sided CRC may benefit from more aggressive radiotherapy.
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Affiliation(s)
- Kathryn R K Benson
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA
| | - Navjot Sandhu
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA
| | - Carrie Zhang
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA
| | - Ryan Ko
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA
| | - Diego A S Toesca
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA
| | - Phoebe E Lee
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA
| | - Rie Von Eyben
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA
| | - Maximilian Diehn
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA
| | - Michael Gensheimer
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA
| | - Peter G Maxim
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN
| | - Karl Bush
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA
| | - Billy W Loo
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA
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Park SJ, Lim SH, Kim YJ, Moon KS, Kim IY, Jung S, Kim SK, Oh IJ, Hong JH, Jung TY. The Tumor Control According to Radiation Dose of Gamma Knife Radiosurgery for Small and Medium-Sized Brain Metastases from Non-Small Cell Lung Cancer. J Korean Neurosurg Soc 2021; 64:983-994. [PMID: 34689476 PMCID: PMC8590918 DOI: 10.3340/jkns.2021.0165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/07/2021] [Indexed: 11/27/2022] Open
Abstract
Objective The effectiveness of gamma knife radiosurgery (GKR) in the treatment of brain metastases is well established. The aim of this study was to evaluate the efficacy and safety of maximizing the radiation dose in GKR and the factors influencing tumor control in cases of small and medium-sized brain metastases from non-small cell lung cancer (NSCLC).
Methods We analyzed 230 metastatic brain tumors less than 5 mL in volume in 146 patients with NSCLC who underwent GKR. The patients had no previous radiation therapy for brain metastases. The pathologies of the tumors were adenocarcinoma (n=207), squamous cell carcinoma (n=18), and others (n=5). The radiation doses were classified as 18, 20, 22, and 24 Gy, and based on the tumor volume, the tumors were categorized as follows : small-sized (less than 1 mL) and medium-sized (1–3 and 3–5 mL). The progression-free survival (PFS) of the individual 230 tumors and 146 brain metastases was evaluated after GKR depending on the pathology, Eastern Cooperative Oncology Group (ECOG) performance score (PS), tumor volume, radiation dose, and anti-cancer regimens. The radiotoxicity after GKR was also evaluated.
Results After GKR, the restricted mean PFS of individual 230 tumors at 24 months was 15.6 months (14.0–17.1). In small-sized tumors, as the dose of radiation increased, the tumor control rates tended to increase (p=0.072). In medium-sized tumors, there was no statistically difference in PFS with an increase of radiation dose (p=0.783). On univariate analyses, a statistically significant increase in PFS was associated with adenocarcinomas (p=0.001), tumors with ECOG PS 0 (p=0.005), small-sized tumors (p=0.003), radiation dose of 24 Gy (p=0.014), synchronous lesions (p=0.002), and targeted therapy (p=0.004). On multivariate analyses, an improved PFS was seen with targeted therapy (hazard ratio, 0.356; 95% confidence interval, 0.150–0.842; p=0.019). After GKR, the restricted mean PFS of brain at 24 months was 9.8 months (8.5–11.1) in 146 patients, and the pattern of recurrence was mostly distant within the brain (66.4%). The small and medium-sized tumors treated with GKR showed radiotoxicitiy in five out of 230 tumors (2.2%), which were controlled with medical treatment.
Conclusion The small-sized tumors were effectively controlled without symptomatic radiation necrosis as the radiation dose was increased up to 24 Gy. The medium-sized tumors showed potential for symptomatic radiation necrosis without signifcant tumor control rate, when greater than 18 Gy. GKR combined targeted therapy improved the tumor control of GKR-treated tumors.
