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Carrete LR, Morshed RA, Young JS, Avalos LN, Sneed PK, Aghi MK, McDermott MW, Theodosopoulos PV. Analysis of upfront resection or stereotactic radiosurgery for local control of solid and cystic cerebellar hemangioblastomas. J Neurosurg 2024; 140:404-411. [PMID: 37542443 DOI: 10.3171/2023.6.jns222629] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 06/04/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE The purpose of this study was to identify rates of and risk factors for local tumor progression in patients who had undergone surgery or radiosurgery for the management of cerebellar hemangioblastoma and to describe treatments pursued following tumor progression. METHODS The authors conducted a retrospective single-center review of patients who had undergone treatment of a cerebellar hemangioblastoma with either surgery or stereotactic radiosurgery (SRS) between 1996 and 2019. Univariate and multivariate regression analyses were performed to examine factors associated with local tumor control. RESULTS One hundred nine patients met the study inclusion criteria. Overall, these patients had a total of 577 hemangioblastomas, 229 of which were located in the cerebellum. The surgical and SRS cohorts consisted of 106 and 123 cerebellar hemangioblastomas, respectively. For patients undergoing surgery, tumors were treated with subtotal resection and gross-total resection in 5.7% and 94.3% of cases, respectively. For patients receiving SRS, the mean target volume was 0.71 cm3 and the mean margin dose was 18.0 Gy. Five-year freedom from lesion progression for the surgical and SRS groups was 99% and 82%, respectively. The surgical and SRS cohorts contained 32% versus 97% von Hippel-Lindau tumors, 78% versus 7% cystic hemangioblastomas, and 12.8- versus 0.56-cm3 mean tumor volumes, respectively. On multivariate analysis, factors associated with local tumor progression in the SRS group included older patient age (HR 1.06, 95% CI 1.03-1.09, p < 0.001) and a cystic component (HR 9.0, 95% CI 2.03-32.0, p = 0.001). Repeat SRS as salvage therapy was used more often for smaller tumor recurrences, and no tumor recurrences of < 1.0 cm3 required additional salvage surgery following repeat SRS. CONCLUSIONS Both surgery and SRS achieve high rates of local control of hemangioblastomas. Age and cystic features are associated with local progression after SRS treatment for cerebellar hemangioblastomas. In cases of local tumor recurrence, salvage surgery and repeat SRS are valid forms of treatment to achieve local tumor control, although resection may be preferable for larger recurrences.
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Affiliation(s)
| | | | | | | | - Penny K Sneed
- 2Radiation Oncology, University of California, San Francisco, California
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2
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Salans M, Ni L, Morin O, Ziemer B, Capaldi DPI, Raleigh DR, Vasudevan HN, Chew J, Nakamura J, Sneed PK, Boreta L, Villanueva-Meyer JE, Theodosopoulos P, Braunstein S. Adverse radiation effect versus tumor progression following stereotactic radiosurgery for brain metastases: Implications of radiologic uncertainty. J Neurooncol 2024; 166:535-546. [PMID: 38316705 PMCID: PMC10876820 DOI: 10.1007/s11060-024-04578-6] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 01/17/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Adverse radiation effect (ARE) following stereotactic radiosurgery (SRS) for brain metastases is challenging to distinguish from tumor progression. This study characterizes the clinical implications of radiologic uncertainty (RU). METHODS Cases reviewed retrospectively at a single-institutional, multi-disciplinary SRS Tumor Board between 2015-2022 for RU following SRS were identified. Treatment history, diagnostic or therapeutic interventions performed upon RU resolution, and development of neurologic deficits surrounding intervention were obtained from the medical record. Differences in lesion volume and maximum diameter at RU onset versus resolution were compared with paired t-tests. Median time from RU onset to resolution was estimated using the Kaplan-Meier method. Univariate and multivariate associations between clinical characteristics and time to RU resolution were assessed with Cox proportional-hazards regression. RESULTS Among 128 lesions with RU, 23.5% had undergone ≥ 2 courses of radiation. Median maximum diameter (20 vs. 16 mm, p < 0.001) and volume (2.7 vs. 1.5 cc, p < 0.001) were larger upon RU resolution versus onset. RU resolution took > 6 and > 12 months in 25% and 7% of cases, respectively. Higher total EQD2 prior to RU onset (HR = 0.45, p = 0.03) and use of MR perfusion (HR = 0.56, p = 0.001) correlated with shorter time to resolution; larger volume (HR = 1.05, p = 0.006) portended longer time to resolution. Most lesions (57%) were diagnosed as ARE. Most patients (58%) underwent an intervention upon RU resolution; of these, 38% developed a neurologic deficit surrounding intervention. CONCLUSIONS RU resolution took > 6 months in > 25% of cases. RU may lead to suboptimal outcomes and symptom burden. Improved characterization of post-SRS RU is needed.
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Affiliation(s)
- Mia Salans
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
| | - Lisa Ni
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
| | - Olivier Morin
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
| | - Benjamin Ziemer
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
| | - Dante P I Capaldi
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
| | - David R Raleigh
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
- Department of Neurosurgery, University of California San Francisco (DRR, JEVM, PT), San Francisco, USA
- Department of Pathology, University of California San Francisco (DRR), San Francisco, USA
| | - Harish N Vasudevan
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
- Department of Neurosurgery, University of California San Francisco (DRR, JEVM, PT), San Francisco, USA
| | - Jessica Chew
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
| | - Jean Nakamura
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
| | - Penny K Sneed
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
| | - Lauren Boreta
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA
| | - Javier E Villanueva-Meyer
- Department of Neurosurgery, University of California San Francisco (DRR, JEVM, PT), San Francisco, USA
- Department of Radiology and Biomedical Imaging, University of California San Francisco (JEVM), San Francisco, USA
| | - Philip Theodosopoulos
- Department of Neurosurgery, University of California San Francisco (DRR, JEVM, PT), San Francisco, USA
| | - Steve Braunstein
- Department of Radiation Oncology, University of California San Francisco (MS, LN, OM, BZ, DPIC, DRR, HNV, JC, JN, PKS, LB, SB), 505 Parnassus Ave, L75, San Francisco, CA, 94158, USA.
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3
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Liu SJ, Casey-Clyde T, Cho NW, Swinderman J, Pekmezci M, Dougherty MC, Foster K, Chen WC, Villanueva-Meyer JE, Swaney DL, Vasudevan HN, Choudhury A, Pak J, Breshears JD, Lang UE, Eaton CD, Hiam-Galvez KJ, Stevenson E, Chen KH, Lien BV, Wu D, Braunstein SE, Sneed PK, Magill ST, Lim D, McDermott MW, Berger MS, Perry A, Krogan NJ, Hansen MR, Spitzer MH, Gilbert L, Theodosopoulos PV, Raleigh DR. Epigenetic reprogramming shapes the cellular landscape of schwannoma. Nat Commun 2024; 15:476. [PMID: 38216587 PMCID: PMC10786948 DOI: 10.1038/s41467-023-40408-5] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/25/2023] [Indexed: 01/14/2024] Open
Abstract
Mechanisms specifying cancer cell states and response to therapy are incompletely understood. Here we show epigenetic reprogramming shapes the cellular landscape of schwannomas, the most common tumors of the peripheral nervous system. We find schwannomas are comprised of 2 molecular groups that are distinguished by activation of neural crest or nerve injury pathways that specify tumor cell states and the architecture of the tumor immune microenvironment. Moreover, we find radiotherapy is sufficient for interconversion of neural crest schwannomas to immune-enriched schwannomas through epigenetic and metabolic reprogramming. To define mechanisms underlying schwannoma groups, we develop a technique for simultaneous interrogation of chromatin accessibility and gene expression coupled with genetic and therapeutic perturbations in single-nuclei. Our results elucidate a framework for understanding epigenetic drivers of tumor evolution and establish a paradigm of epigenetic and metabolic reprograming of cancer cells that shapes the immune microenvironment in response to radiotherapy.
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Affiliation(s)
- S John Liu
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
- Arc Institute, Palo Alto, CA, 94304, USA
| | - Tim Casey-Clyde
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Nam Woo Cho
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
- Parker Institute for Cancer Immunotherapy, Chan Zuckerberg Biohub, and Departments of Otolaryngology, and Microbiology and Immunology, University of California San Francisco, San Francisco, CA, 94115, USA
| | - Jason Swinderman
- Arc Institute, Palo Alto, CA, 94304, USA
- Department of Urology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Melike Pekmezci
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Mark C Dougherty
- Departments of Otolaryngology and Neurosurgery, University of Iowa, Iowa City, IA, 52242, USA
| | - Kyla Foster
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - William C Chen
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Javier E Villanueva-Meyer
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Danielle L Swaney
- J. David Gladstone Institutes, California Institute for Quantitative Biosciences, Department of Cellular and Molecular Pharmacology, University of California San Francisco, San Francisco, CA, 94158, USA
| | - Harish N Vasudevan
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Abrar Choudhury
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Joanna Pak
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
- Arc Institute, Palo Alto, CA, 94304, USA
| | - Jonathan D Breshears
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Ursula E Lang
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Dermatology, University of California San Francisco, San Francisco, CA, 94115, USA
| | - Charlotte D Eaton
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Kamir J Hiam-Galvez
- Parker Institute for Cancer Immunotherapy, Chan Zuckerberg Biohub, and Departments of Otolaryngology, and Microbiology and Immunology, University of California San Francisco, San Francisco, CA, 94115, USA
| | - Erica Stevenson
- J. David Gladstone Institutes, California Institute for Quantitative Biosciences, Department of Cellular and Molecular Pharmacology, University of California San Francisco, San Francisco, CA, 94158, USA
| | - Kuei-Ho Chen
- J. David Gladstone Institutes, California Institute for Quantitative Biosciences, Department of Cellular and Molecular Pharmacology, University of California San Francisco, San Francisco, CA, 94158, USA
| | - Brian V Lien
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
| | - David Wu
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Penny K Sneed
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Stephen T Magill
- Department of Neurological Surgery, Northwestern University, Chicago, IL, 60611, USA
| | - Daniel Lim
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
| | | | - Mitchel S Berger
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Arie Perry
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Nevan J Krogan
- J. David Gladstone Institutes, California Institute for Quantitative Biosciences, Department of Cellular and Molecular Pharmacology, University of California San Francisco, San Francisco, CA, 94158, USA
| | - Marlan R Hansen
- Departments of Otolaryngology and Neurosurgery, University of Iowa, Iowa City, IA, 52242, USA
| | - Matthew H Spitzer
- Parker Institute for Cancer Immunotherapy, Chan Zuckerberg Biohub, and Departments of Otolaryngology, and Microbiology and Immunology, University of California San Francisco, San Francisco, CA, 94115, USA
| | - Luke Gilbert
- Arc Institute, Palo Alto, CA, 94304, USA
- Department of Urology, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Philip V Theodosopoulos
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA
| | - David R Raleigh
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94143, USA.
