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Vlachos N, Lampros MG, Filis P, Voulgaris S, Alexiou GA. Stereotactic radiosurgery versus whole-brain radiotherapy after resection of solitary brain metastasis: A systematic review and meta-analysis. World Neurosurg X 2023; 18:100170. [PMID: 36825221 PMCID: PMC9942116 DOI: 10.1016/j.wnsx.2023.100170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/04/2023] Open
Abstract
Objective The standard of care in patients with solitary brain metastasis involves surgical resection and postoperative whole-brain radiotherapy (WBRT). However, WBRT is associated with adverse effects, mainly neurocognitive deterioration. Stereotactic radiosurgery (SRS) is a more targeted form of radiation therapy that could be as effective as WBRT without the detrimental neurocognitive decline. Methods We performed the first systematic review and meta-analysis comparing postoperative SRS versus postoperative WBRT in patients with one resected brain metastasis. PubMed, Scopus, and Cochrane library were systematically searched for studies comparing the efficacy of the two radiation modalities in terms of local and distant brain control, leptomeningeal disease control, and overall survival. Additionally, we extracted patients' neurocognitive function and quality of life after each postoperative radiation form. Results Four studies with 248 patients (128: WBRT, 120: SRS) were included in our analysis. There was no difference between SRS and WBRT in the risk of local recurrence (RR = 0.92, CI = 0.51-1.66, p = 0.78, I2 = 0%) and leptomeningeal disease (RR = 1.21, CI = 0.49-2.98, p = 0.67, I2 = 18%), neither in the patients' overall survival (HR = 1.06, CI = 0.61-1.85, p = 0.83, I2 = 63%). Nevertheless, SRS appeared to increase the risk of distant brain failure (RR = 2.03, CI = 0.94-4.40, p = 0.07, I2 = 61%). Neurocognitive function and quality of life in the SRS group were equal or superior to the WBRT group. Conclusions Although SRS may increase the risk of distant brain failure, it appears to be as effective as WBRT in terms of local control, risk of leptomeningeal disease, and overall survival while sparing the patients of the detrimental, WBRT-associated cognitive deterioration.
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Key Words
- Brain metastasis
- CI, Confidence Interval
- HR, Hazard Ratio
- KPS, Karnofsky Performance Status
- M-H, Mantel – Haenszel
- MMME, Mini-Mental State Examination
- MRC, Medical Research Council
- Neurocognitive function
- Overall survival
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-analyses
- QLQ, Quality of Life Questionnaire
- RCTs, Randomized Controlled Trials
- RR, Risk Ratio
- SRS, Stereotactic radiosurgery
- Stereotactic radiosurgery
- WBRT, whole-brain radiotherapy
- Whole-brain radiotherapy
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Affiliation(s)
- Nikolaos Vlachos
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece
| | - Marios G. Lampros
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece
| | - Panagiotis Filis
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece,Department of Hygiene and Epidemiology, School of Medicine, University of Ioannina, 45110, Ioannina, Greece
| | - Spyridon Voulgaris
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece
| | - George A. Alexiou
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece,Corresponding author.
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Bodensohn R, Werner S, Reis J, Pazos Escudero M, Kaempfel AL, Hadi I, Forbrig R, Manapov F, Corradini S, Belka C, Theurich S, Heinzerling L, Schlaak M, Niyazi M. Stereotactic radiosurgery and combined immune checkpoint therapy with ipilimumab and nivolumab in patients with melanoma brain metastases: A retrospective monocentric toxicity analysis. Clin Transl Radiat Oncol 2023; 39:100573. [PMID: 36655118 PMCID: PMC9841023 DOI: 10.1016/j.ctro.2022.100573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 12/28/2022] [Accepted: 12/28/2022] [Indexed: 01/06/2023] Open
Abstract
Purpose and objective Adding stereotactic radiosurgery (SRS) to combined immune checkpoint therapy with ipilimumab and nivolumab (IPI + NIVO) has led to promising results for patients with melanoma brain metastases (MBM). This study retrospectively analyzes the toxicity profile depending on the timing of SRS with regard to IPI + NIVO. Materials and methods For this study, the clinical database was searched for all patients with MBM who were treated with SRS and IPI + NIVO. The patients were separated into three groups: group A completed IPI + NIVO (usually up to four cycles) >14 days before SRS, in group B IPI + NIVO was initiated>14 days after SRS, and group C received SRS concurrently to IPI + NIVO. Treatment related toxicity was obtained from clinical and neuroradiological records. Analyses were performed using the Fisher-Yates-test. Results 31 patients were assessed including six (19.4 %), seven (22.6 %) and 18 (58.1 %) patients, in groups A, B and C, respectively. Baseline prognostic markers between groups were balanced. In total, five (16.1 %) patients experienced neurological grade 3 toxicities related to SRS. All of these five patients were in group C, which was near-significantly correlated with a risk for grade 3 toxicities (p = 0.058). Post-hoc analyses showed that a maximum time period of seven days between SRS and IPI + NIVO was significantly correlated with grade 3 toxicity (p = 0.048). Conclusion Application of SRS to IPI + NIVO within a seven-day span was related to higher toxicity rates in this retrospective analysis. After previous studies focused on immune checkpoint monotherapies with SRS and declared it as safe, this study indicates that concomitant application of IPI + NIVO and SRS might increase side effects. Prospective validation is warranted to corroborate these findings.