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Affiliation(s)
- Sue Jee Park
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Sa-Hoe Lim
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Young-Jin Kim
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Kyung-Sub Moon
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - In-Young Kim
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Shin Jung
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Seul-Kee Kim
- Department of Radiology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - In-Jae Oh
- Department of Internal Medicine, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Jong-Hwan Hong
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Tae-Young Jung
- Department of Neurosurgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
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Reirradiation With Stereotactic Radiosurgery After Local or Marginal Recurrence of Brain Metastases From Previous Radiosurgery. Int J Radiat Oncol Biol Phys 2021; 112:726-734. [PMID: 34644606 DOI: 10.1016/j.ijrobp.2021.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 09/22/2021] [Accepted: 10/05/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE Brain metastases represent a major indication for stereotactic radiosurgery (SRS), but further study is needed regarding repeat SRS (SRS2) after local or marginal recurrence after prior SRS (SRS1). We report local tumor control (LC) after SRS2 and identify predictors of radiation necrosis (RN) and symptomatic RN (SRN). METHODS AND MATERIALS Patients had biopsy-proven non-small cell lung cancer and at least 1 brain metastasis previously treated with SRS. SRS2 was performed from 2015 to 2020 and required overlap of the prescription isodose lines with those from SRS1. Patients treated with preoperative SRS were excluded. Primary endpoints were LC by Response Assessment in Neuro-oncology criteria, RN, and SRN. RESULTS From 8 institutions, 102 patients with 123 treated lesions were included. SRS2 was performed at a median 12 months after SRS1. SRS2 delivered a median 18 Gy (interquartile range [IQR], 16-18) margin dose to the 50% (IQR, 50%-70%) isodose line, maximum dose of 30.5 Gy (IQR, 25.0-36.0), and V12Gy of 3.38 cm3 (IQR, 0.83-7.64). One-year and 2-year LC were 79% and 72%, respectively. Local tumor control was improved with tumor volume ≤1 cm3 (P < .005). There were 25 (20%) cases of RN and 9 (7%) cases of SRN. For SRS1 and SRS2, SRN rates were higher with maximum doses ≥40 Gy or SRS2 V12Gy >9 cm3 (P < .025 for each). SRS1 and SRS2 maximum dose ≥40 Gy was also predictive of increased RN (P < .05 for each). Prior immunotherapy was not predictive of RN or SRN. CONCLUSIONS Repeat SRS afforded a high rate of local tumor control and a low rate of SRN. At SRS2, V12Gy ≤9 cm3 and maximum dose <40 Gy may reduce the risks of RN and SRN. These results are most applicable to lesions with approximately 1 cm3 volume and 1-year interval between SRS courses.
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Torizuka D, Uto M, Takehana K, Mizowaki T. Dosimetric comparison among dynamic conformal arc therapy, coplanar and non-coplanar volumetric modulated arc therapy for single brain metastasis. JOURNAL OF RADIATION RESEARCH 2021:rrab092. [PMID: 34604907 DOI: 10.1093/jrr/rrab092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/16/2021] [Indexed: 06/13/2023]
Abstract
In the delivery of stereotactic radiosurgery (SRS) by linear accelerator (LINAC), dynamic conformal arc therapy (DCAT) with non-coplanar beams is conventionally used. However, volumetric modulated arc therapy (VMAT) can improve target conformity, thereby decreasing the dose to organs at risk by inversed planning methods, but few studies have directly compared DCAT and VMAT with and without non-coplanar beams in patients with single brain metastasis. We therefore conducted a planning study to compare the dose distribution in DCAT, VMAT using only a coplanar arc (CoVMAT) and VMAT with non-coplanar arcs (NcVMAT) in the treatment of single brain metastasis. DCAT, CoVMAT and NcVMAT plans were created for 15 patients. The three modalities were compared in terms of target conformity, target coverage, the dose to normal brain tissue, monitor units (MUs) and beam-on time. Both conformity indices (RTOG-CI and IP-CI) as well as the D98% of the gross target volume (GTV) were significantly better in the NcVMAT plans than in the DCAT plans. Comparisons of the doses to normal brain tissue revealed that the V20Gy, V15Gy, V12Gy, V10Gy and V5Gy were significantly smaller in the NcVMAT plans than in the plans based on the other two modalities. The MUs of the DCAT and NcVMAT plans were larger than those of the CoVMAT plans, and the beam-on time was longer in the NcVMAT and CoVMAT plans than in the DCAT plans. Compared to the CoVMAT and DCAT plans, NcVMAT plans significantly improved target conformity and reduced the doses to normal brain tissue at V20Gy, V15Gy, V12Gy, V10Gy and V5Gy.
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Affiliation(s)
- Daichi Torizuka
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan
| | - Megumi Uto
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan
| | - Keiichi Takehana
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan
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