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, 94143, USA.
- Department of Pathology, University of California San Francisco, San Francisco, CA, 94143, USA.
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4
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Chen WC, Choudhury A, Youngblood MW, Polley MYC, Lucas CHG, Mirchia K, Maas SLN, Suwala AK, Won M, Bayley JC, Harmanci AS, Harmanci AO, Klisch TJ, Nguyen MP, Vasudevan HN, McCortney K, Yu TJ, Bhave V, Lam TC, Pu JKS, Li LF, Leung GKK, Chan JW, Perlow HK, Palmer JD, Haberler C, Berghoff AS, Preusser M, Nicolaides TP, Mawrin C, Agnihotri S, Resnick A, Rood BR, Chew J, Young JS, Boreta L, Braunstein SE, Schulte J, Butowski N, Santagata S, Spetzler D, Bush NAO, Villanueva-Meyer JE, Chandler JP, Solomon DA, Rogers CL, Pugh SL, Mehta MP, Sneed PK, Berger MS, Horbinski CM, McDermott MW, Perry A, Bi WL, Patel AJ, Sahm F, Magill ST, Raleigh DR. Targeted gene expression profiling predicts meningioma outcomes and radiotherapy responses. Nat Med 2023; 29:3067-3076. [PMID: 37944590 PMCID: PMC11073469 DOI: 10.1038/s41591-023-02586-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 09/11/2023] [Indexed: 11/12/2023]
Abstract
Surgery is the mainstay of treatment for meningioma, the most common primary intracranial tumor, but improvements in meningioma risk stratification are needed and indications for postoperative radiotherapy are controversial. Here we develop a targeted gene expression biomarker that predicts meningioma outcomes and radiotherapy responses. Using a discovery cohort of 173 meningiomas, we developed a 34-gene expression risk score and performed clinical and analytical validation of this biomarker on independent meningiomas from 12 institutions across 3 continents (N = 1,856), including 103 meningiomas from a prospective clinical trial. The gene expression biomarker improved discrimination of outcomes compared with all other systems tested (N = 9) in the clinical validation cohort for local recurrence (5-year area under the curve (AUC) 0.81) and overall survival (5-year AUC 0.80). The increase in AUC compared with the standard of care, World Health Organization 2021 grade, was 0.11 for local recurrence (95% confidence interval 0.07 to 0.17, P < 0.001). The gene expression biomarker identified meningiomas benefiting from postoperative radiotherapy (hazard ratio 0.54, 95% confidence interval 0.37 to 0.78, P = 0.0001) and suggested postoperative management could be refined for 29.8% of patients. In sum, our results identify a targeted gene expression biomarker that improves discrimination of meningioma outcomes, including prediction of postoperative radiotherapy responses.
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Affiliation(s)
- William C Chen
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA.
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA.
| | - Abrar Choudhury
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
- Medical Scientist Training Program, University of California San Francisco, San Francisco, CA, USA
| | - Mark W Youngblood
- Department of Neurological Surgery, Northwestern University, Chicago, IL, USA
| | - Mei-Yin C Polley
- NRG Statistics and Data Management Center, NRG Oncology, Philadelphia, PA, USA
| | | | - Kanish Mirchia
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Sybren L N Maas
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Abigail K Suwala
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
- Department of Neuropathology, University Hospital Heidelberg and CCU Neuropathology, German Consortium for Translational Cancer Research, German Cancer Research Center, Heidelberg, Germany
| | - Minhee Won
- NRG Statistics and Data Management Center, NRG Oncology, Philadelphia, PA, USA
| | - James C Bayley
- Jan and Dan Duncan Neurological Research Institute, Texas Children's Hospital, Houston, TX, USA
| | - Akdes S Harmanci
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Arif O Harmanci
- Center for Secure Artificial Intelligence for Healthcare, Center for Precision Health, School of Biomedical Informatics, The University of Texas Health Science Center, Houston, TX, USA
| | - Tiemo J Klisch
- Department of Molecular and Human Genetics, Baylor College of Medicine, and Jan and Dan Duncan Neurological Research Institute, Texas Children's Hospital, Houston, TX, USA
| | - Minh P Nguyen
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Harish N Vasudevan
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Kathleen McCortney
- Department of Neurological Surgery, Northwestern University, Chicago, IL, USA
| | - Theresa J Yu
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Varun Bhave
- Department of Neurosurgery, Brigham and Women's Hospital, and Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Tai-Chung Lam
- Department of Clinical Oncology, The University of Hong Kong, Pokfulam, China
| | - Jenny Kan-Suen Pu
- Division of Neurosurgery, Department of Surgery, The University of Hong Kong, Pokfulam, China
| | - Lai-Fung Li
- Division of Neurosurgery, Department of Surgery, The University of Hong Kong, Pokfulam, China
| | - Gilberto Ka-Kit Leung
- Division of Neurosurgery, Department of Surgery, The University of Hong Kong, Pokfulam, China
| | - Jason W Chan
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Haley K Perlow
- Department of Radiation Oncology, Ohio State University, Columbus, OH, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University, Columbus, OH, USA
| | - Christine Haberler
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Anna S Berghoff
- Division of Oncology, Department of Medicine, Medical University of Vienna, Vienna, Austria
| | - Matthias Preusser
- Division of Oncology, Department of Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Christian Mawrin
- Department of Neuropathology, University of Magdeburg, Magdeburg, Germany
| | - Sameer Agnihotri
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Adam Resnick
- Department of Neurological Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brian R Rood
- Brain Tumor Institute, Children's National Hospital, Washington, DC, USA
| | - Jessica Chew
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Jacob S Young
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Lauren Boreta
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Jessica Schulte
- Neurosciences Department, University of California San Diego, La Jolla, CA, USA
| | - Nicholas Butowski
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Sandro Santagata
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Nancy Ann Oberheim Bush
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Javier E Villanueva-Meyer
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - James P Chandler
- Department of Neurological Surgery, Northwestern University, Chicago, IL, USA
| | - David A Solomon
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - C Leland Rogers
- NRG Statistics and Data Management Center, NRG Oncology, Philadelphia, PA, USA
| | - Stephanie L Pugh
- NRG Statistics and Data Management Center, NRG Oncology, Philadelphia, PA, USA
| | - Minesh P Mehta
- NRG Statistics and Data Management Center, NRG Oncology, Philadelphia, PA, USA
- Miami Neuroscience Institute, Baptist Health, Miami, FL, USA
| | - Penny K Sneed
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Craig M Horbinski
- Department of Neurological Surgery, Northwestern University, Chicago, IL, USA
- Department of Pathology, Northwestern University, Chicago, IL, USA
| | | | - Arie Perry
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Wenya Linda Bi
- Department of Neurosurgery, Brigham and Women's Hospital, and Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Akash J Patel
- Jan and Dan Duncan Neurological Research Institute, Texas Children's Hospital, Houston, TX, USA
| | - Felix Sahm
- Department of Neuropathology, University Hospital Heidelberg and CCU Neuropathology, German Consortium for Translational Cancer Research, German Cancer Research Center, Heidelberg, Germany
| | - Stephen T Magill
- Department of Neurological Surgery, Northwestern University, Chicago, IL, USA.
| | - David R Raleigh
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA.
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA.