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Key Words
- AE, Adverse events
- CTCAE, Common Terminology Criteria for Adverse Events
- Checkpoint inhibition
- GPA, graded prognostic assessment
- IPI, ipilimumab
- Intracranial hemorrhage
- Ipilimumab
- LDH, lactate dehydrogenase
- MBM, Melanoma brain metastases
- MRI, magnet resonance imaging
- NIVO, nivolumab
- Nivolumab
- OS, overall survival
- PFS, progression-free survival
- RN, radiation necrosis
- Radiation necrosis
- SRS, Stereotactic radiosurgery
- SRT, Stereotactic radiotherapy
- Side effects
- Stereotactic radiosurgery
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Affiliation(s)
- Raphael Bodensohn
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Simone Werner
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Jonas Reis
- Institute of Neuroradiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Montserrat Pazos Escudero
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Anna-Lena Kaempfel
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Indrawati Hadi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Robert Forbrig
- Institute of Neuroradiology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Farkhad Manapov
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany,German Cancer Consortium (DKTK), Partner Site, Munich, Germany
| | - Sebastian Theurich
- Department of Medicine III, University Hospital, LMU Munich, Ziemssenstraße 1, 80336 Munich, Germany
| | - Lucie Heinzerling
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Frauenlobstraße 9-11, 80337 Munich, Germany,Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Ulmenweg 18, 91052 Erlangen, Germany
| | - Max Schlaak
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Dermatology, Venereology and Allergology, Charitéplatz 1, 10117 Berlin, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany,German Cancer Consortium (DKTK), Partner Site, Munich, Germany,Corresponding author at: Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany.
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Bilger A, Frenzel F, Oehlke O, Wiehle R, Milanovic D, Prokic V, Nieder C, Grosu AL. Local control and overall survival after frameless radiosurgery: A single center experience. Clin Transl Radiat Oncol 2017; 7:55-61. [PMID: 29594230 PMCID: PMC5862646 DOI: 10.1016/j.ctro.2017.09.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/20/2017] [Accepted: 09/23/2017] [Indexed: 12/26/2022] Open
Abstract
Introduction Stereotactic radiosurgery (SRS) has been increasingly advocated for 1-3 small brain metastases. The goal of this study was to evaluate the clinical results in patients with brain metastases treated with LINAC-based SRS using a thermoplastic mask (non-invasive fixation system) and Image-Guided Radiotherapy (IGRT). Material and Methods In this single-institution study 48 patients with 77 brain metastases were treated between February 2012 and January 2014. The prescribed dose was 20 Gy or 18 Gy as a single fraction. SRS was performed with a True Beam STX Novalis Radiosurgery LINAC (Varian Medical Systems). The verification of positioning was done using the BrainLAB ExacTrac ® X-ray 6D system and cone-beam CT. Results In 69 of 77 treated brain metastases (90%) the follow-up was documented on MR imaging performed every 3 months. Mean follow-up time was 10.86 months. Estimated 1-year local control was 83%, using the Kaplan-Meier method. In 7/69 brain metastases (10%) local failure (LF) was diagnosed. Median progression free survival (PFS) was 3.73 months, largely due to distant brain relapse. A GTV of ≤2.0 cm3 was significantly associated with a better PFS than a GTV >2.0 cm3. Extracranial stable disease and GTV ≤2.5 cm³ were significant predictors of OS.We observed 2 cases of radiation necrosis diagnosed by histology after surgical resection. No other cases of severe side effects (CTACE ≥ 3) were observed. Conclusion LINAC-based frameless SRS with the BrainLAB Mask using the BrainLAB ExacTrac ® X-ray 6D system for patient positioning is well tolerated, safe and leads to favorable crude local control of 90%. In our experience, local control after frameless (ringless) SRS is as good as ring-based SRS reported in literature. Without invasive head fixation, radiotherapy is more comfortable for patients.
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Key Words
- Brain metastases
- CBCT, cone-beam CT
- CT, computed tomography
- CTCAE, Common Terminology Criteria for Adverse Events v4.0
- DC, distant intracranial tumor control
- DRR, digitally reconstructed radiographs
- GTV, Gross Tumor Volume
- IGRT, Image-Guided Radiotherapy
- LC, Local Control
- LINAC
- LINAC, Linear Accelerator
- OS, Overall Survival
- PFS, progression-free survival
- PTV, planning target volume
- RPA, recursive partitioning analysis
- Radiosurgery
- SRS, Stereotactic radiosurgery
- WBRT, Whole Brain Radiotherapy
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Affiliation(s)
- Angelika Bilger
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany
| | - Florian Frenzel
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany
| | - Oliver Oehlke
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany
| | - Rolf Wiehle
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany
| | - Dusan Milanovic
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany
| | - Vesna Prokic
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany.,University of Applied Sciences Koblenz, Joseph-Rovan-Allee 2, 53424 Remagen, Germany
| | - Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092 Bodø, Norway.,Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, 9037 Tromsø, Norway
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University Medical Center Freiburg, Medical Faculty Freiburg, Robert-Koch-Str.3, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Germany
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