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5
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Liu SJ, Chen WC, Zhang Y, Young JS, Morshed RA, Nguyen MP, Villanueva-Meyer J, Phillips J, Oberheim NA, Aghi MK, Sneed PK, Braunstein SE, de Groot J, Berger MS, Molinaro AM, Hervey-Jumper S, Raleigh D. Adjuvant Chemoradiotherapy within One Year of Resection for Molecularly Defined Astrocytoma. Int J Radiat Oncol Biol Phys 2023; 117:e130-e131. [PMID: 37784692 DOI: 10.1016/j.ijrobp.2023.06.930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Treatments for diffuse low-grade gliomas (LGG) are controversial. Level I evidence supports the use of adjuvant radiotherapy (RT) and PCV chemotherapy for histologic LGG, but integration of molecular biomarkers in recent WHO classification and the emergence of temozolomide chemotherapy for gliomas necessitates additional investigation of the optimal treatment and timing of postoperative interventions. We hypothesized molecularly-defined LGG (IDH-mutant astrocytoma (astro) and IDH-mutant, 1p/19q-codeleted oligodendroglioma (oligo)) may have different clinical outcomes following adjuvant RT (aRT) with chemotherapy (aRT+chemo) vs observation or chemo alone. MATERIALS/METHODS A retrospective analysis of consecutive adult patients diagnosed with WHO Grade 2 astrocytoma or oligodendroglioma who underwent initial resection at a single institution from January 1998 to November 2017 was performed. Wilcoxon rank sum and Chi-squared tests were used to compare continuous and categorical variables, respectively. Survival analyses were performed using the Kaplan-Meier method and Cox proportional hazards models. Patients without clinical progression or death were censored at the date of last follow-up. Pre-operative and post-operative T2 FLAIR hyperintense tumor volumes were quantified using 3D Slicer to calculate extent of resection (EOR). RESULTS A total of 342 patients with molecularly-defined LGG (178 astro, 164 oligo) were identified with a median follow up of 9.1 yr. 171 (50%) patients received RT during their treatment course, of which 31 (18%) were treated with aRT within 1 year of diagnosis. The median aRT dose was 54 Gy (range: 40-60 Gy). aRT was more likely for astro (58%) vs oligo (41%, p = 0.001) and for patients who had resections with lower median EOR (88% vs 95%, p = 0.014). 53 patients (15%) were treated with chemo alone, and 136 patients (40%) were treated with aRT+chemo. Temozolomide was used for 161 patients (85%). For astro, aRT+chemo was associated with longer PFS (median 14.9 yr) compared to observation (4.8 yr, p = 0.05), aRT without chemo (5.2 yr, p = 0.01), or chemo alone (4.7 yr, p = 0.02). For oligo, aRT+chemo was associated with longer PFS (median not reached) compared to aRT without chemo (1.6 yr, p = 0.03), but not when compared to observation (median not reached, p = 0.47), or chemo alone (7.9 yr, p = 0.45). Multivariate analysis showed preoperative tumor volume, EOR, and aRT+chemo (but not aRT or chemo alone) were independently associated with astro PFS compared to observation. Propensity matching based on pre-operative tumor volume, EOR, and age demonstrated longer astro PFS after aRT+chemo (14.9 yr) compared to observation or chemo alone (4.5 yr, p = 0.015), without significant difference in OS (18.2 vs. 11.5 yr, p = 0.40). CONCLUSION Retrospective data from a single institution support the use of adjuvant radiotherapy with chemotherapy for patients with molecular astrocytomas, while the role of this approach for oligodendrogliomas is unclear in this cohort.
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Affiliation(s)
- S J Liu
- University of California San Francisco, Department of Radiation Oncology, San Francisco, CA
| | - W C Chen
- University of California San Francisco, San Francisco, CA
| | - Y Zhang
- University of California San Francisco, Department of Epidemiology and Biostatistics, San Francisco, CA
| | - J S Young
- University of California San Francisco, Department of Neurological Surgery, San Francisco, CA
| | - R A Morshed
- University of California San Francisco, Department of Neurological Surgery, San Francisco, CA
| | - M P Nguyen
- University of California, San Francisco, Department of Radiation Oncology, San Francisco, CA
| | | | - J Phillips
- University of California San Francisco, Department of Neurological Surgery, San Francisco, CA
| | - N A Oberheim
- University of California San Francisco, Department of Neurological Surgery, San Francisco, CA
| | - M K Aghi
- University of California San Francisco, Department of Neurological Surgery, San Francisco, CA
| | - P K Sneed
- University of California San Francisco, Department of Radiation Oncology, San Francisco, CA
| | - S E Braunstein
- University of California San Francisco, Department of Radiation Oncology, San Francisco, CA
| | - J de Groot
- University of California, San Francisco, San Francisco, CA
| | - M S Berger
- University of California San Francisco, Department of Neurological Surgery, San Francisco, CA
| | - A M Molinaro
- University of California San Francisco, Department of Epidemiology and Biostatistics, San Francisco, CA
| | - S Hervey-Jumper
- University of California San Francisco, Department of Neurological Surgery, San Francisco, CA
| | - D Raleigh
- University of California San Francisco, Department of Radiation Oncology, San Francisco, CA
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Vasudevan HN, Susko MS, Ma L, Nakamura JL, Raleigh DR, Boreta L, Fogh S, Theodosopoulos PV, McDermott MW, Tsai KK, Sneed PK, Braunstein SE. Mutational Status and Clinical Outcomes Following Systemic Therapy with or without Focal Radiation for Resected Melanoma Brain Metastases. World Neurosurg 2023; 170:e514-e519. [PMID: 36400359 DOI: 10.1016/j.wneu.2022.11.060] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/12/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Brain metastases occur frequently in advanced melanoma and traditionally require surgery and radiation therapy. New evidence demonstrates that systemic therapies are effective for controlling metastatic melanoma brain metastases. This study evaluated outcomes after resection of melanoma brain metastases treated with systemic therapy, with or without focal radiotherapy. METHODS All patients received immunotherapy or BRAF/MEK inhibitors preoperatively or in the immediate 3 months postoperatively. Resection cavity failure, distant central nervous system progression, and adverse radiation effects were reported in the presence and absence of focal radiotherapy using the Kaplan-Meier method. RESULTS Between 2011 and 2020, 37 resection cavities in 29 patients met criteria for analysis. Of lesions, 22 (59%) were treated with focal radiotherapy, and 15 (41%) were treated with targeted therapy or immunotherapy alone. The 12- and 24-month freedom from local recurrence was 64.8% (95% confidence interval [CI] 42.1%-99.8%) and 46.3% (95% CI 24.5%-87.5%), respectively, for systemic therapy alone and 93.3% (95% CI 81.5%-100%) at both time points for focal radiotherapy (P = 0.01). On univariate analysis, focal radiotherapy was the only significant factor associated with reduction of local recurrence risk (hazard ratio 0.10, 95% CI 0.01-0.85; P = 0.04). There were no significant differences in central nervous system progression-free survival or overall survival between patients who received systemic therapy plus focal radiotherapy compared with systemic therapy alone. BRAF mutation status was reviewed for either the brain metastasis (n = 9 patients, 31%) or the primary site (n = 20 patients, 69%), and patients harboring BRAFV600E mutations had worse progression-free survival (P = 0.043). CONCLUSIONS Focal radiotherapy with systemic therapy for resected melanoma brain metastases significantly decreased resection cavity recurrence compared with systemic therapy alone. BRAF mutation status correlated with poorer outcomes.
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Affiliation(s)
- Harish N Vasudevan
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Matthew S Susko
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Lijun Ma
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Jean L Nakamura
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - David R Raleigh
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA; Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Lauren Boreta
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Shannon Fogh
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Philip V Theodosopoulos
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Michael W McDermott
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Katy K Tsai
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Penny K Sneed
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA.
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Wu SY, Braunstein SE, Rubenstein JL, Sneed PK. Stereotactic Radiosurgery for Primary Central Nervous System Lymphoma. Cureus 2023; 15:e34817. [PMID: 36915845 PMCID: PMC10008121 DOI: 10.7759/cureus.34817] [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] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2023] [Indexed: 02/11/2023] Open
Abstract
Background Primary central nervous system lymphoma (PCNSL) is rare, with a treatment backbone that typically includes high-dose methotrexate-based chemotherapy, with radiation often reserved for persistent or progressive disease. In this study, we report the outcomes of stereotactic radiosurgery (SRS) in patients with PCNSL to potentially defer whole brain radiotherapy (WBRT) or as salvage after WBRT. Methodology We performed a single-institution, retrospective review of 20 patients with PCNSL who received single-fraction or fractionated SRS to 32 lesions between September 1992 and July 2019. Results The median age at SRS was 67 years (interquartile range (IQR) = 56-74 years). The median Karnofsky Performance Status (KPS) at SRS was 80 (IQR = 50-80). In total, 18 (90%) patients received methotrexate-based chemotherapy prior to SRS, with a median of eight cycles (IQR = 5-10). A total of 10 patients received SRS for recurrent disease after chemotherapy and/or WBRT, nine patients received SRS for the persistent disease after chemotherapy alone, and one patient received up-front SRS. Overall, five patients received SRS following WBRT. The median SRS dose was 16 Gy (IQR = 14-22.5 Gy) in one fraction (IQR = 1-5 fractions). Eight patients (40%) were treated with consolidative pomalidomide or lenalidomide following SRS. The local control rate was 100% (32/32 lesions at a median follow-up of 15 months). In total, 13 of 16 (81%) patients with available follow-up experienced distant brain recurrence. The median time to distant failure following SRS was 10 months (IQR = 1-16 months). Three patients received salvage SRS, and three patients received salvage WBRT. The median overall survival from diagnosis was 39 months (95% confidence interval = 24-54 months). KPS at the time of SRS was significantly correlated with time to progression (p = 0.002). The use of lenalidomide or pomalidomide after SRS was associated with improved overall survival after SRS (three vs. 14 months, p = 0.035). Consolidative etoposide and cytarabine after initial methotrexate-based chemotherapy was also associated with improved survival following SRS (eight vs. 47 months, p = 0.028). Conclusions SRS offers effective local tumor control for patients with PCNSL; however, the majority of patients experience distant progression. SRS may have a role in the salvage setting for patients with recurrence after WBRT, or allow deferral of WBRT in select patients, although systemic therapy appears to strongly influence outcomes in this cohort.
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Affiliation(s)
- Susan Y Wu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San Francisco, San Francisco, USA
| | - James L Rubenstein
- Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Penny K Sneed
- Department of Radiation Oncology, University of California San Francisco, San Francisco, USA
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Sneed PK, Chan JW, Ma L, Braunstein SE, Theodosopoulos PV, Fogh SE, Nakamura JL, Boreta L, Raleigh DR, Ziemer BP, Morin O, Hervey-Jumper SL, McDermott MW. Adverse radiation effect and freedom from progression following repeat stereotactic radiosurgery for brain metastases. J Neurosurg 2023; 138:104-112. [PMID: 35594891 DOI: 10.3171/2022.4.jns212597] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 04/05/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The authors previously evaluated risk and time course of adverse radiation effects (AREs) following stereotactic radiosurgery (SRS) for brain metastases, excluding lesions treated after prior SRS. In the present analysis they focus specifically on single-fraction salvage SRS to brain metastases previously treated with SRS or hypofractionated SRS (HFSRS), evaluating freedom from progression (FFP) and the risk and time course of AREs. METHODS Brain metastases treated from September 1998 to May 2019 with single-fraction SRS after prior SRS or HFSRS were analyzed. Serial follow-up magnetic resonance imaging (MRI) and surgical pathology reports were reviewed to score local treatment failure and AREs. The Kaplan-Meier method was used to estimate FFP and risk of ARE measured from the date of repeat SRS with censoring at the last brain MRI. RESULTS A total of 229 retreated brain metastases in 124 patients were evaluable. The most common primary cancers were breast, lung, and melanoma. The median interval from prior SRS/HFSRS to repeat SRS was 15.4 months, the median prescription dose was 18 Gy, and the median duration of follow-up imaging was 14.5 months. At 1 year after repeat SRS, FFP was 80% and the risk of symptomatic ARE was 11%. The 1-year risk of imaging changes, including asymptomatic RE and symptomatic ARE, was 30%. Among lesions that demonstrated RE, the median time to onset was 6.7 months (IQR 4.7-9.9 months) and the median time to peak imaging changes was 10.1 months (IQR 5.6-13.6 months). Lesion size by quadratic mean diameter (QMD) showed similar results for QMDs ranging from 0.75 to 2.0 cm (1-year FFP 82%, 1-year risk of symptomatic ARE 11%). For QMD < 0.75 cm, the 1-year FFP was 86% and the 1-year risk of symptomatic ARE was only 2%. Outcomes were worse for QMDs 2.01-3.0 cm (1-year FFP 65%, 1-year risk of symptomatic ARE 24%). The risk of symptomatic ARE was not increased with tyrosine kinase inhibitors or immunotherapy before or after repeat SRS. CONCLUSIONS RE on imaging was common after repeat SRS (30% at 1 year), but the risk of a symptomatic ARE was much less (11% at 1 year). The results of repeat single-fraction SRS were good for brain metastases ≤ 2 cm. The authors recommend an interval ≥ 6 months from prior SRS and a prescription dose ≥ 18 Gy. Alternatives such as HFSRS, laser interstitial thermal therapy, or resection with adjuvant radiation should be considered for recurrent brain metastases > 2 cm.
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Affiliation(s)
- Penny K Sneed
- 1Department of Radiation Oncology, University of California, San Francisco
| | - Jason W Chan
- 1Department of Radiation Oncology, University of California, San Francisco
| | - Lijun Ma
- 2Department of Radiation Oncology, University of Southern California, Los Angeles
| | - Steve E Braunstein
- 1Department of Radiation Oncology, University of California, San Francisco
| | - Philip V Theodosopoulos
- 3Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Shannon E Fogh
- 1Department of Radiation Oncology, University of California, San Francisco
| | - Jean L Nakamura
- 1Department of Radiation Oncology, University of California, San Francisco
| | - Lauren Boreta
- 1Department of Radiation Oncology, University of California, San Francisco
| | - David R Raleigh
- 1Department of Radiation Oncology, University of California, San Francisco.,3Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Benjamin P Ziemer
- 1Department of Radiation Oncology, University of California, San Francisco
| | - Olivier Morin
- 1Department of Radiation Oncology, University of California, San Francisco
| | - Shawn L Hervey-Jumper
- 3Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Michael W McDermott
- 4Division of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida
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9
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Chen WC, Lafreniere M, Phuong C, Liu SJ, Baal JD, Lometti M, Morin O, Ziemer B, Vasudevan HN, Lucas CHG, Hervey-Jumper SL, Theodosopoulos PV, Magill ST, Fogh S, Nakamura JL, Boreta L, Sneed PK, McDermott MW, Raleigh DR, Braunstein SE. Resection with intraoperative cesium-131 brachytherapy as salvage therapy for recurrent brain tumors. J Neurosurg 2022; 137:924-930. [PMID: 35061986 DOI: 10.3171/2021.10.jns211886] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/27/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors' objective was to examine the safety and efficacy of salvage intracranial cesium-131 brachytherapy in combination with resection of recurrent brain tumors. METHODS The authors conducted a retrospective chart review of consecutive patients treated with intraoperative intracranial cesium-131 brachytherapy at a single institution. Permanent suture-stranded cesium-131 seeds were implanted in the resection cavity after maximal safe tumor resection. The primary outcomes of interest were local, locoregional (within 1 cm), and intracranial control, as well as rates of overall survival (OS), neurological death, symptomatic adverse radiation effects (AREs), and surgical complication rate graded according to Common Terminology Criteria for Adverse Events version 5.0. RESULTS Between 2016 and 2020, 36 patients received 40 consecutive cesium-131 implants for 42 recurrent brain tumors and received imaging follow-up for a median (interquartile range [IQR]) of 17.0 (12.7-25.9) months. Twenty patients (55.6%) with 22 implants were treated for recurrent brain metastasis, 12 patients (33.3%) with 16 implants were treated for recurrent atypical (n = 7) or anaplastic (n = 5) meningioma, and 4 patients (11.1%) were treated for other recurrent primary brain neoplasms. All except 1 tumor (97.6%) had received prior radiotherapy, including 20 (47.6%) that underwent 2 or more prior radiotherapy treatments and 23 (54.8%) that underwent prior resection. The median (IQR) tumor size was 3.0 (2.3-3.7) cm, and 17 lesions (40.5%) had radiographic evidence of ARE prior to salvage therapy. Actuarial 1-year local/locoregional/intracranial control rates for the whole cohort and patients with metastases and meningiomas were 91.6%/83.4%/47.9%, 88.8%/84.4%/45.4%, and 100%/83.9%/46.4%, respectively. No cases of local recurrence of any histology (0 of 27) occurred after gross-total resection (p = 0.012, log-rank test). The 1-year OS rates for the whole cohort and patients with metastases and meningiomas were 82.7%, 79.1%, and 91.7%, respectively, and the median (IQR) survival of all patients was 26.7 (15.6-36.4) months. Seven patients (19.4%) experienced neurological death from progressive intracranial disease (7 of 14 total deaths [50%]), 5 (13.9%) of whom died of leptomeningeal disease. Symptomatic AREs were observed in 9.5% of resection cavities (n = 4), of which 1 (2.4%) was grade 3 in severity. The surgical complication rate was 16.7% (n = 7); 4 (9.5%) of these patients had grade 3 or higher complications, including 1 patient (2.4%) who died perioperatively. CONCLUSIONS Cesium-131 brachytherapy resulted in good local control and acceptable rates of symptomatic AREs and surgical complications in this heavily pretreated cohort, and it may be a reasonable salvage adjuvant treatment for this patient population.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Stephen T Magill
- 5Department of Neurological Surgery, Northwestern University, Chicago, Illinois; and
| | | | | | | | | | - Michael W McDermott
- 6Department of Neurological Surgery, Miami Neuroscience Institute, Miami, Florida
| | - David R Raleigh
- Departments of1Radiation Oncology
- 4Neurological Surgery, University of California, San Francisco, California
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Phuong C, Vasudevan HN, Chen WC, Raleigh DR, Fogh S, Boreta L, Daras M, Tsai K, Nakamura J, Sneed PK, Braunstein SE. MMAP-10 ADVERSE RADIATION EFFECT AFTER STEREOTACTIC RADIOSURGERY AND IMMUNOTHERAPY/TARGETED THERAPY FOR MELANOMA BRAIN METASTASES. Neurooncol Adv 2022. [PMCID: PMC9354150 DOI: 10.1093/noajnl/vdac078.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Safety of immunotherapy (IO) and targeted therapy (TT) with stereotactic radiosurgery (SRS) in melanoma brain metastases (MBM) treatment remains incompletely understood. We aim to identify whether timing of IO/TT in relation to SRS impacts rates of adverse radiation effect (ARE) in MBM. METHODS Retrospective review of patients with MBM treated with SRS and IO/TT within three months prior and one year after SRS, from 2011-2021 at a single institution with at least two months MRI follow-up, identified 108 patients with 939 unique MBM meeting criteria. ARE was confirmed on independent imaging review. Concurrent IO/TT was defined as receiving IO/TT within 4 weeks before or after SRS. Data analysis was performed with the univariate cox proportional hazard model and Kaplan-Meier method. RESULTS Median radiographic follow-up from time of SRS was 16months. IO/TT was initiated prior to SRS for 681 (72.5%) metastases and after SRS for 258 (27.5%) metastases. 837 (89.1%) metastases received concurrent IO/TT. Most common IO agents were ipilimumab (n=416), nivolumab (n=448), and pembrolizumab (n=203). Most common TT agents were dabrafenib (n=548), trametinib (n=540), and vemurafenib (n=81). 2-year local progression-free survival (PFS), distant intracranial PFS, and overall survival were 94.1%, 33.3%, and 55.2%, respectively. 55 (5.9%) metastases in 33 (30.6%) patients experienced ARE. Median time to ARE was 5mo (IQR 4-9mo). Of those who experienced ARE, 22 (66.7%) patients were symptomatic and treated with steroids; 12 (36.4%) patients underwent surgical intervention. ARE rates were not impacted by concurrent vs nonconcurrent IO/TT (5.5% vs 4.9%, p=0.34) nor IO/TT initiation pre vs post SRS (6.0% vs 5.4%, p=0.61). CONCLUSION IO/TT in conjunction with SRS resulted in low ARE rates as compared to historical controls in the pre-IO/TT era. Timing of IO/TT in relation to SRS may not significantly impact ARE rates in MBM treatment.
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Affiliation(s)
- Christina Phuong
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA , USA
| | - Harish N Vasudevan
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA , USA
| | - William C Chen
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA , USA
| | - David R Raleigh
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA , USA
| | - Shannon Fogh
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA , USA
| | - Lauren Boreta
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA , USA
| | - Mariza Daras
- Department of Neuro-Oncology, University of California San Francisco, San Francisco, CA , USA
| | - Katy Tsai
- Department of Medical Oncology, University of California San Francisco, San Francisco, CA , USA
| | - Jean Nakamura
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA , USA
| | - Penny K Sneed
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA , USA
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA , USA
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Chew JJ, Sneed PK, Chang EF. Recurrent Radiation-Induced Cavernous Malformation After Gamma Knife Stereotactic Radiosurgery for Brain Metastasis. Cureus 2022; 14:e22815. [PMID: 35382197 PMCID: PMC8976526 DOI: 10.7759/cureus.22815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2022] [Indexed: 11/05/2022] Open
Abstract
Cavernous malformations are a rare complication of radiation therapy reported most commonly as a late complication after cranial irradiation for pediatric malignancies. However, cavernous malformations after stereotactic radiosurgery in adult patients are not well characterized. We present a case of a 67-year-old female with metastatic breast cancer who received Gamma Knife stereotactic radiosurgery for brain metastases and developed a cavernous malformation at the site of a treated metastasis 30 months after treatment. She underwent resection and did well until 55 months later, when she developed symptomatic recurrence of cavernous malformation without evidence of tumor recurrence, requiring repeat resection. This represents the first reported case of radiation-induced cavernous malformation treated with stereotactic radiosurgery for brain metastases, who later developed a recurrence of the cavernous malformation. As patients with brain metastases are living longer and are increasingly treated with stereotactic radiosurgery, awareness of cavernous malformation as a potential complication and the risk of recurrence is critical to ensure appropriate diagnosis and management.
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Fleming JL, Pugh SL, Fisher BJ, Lesser GJ, Macdonald DR, Bell EH, McElroy JP, Becker AP, Timmers CD, Aldape KD, Rogers CL, Doyle TJ, Werner-Wasik M, Bahary JP, Yu HHM, D'Souza DP, Laack NN, Sneed PK, Kwok Y, Won M, Mehta MP, Chakravarti A. Long-Term Report of a Comprehensive Molecular and Genomic Analysis in NRG Oncology/RTOG 0424: A Phase II Study of Radiation and Temozolomide in High-Risk Grade II Glioma. JCO Precis Oncol 2021; 5:PO.21.00112. [PMID: 34589661 PMCID: PMC8462570 DOI: 10.1200/po.21.00112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/18/2021] [Accepted: 07/27/2021] [Indexed: 01/16/2023] Open
Abstract
PURPOSE This study sought to determine the prognostic significance of the WHO-defined glioma molecular subgroups along with additional alterations, including MGMT promoter methylation and mutations in ATRX, CIC, FUBP1, TERT, and TP53, in NRG/RTOG 0424 using long-term follow-up data. METHODS Mutations were determined using an Ion Torrent sequencing panel. 1p/19q co-deletion and MGMT promoter methylation were determined by Affymetrix OncoScan and Illumina 450K arrays. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method and tested using the log-rank test. Hazard ratios were calculated using the Cox proportional hazard model. Multivariable analyses (MVAs) included patient pretreatment characteristics. RESULTS We obtained complete molecular data to categorize 80/129 eligible patients within the WHO subgroups. Of these, 26 (32.5%) were IDHmutant/co-deleted, 28 (35%) were IDHmutant/non-co-deleted, and 26 (32.5%) were IDHwild-type. Upon single-marker MVA, both IDHmutant subgroups were associated with significantly better OS and PFS (P values < .001), compared with the IDHwild-type subgroup. MGMT promoter methylation was obtained on 76 patients, where 58 (76%) were methylated and 18 (24%) were unmethylated. Single-marker MVAs demonstrated that MGMT promoter methylation was statistically significant for OS (P value < .001) and PFS (P value = .003). In a multimarker MVA, one WHO subgroup comparison (IDHmutant/co-deleted v IDHwild-type) was significant for OS (P value = .045), whereas MGMT methylation did not retain significance. CONCLUSION This study reports the long-term prognostic effect of the WHO molecular subgroups, MGMT promoter methylation, and other mutations in NRG/RTOG 0424. These results demonstrate that the WHO molecular classification and MGMT both serve as strong prognostic indicators, but that MGMT does not appear to add statistically significant prognostic value to the WHO subgrouping, above and beyond IDH and 1p/19q status.
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Affiliation(s)
| | - Stephanie L. Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | | | | | | | - Erica H. Bell
- Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | - Aline P. Becker
- Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | | | - C. Leland Rogers
- Barrow Neurological Institute, Phoenix, AZ (accruals under Arizona Oncology Services Foundation)
| | | | | | - Jean-Paul Bahary
- Centre Hospitalier de l`université De Montréal, Montreal, QC, Canada
| | | | | | | | | | - Young Kwok
- University of Maryland/Greenebaum Cancer Center, Baltimore, MA
| | - Minhee Won
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
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13
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Seymour ZA, Chan JW, McDermott MW, Grills I, Ye H, Kano H, Lehocky CA, Jacobs RC, Lunsford LD, Chytka T, Liščák R, Lee CC, Yang HC, Ding D, Sheehan JP, Feliciano CE, Rodriguez-Mercado R, Chiang VL, Hess JA, Sommaruga S, McShane B, Lee JYK, Vasas LT, Kaufmann AM, Sneed PK. Adverse radiation effects in volume-staged radiosurgery for large arteriovenous malformations: a multiinstitutional study. J Neurosurg 2021; 136:503-511. [PMID: 34450589 DOI: 10.3171/2020.12.jns201866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 12/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The optimal treatment paradigm for large arteriovenous malformations (AVMs) is controversial. One approach is volume-staged stereotactic radiosurgery (VS-SRS). The authors previously reported efficacy of VS-SRS for large AVMs in a multiinstitutional cohort; here they focus on risk of symptomatic adverse radiation effects (AREs). METHODS This is a multicentered retrospective review of patients treated with a planned prospective volume staging approach to stereotactically treat the entire nidus of an AVM, with volume stages separated by intervals of 3-6 months. A total of 9 radiosurgical centers treated 257 patients with VS-SRS between 1991 and 2016. The authors evaluated permanent, transient, and total ARE events that were symptomatic. RESULTS Patients received 2-4 total volume stages. The median age was 33 years at the time of the first SRS volume stage, and the median follow-up was 5.7 years after VS-SRS. The median total AVM nidus volume was 23.25 cm3 (range 7.7-94.4 cm3), with a median margin dose per stage of 17 Gy (range 12-20 Gy). A total of 64 patients (25%) experienced an ARE, of which 19 were permanent. Rather than volume, maximal linear dimension in the Z (craniocaudal) dimension was associated with toxicity; a threshold length of 3.28 cm was associated with an ARE, with a 72.5% sensitivity and a 58.3% specificity. In addition, parietal lobe involvement for superficial lesions and temporal lobe involvement for deep lesions were associated with an ARE. CONCLUSIONS Size remains the dominant predictor of toxicity following SRS, but overall rates of AREs were lower than anticipated based on baseline features, suggesting that dose and size were relatively dissociated through volume staging. Further techniques need to be assessed to optimize outcomes.
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Affiliation(s)
- Zachary A Seymour
- 1Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan
| | - Jason W Chan
- 2Department of Radiation Oncology, University of California, San Francisco, California
| | - Michael W McDermott
- 3Department of Neurological Surgery, Miami Neuroscience Institute, Miami, Florida
| | - Inga Grills
- 1Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan
| | - Hong Ye
- 1Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan
| | - Hideyuki Kano
- 4Department of Neurosurgery, University of Pittsburgh
| | | | - Rachel C Jacobs
- 5Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Tomas Chytka
- 6Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Roman Liščák
- 6Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Cheng-Chia Lee
- 7Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- 7Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Dale Ding
- 8Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P Sheehan
- 8Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Caleb E Feliciano
- 9Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Veronica L Chiang
- 10Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Judith A Hess
- 10Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Samuel Sommaruga
- 10Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Brendan McShane
- 11Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - John Y K Lee
- 11Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Lucas T Vasas
- 12Department of Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Anthony M Kaufmann
- 12Department of Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Penny K Sneed
- 2Department of Radiation Oncology, University of California, San Francisco, California
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14
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Susko MS, Chen WC, Vasudevan HN, Magill ST, Lucas CHG, Oberheim Bush NA, Solomon DA, Theodosopoulos PV, McDermott MW, Villanueva-Meyer JE, Boreta L, Nakamura JL, Sneed PK, Braunstein SE, Raleigh DR. Letter: Patterns of Intermediate- and High-Risk Meningioma Recurrence After Treatment With Postoperative External Beam Radiotherapy. Neurosurgery 2021; 89:E99-E101. [PMID: 33887769 DOI: 10.1093/neuros/nyab143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Matthew S Susko
- Department of Radiation Oncology University of California San Francisco San Francisco, California, USA
| | - William C Chen
- Department of Radiation Oncology University of California San Francisco San Francisco, California, USA.,Department of Neurological Surgery University of California San Francisco San Francisco, California, USA
| | - Harish N Vasudevan
- Department of Radiation Oncology University of California San Francisco San Francisco, California, USA.,Department of Neurological Surgery University of California San Francisco San Francisco, California, USA
| | - Stephen T Magill
- Department of Neurological Surgery University of California San Francisco San Francisco, California, USA
| | - Calixto-Hope G Lucas
- Department of Pathology University of California San Francisco San Francisco, California, USA
| | - Nancy Ann Oberheim Bush
- Department of Neurological Surgery University of California San Francisco San Francisco, California, USA
| | - David A Solomon
- Department of Pathology University of California San Francisco San Francisco, California, USA
| | - Philip V Theodosopoulos
- Department of Neurological Surgery University of California San Francisco San Francisco, California, USA
| | - Michael W McDermott
- Department of Neurological Surgery University of California San Francisco San Francisco, California, USA
| | - Javier E Villanueva-Meyer
- Department of Radiology and Biomedical Imaging University of California San Francisco San Francisco, California, USA
| | - Lauren Boreta
- Department of Radiation Oncology University of California San Francisco San Francisco, California, USA
| | - Jean L Nakamura
- Department of Radiation Oncology University of California San Francisco San Francisco, California, USA
| | - Penny K Sneed
- Department of Radiation Oncology University of California San Francisco San Francisco, California, USA
| | - Steve E Braunstein
- Department of Radiation Oncology University of California San Francisco San Francisco, California, USA
| | - David R Raleigh
- Department of Radiation Oncology University of California San Francisco San Francisco, California, USA.,Department of Neurological Surgery University of California San Francisco San Francisco, California, USA
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15
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Vasudevan HN, Susko MS, Ma L, Nakamura JL, Raleigh DR, Boreta L, Fogh S, Theodosopoulos PV, McDermott MW, Tsai KK, Sneed PK, Braunstein SE. Abstract PO-073: Mutational status and clinical outcomes following systemic therapy and focal radiation for melanoma brain metastases. Clin Cancer Res 2021. [DOI: 10.1158/1557-3265.radsci21-po-073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Brain metastases are the most common intracranial neoplasm yet clinical outcomes remain poor. The purpose of this study was to evaluate the efficacy of multimodal therapy comprising surgery followed by focal radiation, and/or systemic therapy and elucidate clinically significant biomarkers for resected melanoma brain metastases. Forty consecutive patients with newly diagnosed melanoma brain metastases who underwent surgical resection and targeted mutational analysis at UCSF between 2011 and 2020 were identified. Demographic, clinical, and outcome data were extracted from the medical record and institutional cancer registry. Surgical cavity local recurrence free survival (LRFS), intracranial progression free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method. The median age of patients in this cohort was 58 years (range: 27-75 years) with median MRI follow up of 13.15 months. Twenty patients (50%) were treated with concurrent stereotactic radiation (1-5 fractions) and systemic therapy while 16 patients (40%) were treated with systemic therapy only. Mutational testing demonstrated the most common pathogenic variant was BRAF V600E, found in 16 patients (40%), while the remaining 24 patients (60%) did not harbor this mutation. Microsatellite instability (MSI) estimation was available for 8 patients (20%), all of which were found to be MSI low (<2%). Median LRFS was significantly improved with combined focal radiation and systemic therapy compared to systemic therapy alone (NR versus 15 months, p=0.01; log-rank test). Patients harboring BRAF V600E mutations had worse intracranial PFS compared to those without V600E mutation (4 months versus 12 months, p=0.048; log-rank test), as well as a trend toward worse OS (NR vs 13 months, p=0.09; log-rank test). Systemic agent choice was heterogeneous, with 24 patients (60%) treated with immunotherapy alone, 12 patients (30%) treated with dual BRAF/MEK inhibitor therapy alone, and the remainder treated with mixed regimens (10%) with no differences in efficacy or toxicity between these subgroups. Our results suggest combined focal radiation and systemic therapy is effective for melanoma brain metastases. Moreover, specific molecular alterations such as BRAF V600E mutation are associated with poorer outcomes, and all brain metastases in our cohort were MSI low. Limitations of our study include its retrospective nature, limited sample size, and heterogeneity of systemic regimens, and future prospective validation and multiplatform genomic analysis are needed to build on our findings.
Citation Format: Harish N. Vasudevan, Matthew S. Susko, Lijun Ma, Jean L. Nakamura, David R. Raleigh, Lauren Boreta, Shannon Fogh, Philip V. Theodosopoulos, Michael W. McDermott, Katy K. Tsai, Penny K. Sneed, Steve E. Braunstein. Mutational status and clinical outcomes following systemic therapy and focal radiation for melanoma brain metastases [abstract]. In: Proceedings of the AACR Virtual Special Conference on Radiation Science and Medicine; 2021 Mar 2-3. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(8_Suppl):Abstract nr PO-073.
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Affiliation(s)
| | | | - Lijun Ma
- University of California, San Francisco, San Francisco, CA
| | | | | | - Lauren Boreta
- University of California, San Francisco, San Francisco, CA
| | - Shannon Fogh
- University of California, San Francisco, San Francisco, CA
| | | | | | - Katy K. Tsai
- University of California, San Francisco, San Francisco, CA
| | - Penny K. Sneed
- University of California, San Francisco, San Francisco, CA
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16
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Chen WC, Vasudevan HN, Choudhury A, Pekmezci M, Lucas CHG, Phillips J, Magill ST, Susko MS, Braunstein SE, Oberheim Bush NA, Boreta L, Nakamura JL, Villanueva-Meyer JE, Sneed PK, Perry A, McDermott MW, Solomon DA, Theodosopoulos PV, Raleigh DR. A Prognostic Gene-Expression Signature and Risk Score for Meningioma Recurrence After Resection. Neurosurgery 2020; 88:202-210. [PMID: 32860417 PMCID: PMC7735867 DOI: 10.1093/neuros/nyaa355] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/19/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Prognostic markers for meningioma are needed to risk-stratify patients and guide postoperative surveillance and adjuvant therapy. OBJECTIVE To identify a prognostic gene signature for meningioma recurrence and mortality after resection using targeted gene-expression analysis. METHODS Targeted gene-expression analysis was used to interrogate a discovery cohort of 96 meningiomas and an independent validation cohort of 56 meningiomas with comprehensive clinical follow-up data from separate institutions. Bioinformatic analysis was used to identify prognostic genes and generate a gene-signature risk score between 0 and 1 for local recurrence. RESULTS We identified a 36-gene signature of meningioma recurrence after resection that achieved an area under the curve of 0.86 in identifying tumors at risk for adverse clinical outcomes. The gene-signature risk score compared favorably to World Health Organization (WHO) grade in stratifying cases by local freedom from recurrence (LFFR, P < .001 vs .09, log-rank test), shorter time to failure (TTF, F-test, P < .0001), and overall survival (OS, P < .0001 vs .07) and was independently associated with worse LFFR (relative risk [RR] 1.56, 95% CI 1.30-1.90) and OS (RR 1.32, 95% CI 1.07-1.64), after adjusting for clinical covariates. When tested on an independent validation cohort, the gene-signature risk score remained associated with shorter TTF (F-test, P = .002), compared favorably to WHO grade in stratifying cases by OS (P = .003 vs P = .10), and was significantly associated with worse OS (RR 1.86, 95% CI 1.19-2.88) on multivariate analysis. CONCLUSION The prognostic meningioma gene-expression signature and risk score presented may be useful for identifying patients at risk for recurrence.
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Affiliation(s)
- William C Chen
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Harish N Vasudevan
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Abrar Choudhury
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Melike Pekmezci
- Department of Pathology, University of California San Francisco, San Francisco, California
| | - Calixto-Hope G Lucas
- Department of Pathology, University of California San Francisco, San Francisco, California
| | - Joanna Phillips
- Department of Pathology, University of California San Francisco, San Francisco, California
| | - Stephen T Magill
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Matthew S Susko
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Nancy Ann Oberheim Bush
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Lauren Boreta
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Jean L Nakamura
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Javier E Villanueva-Meyer
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Penny K Sneed
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Arie Perry
- Department of Pathology, University of California San Francisco, San Francisco, California
| | - Michael W McDermott
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - David A Solomon
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Philip V Theodosopoulos
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - David R Raleigh
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
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17
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Choudhury A, Magill S, Prager B, Eaton C, Lam TC, Pu JKS, Li LF, Leung G, Vasudevan HN, Lucas CHG, Chan JW, Wendt J, Guerra G, Susko MS, Braunstein S, Villanueva-Meyer J, Bush NAO, Sneed PK, Berger M, Perry A, Solomon D, McDermott MW, Costello J, Francis S, Rich J, Raleigh D. EPCO-36. GENOMIC INSTABILITY AND TRANSCRIPTOMIC SIGNATURES UNDERLYING EPIGENETIC MENINGIOMA SUBGROUPS REVEALS MECHANISMS OF IMMUNE INFILTRATION AND THERAPEUTIC VULNERABILITIES. Neuro Oncol 2020. [DOI: 10.1093/neuonc/noaa215.315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Meningioma treatments are limited due to incomplete understanding of meningioma biology. To address this, we performed multiplatform molecular profiling on 565 meningiomas with comprehensive clinical data to define genomic drivers and identify therapeutic vulnerabilities.
METHODS
DNA methylation profiling was performed on meningiomas from UCSF (n=200, discovery) and Hong Kong University (n=365, validation). Median follow-up was 5.6 years, and there were 388/142/35 WHO grade I/II/III meningiomas. Copy number variants (CNVs) were calculated for all meningiomas, and RNA sequencing was performed on UCSF meningiomas. Cell type deconvolution, metagenomics, CRISPR, and pharmacology were used for mechanistic and functional validation.
RESULTS
Unsupervised hierarchical clustering of differentially methylated DNA probes revealed that meningiomas were comprised of 3 epigenetic subgroups associated with good, intermediate, and poor outcomes, with representation from all WHO grades in each subgroup. Meningiomas from the subgroup with the best outcomes (52% WHO grade I) were distinguished by recurrent gain of Chr5. Meningiomas from the subgroup with intermediate outcomes (31% WHO grade II) were distinguished by genomic stability, enrichment of innate immune genes, and immune infiltration in the setting of endogenous retroviral gene re-expression, a mechanism of immune recruitment. The most aggressive subgroup of meningiomas (57% WHO grade III) was distinguished by genomic instability, including recurrent loss of Chr22q harboring NF2, and decreased immune infiltration. Consistently, NF2 suppression in primary meningioma cells derived from immunogenic meningiomas decreased expression of innate immune genes critical for immune recruitment, suggesting a novel immunostimulatory function of NF2. The most aggressive subgroup of meningiomas were further distinguished by activation of the mitogenic FOXM1 transcriptional program, and recurrent loss of Chr9p harboring CDKN2A/B, which rendered primary meningioma cells from this subgroup susceptible to CDK4/6 inhibitors.
CONCLUSIONS
Meningiomas are comprised of 3 epigenetic subgroups defined by genetic mechanisms driving immune infiltration in the tumor microenvironment and meningioma cell proliferation.
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Affiliation(s)
- Abrar Choudhury
- University of California, San Francisco, San Francisco, CA, USA
| | - Stephen Magill
- University of California, San Francisco, San Francisco, CA, USA
| | - Briana Prager
- University of California, San Diego, San Diego, CA, USA
| | - Charlotte Eaton
- University of California, San Francisco, San Francisco, CA, USA
| | | | | | | | - Gerald Leung
- The University of Hong Kong, Hong Kong, Hong Kong
| | | | | | - Jason W Chan
- University of California, San Francisco, San Francisco, CA, USA
| | - Jake Wendt
- University of California, San Francisco, San Francisco, CA, USA
| | - Geno Guerra
- University of California, San Francisco, San Francisco, CA, USA
| | - Matthew S Susko
- University of California, San Francisco, San Francisco, CA, USA
| | | | | | | | - Penny K Sneed
- University of California, San Francisco, San Francisco, CA, USA
| | - Mitchel Berger
- University of California, San Francisco, San Francisco, CA, USA
| | - Arie Perry
- University of California, San Francisco, San Francisco, CA, USA
| | - David Solomon
- University of California, San Francisco, San Francisco, CA, USA
| | | | - Joseph Costello
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Stephen Francis
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Jeremy Rich
- University of California - San Diego and Sanford Consortium for Regenerative Medicine, La Jolla, CA, USA
| | - David Raleigh
- University of California, San Francisco, San Francisco, CA, USA
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18
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Chen W, Vasudevan HN, Choudhury A, Lucas CHG, Magill S, Susko MS, Braunstein S, Boreta L, Nakamura J, Sneed PK, Bush NAO, Villanueva-Meyer J, Perry A, Solomon D, McDermott M, Theodosopoulos P, Raleigh D. BIOM-52. A PROGNOSTIC GENE EXPRESSION RISK SCORE FOR MENINGIOMA. Neuro Oncol 2020. [DOI: 10.1093/neuonc/noaa215.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Clinical biomarkers for identifying patients at risk for recurrence after resection of meningioma are lacking and are needed for guiding adjuvant therapy. The aim of this study was to identify a prognostic gene expression signature for meningioma.
METHODS
Targeted gene expression analysis was performed on a discovery dataset of 96 meningiomas with suitable tissue identified from a retrospective institutional biorepository. Recurrence was dichotomized based on the median time to local recurrence (TTR). With median follow-up of 6.4 years, the discovery dataset was enriched for clinical endpoints of local recurrence (58%), mortality (42%), and disease-specific mortality (49% of deaths). A 266 gene expression panel was used to interrogate the discovery dataset, and a prognostic gene signature and risk score was generated using prediction analysis for microarrays (PAM) and elastic net regression. The risk score was validated using gene expression data (GSE58037) from 56 meningiomas resected at an independent institution (20% local recurrence, 18% mortality, median follow-up 5.4 years).
RESULTS
A 36-gene signature was identified achieving an AUC of 0.86 for TTR faster than the median in the discovery cohort. A risk score between 0 and 1 based on this signature was strongly associated with shorter TTR (F-test, P< 0.0001), and on multivariate Cox regression (MVA), was independently associated with recurrence (RR 1.56 per 0.1 increase, 95% CI 1.30–1.90, P< 0.0001) and mortality (RR 1.32 per 0.1 increase, 1.07–1.64, P=0.01) after adjusting for WHO grade, age, extent of resection, and sex. Similarly, in the validation dataset, the gene risk score was correlated with shorter TTR (P=0.002) and associated with mortality on MVA (RR 1.86 per 0.1 increase, 1.19–2.88, P=0.005) after adjustment for WHO grade.
CONCLUSIONS
The prognostic meningioma gene expression risk score presented here could be useful in identifying patients at higher risk of progression after resection.
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Affiliation(s)
- William Chen
- University of California San Francisco, San Francisco, CA, USA
| | | | - Abrar Choudhury
- University of California San Francisco, San Francisco, CA, USA
| | | | - Stephen Magill
- University of California San Francisco, San Francisco, CA, USA
| | - Matthew S Susko
- University of California San Francisco, San Francisco, CA, USA
| | | | - Lauren Boreta
- University of California San Francisco, San Francisco, CA, USA
| | - Jean Nakamura
- University of California San Francisco, San Francisco, CA, USA
| | - Penny K Sneed
- University of California San Francisco, San Francisco, CA, USA
| | | | | | - Arie Perry
- University of California San Francisco, San Francisco, CA, USA
| | - David Solomon
- University of California San Francisco, San Francisco, CA, USA
| | | | | | - David Raleigh
- University of California San Francisco, San Francisco, CA, USA
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19
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Breshears JD, Chang J, Molinaro AM, Sneed PK, McDermott MW, Tward A, Theodosopoulos PV. Temporal Dynamics of Pseudoprogression After Gamma Knife Radiosurgery for Vestibular Schwannomas-A Retrospective Volumetric Study. Neurosurgery 2020. [PMID: 29518221 DOI: 10.1093/neuros/nyy019] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The optimal observation interval after the radiosurgical treatment of a sporadic vestibular schwannoma, prior to salvage intervention, is unknown. OBJECTIVE To determine an optimal postradiosurgical treatment interval for differentiating between pseudoprogression and true tumor growth by analyzing serial volumetric data. METHODS This single-institution retrospective study included all sporadic vestibular schwannomas treated with Gamma Knife radiosurgery (Eketa AB, Stockholm, Sweden; 12-13 Gy) from 2002 to 2014. Volumetric analysis was performed on all available pre- and posttreatment magnetic resonance imaging scans. Tumors were classified as "stable/decreasing," "transient enlargement", or "persistent growth" after treatment, based on incrementally increasing follow-up durations. RESULTS A total of 118 patients included in the study had a median treatment tumor volume of 0.74 cm3 (interquartile range [IQR] = 0.34-1.77 cm3) and a median follow-up of 4.1 yr (IQR = 2.6-6.0 yr). Transient tumor enlargement was observed in 44% of patients, beginning at a median of 1 yr (IQR = 0.6-1.4 yr) posttreatment, with 90% reaching peak volume within 3.5 yr, posttreatment. Volumetric enlargement resolved at a median of 2.4 yr (IQR 1.9-3.6 yr), with 90% of cases resolved at 6.9 yr. Increasing follow-up revealed that many of the tumors initially enlarging 1 to 3 yr after stereotactic radiosurgery ultimately begin to shrink on longer follow-up (45% by 4 yr, 77% by 6 yr). CONCLUSION Tumor enlargement within ∼3.5 yr of treatment should not be used as a sole criterion for salvage treatment. Patient symptoms and tumor size must be considered, and giving tumors a chance to regress before opting for salvage treatment may be worthwhile.
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Affiliation(s)
- Jonathan D Breshears
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Joseph Chang
- Department of Otolaryngology, Head and Neck Surgery, University of California, San Francisco, San Francisco, California
| | - Annette M Molinaro
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,Department of Epidemiology and Biostatistics, Uni-versity of California, San Francisco, San Francisco, California
| | - Penny K Sneed
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Michael W McDermott
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Aaron Tward
- Department of Otolaryngology, Head and Neck Surgery, University of California, San Francisco, San Francisco, California
| | - Philip V Theodosopoulos
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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20
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Paddick I, Hopewell JW, Klinge T, Graffeo CS, Pollock BE, Sneed PK. Letter: Treatment Outcomes and Dose Rate Effects Following Gamma Knife Stereotactic Radiosurgery for Vestibular Schwannomas. Neurosurgery 2019; 86:E407-E409. [DOI: 10.1093/neuros/nyz547] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ian Paddick
- Queen Square Gamma Knife Centre National Hospital for Neurology and Neurosurgery London, United Kingdom
| | - John W Hopewell
- Green Templeton College University of Oxford Oxford, United Kingdom
| | - Thomas Klinge
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences Department Medical Physics and Biomedical Engineering University College London London, United Kingdom
- Centre for Medical Image Computing Department Medical Physics and Biomedical Engineering University College London London, United Kingdom
- School of Biomedical Engineering & Imaging Sciences King's College London London, United Kingdom
| | | | - Bruce E Pollock
- Department of Neurosurgery Mayo Clinic and Foundation Rochester, Minnesota
| | - Penny K Sneed
- Department of Radiation Oncology University of California San Francisco San Francisco, California
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21
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Seymour ZA, Chan JW, Sneed PK, Kano H, Lehocky CA, Jacobs RC, Ye H, Chytka T, Liscak R, Lee CC, Yang HC, Ding D, Sheehan J, Feliciano CE, Rodriguez-Mercado R, Chiang VL, Hess JA, Sommaruga S, McShane B, Lee J, Vasas LT, Kaufmann AM, Grills I, McDermott MW. Dose response and architecture in volume staged radiosurgery for large arteriovenous malformations: A multi-institutional study. Radiother Oncol 2019; 144:180-188. [PMID: 31835173 DOI: 10.1016/j.radonc.2019.09.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 08/13/2019] [Accepted: 09/24/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Optimal treatment paradigm for large arteriovenous malformations (AVMs) is controversial. Volume-staged stereotactic radiosurgery (VS-SRS) provides an effective option for these high-risk lesions, but optimizing treatment for these recalcitrant and rare lesions has proven difficult. METHODS This is a multi-centered retrospective review of patients treated with a planned prospective volume staging approach to stereotactically treat the entire nidus of an AVM with volume stages separated by intervals of 3-6 months. A total of 9 radiosurgical centers treated 257 patients with VS-SRS between 1991 and 2016. We evaluated near complete response (nCR), obliteration, cure, and overall survival. RESULTS With a median age of 33 years old at the time of first SRS volume stage, patients received 2-4 total volume stages and a median follow up of 5.7 years after VS-SRS. The median total AVM nidus volume was 23.25 cc (range: 7.7-94.4 cc) with a median margin dose per stage of 17 Gy (range: 12-20 Gy). Total AVM volume, margin dose per stage, compact nidus, lack of prior embolization, and lack of thalamic location involvement were all associated with improved outcomes. Dose >/= 17.5 Gy was strongly associated with improved rates of nCR, obliteration, and cure. With dose >/= 17.5 Gy, 5- and 10-year cure rates were 33.7% and 76.8% in evaluable patients compared to 23.7% and 34.7% of patients with 17 Gy and 6.4% and 20.6% with <17 Gy per volume-stage (p = 0.004). Obliteration rates in diffuse nidus architecture with <17 Gy were particularly poor with none achieving obliteration compared to 32.3% with doses >/= 17 Gy at 5 years (p = 0.007). Comparatively, lesions with a compact nidus architecture exhibited obliteration rates at 5 years were 10.7% vs 9.3% vs 26.6% for dose >17 Gy vs 17 Gy vs >/=17.5 Gy. CONCLUSION VS-SRS is an option for upfront treatment of large AVMs. Higher dose was associated with improved rates of nCR, obliteration, and cure suggesting that larger volumetric responses may facilitate salvage therapy and optimize the chance for cure.
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Affiliation(s)
- Zachary A Seymour
- Beaumont Health, Oakland University William Beaumont School of Medicine, Department of Radiation Oncology, United States.
| | - Jason W Chan
- University of California - San Francisco School of Medicine, Department of Radiation Oncology, United States
| | - Penny K Sneed
- University of California - San Francisco School of Medicine, Department of Radiation Oncology, United States
| | - Hideyuki Kano
- University of Pittsburgh, School of Medicine, Department of Neurosurgery, United States
| | - Craig A Lehocky
- University of Pittsburgh, School of Medicine, Department of Neurosurgery, United States
| | - Rachel C Jacobs
- University of Pittsburgh, School of Medicine, Department of Neurosurgery, United States
| | - Hong Ye
- Beaumont Health, Department of Radiation Oncology, United States
| | - Tomas Chytka
- Na Homolce Hospital, Department of Stereotactic Radioneurosurgery, Prague, Czech Republic
| | - Roman Liscak
- Na Homolce Hospital, Department of Stereotactic Radioneurosurgery, Prague, Czech Republic
| | - Cheng-Chia Lee
- Taipei General Hospital, Department of Neurosurgery, Taiwan
| | - Huai-Che Yang
- Taipei General Hospital, Department of Neurosurgery, Taiwan
| | - Dale Ding
- University of Virginia School of Medicine, Department of Neurosurgery, United States
| | - Jason Sheehan
- University of Virginia School of Medicine, Department of Neurosurgery, United States
| | - Caleb E Feliciano
- University of Puerto Rico School of Medicine, Department of Neurosurgery, United States
| | | | - Veronica L Chiang
- Yale University School of Medicine, Department of Neurosurgery, United States
| | - Judith A Hess
- Yale University School of Medicine, Department of Neurosurgery, United States
| | - Samuel Sommaruga
- Yale University School of Medicine, Department of Neurosurgery, United States
| | - Brendan McShane
- University of Pennsylvania School of Medicine, Department of Neurosurgery, United States
| | - John Lee
- University of Pennsylvania School of Medicine, Department of Neurosurgery, United States
| | - Lucas T Vasas
- University of Manitoba School of Medicine, Department of Neurosurgery, Canada
| | - Anthony M Kaufmann
- University of Manitoba School of Medicine, Department of Neurosurgery, Canada
| | - Inga Grills
- Beaumont Health, Oakland University William Beaumont School of Medicine, Department of Radiation Oncology, United States
| | - Michael W McDermott
- University of California - San Francisco School of Medicine, Department of Neurosurgery, United States
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22
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Susko MS, Garcia MA, Ma L, Nakamura JL, Raleigh DR, Fogh S, Theodosopoulos P, McDermott M, Sneed PK, Braunstein SE. Stereotactic Radiosurgery to More Than 10 Brain Metastases: Evidence to Support the Role of Radiosurgery for Ideal Hippocampal Sparing in the Treatment of Multiple Brain Metastases. World Neurosurg 2019; 135:e174-e180. [PMID: 31785436 DOI: 10.1016/j.wneu.2019.11.089] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/14/2019] [Accepted: 11/15/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Brain metastases are a common occurrence, with literature supporting the treatment of a limited number of brain metastases with stereotactic radiosurgery (SRS), as opposed to whole brain radiotherapy (WBRT). Less well understood is the role of SRS in patients with ≥10 brain metastases. METHODS Patients treated with SRS to ≥10 brain metastases without concurrent WBRT between March 1999 and December 2016 were reviewed. Analysis was performed for overall survival, treated lesion freedom from progression (FFP), freedom from new metastases (FFNMs), and adverse radiation effect. Hippocampal volumes were retrospectively generated in patients treated with up-front SRS for evaluation of dose volume metrics. RESULTS A total of 143 patients were identified with 75 patients having up-front SRS and 68 patients being treated as salvage therapy after prior WBRT. The median number of lesions per patient was 13 (interquartile range [IQR], 11-17). Median total volume of treatment was 4.1 cm3 (IQR, 2.0-9.9 cm3). The median 12-month FFP for up-front and salvage treatment was 96.8% (95% confidence interval [CI], 95.5-98.1) and 83.6% (95% CI, 79.9-87.5), respectively (P < 0.001). Twelve-month FFNMs for up-front and salvage SRS was 18.8% (95% CI, 10.9-32.3) versus 19.2% (95% CI, 9.7-37.8), respectively (P = 0.90). The mean hippocampal dose was 150 cGy (IQR, 100-202 cGy). CONCLUSIONS Excellent rates of local control can be achieved when treating patients with >10 intracranial metastases either in the up-front or salvage setting. Hippocampal sparing is readily achievable with expected high rates of new metastatic lesions in treated patients.
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Affiliation(s)
- Matthew S Susko
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Michael A Garcia
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Lijun Ma
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Jean L Nakamura
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - David R Raleigh
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Shannon Fogh
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Philip Theodosopoulos
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Michael McDermott
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Penny K Sneed
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA.
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23
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Vasudevan HN, Braunstein SE, Phillips JJ, Pekmezci M, Tomlin BA, Wu A, Reis GF, Magill ST, Zhang J, Feng FY, Nicholaides T, Chang SM, Sneed PK, McDermott MW, Berger MS, Perry A, Raleigh DR. Comprehensive Molecular Profiling Identifies FOXM1 as a Key Transcription Factor for Meningioma Proliferation. Cell Rep 2019; 22:3672-3683. [PMID: 29590631 PMCID: PMC8204688 DOI: 10.1016/j.celrep.2018.03.013] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [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: 09/19/2017] [Revised: 01/08/2018] [Accepted: 03/04/2018] [Indexed: 12/24/2022] Open
Abstract
Meningioma is the most common primary intracranial tumor, but the molecular drivers of aggressive meningioma are incompletely understood. Using 280 human meningioma samples and RNA sequencing, immunohistochemistry, whole-exome sequencing, DNA methylation arrays, and targeted gene expression profiling, we comprehensively define the molecular profile of aggressive meningioma. Transcriptomic analyses identify FOXM1 as a key transcription factor for meningioma proliferation and a marker of poor clinical outcomes. Consistently, we discover genomic and epigenomic factors associated with FOXM1 activation in aggressive meningiomas. Finally, we define a FOXM1/Wnt signaling axis in meningioma that is associated with a mitotic gene expression program, poor clinical outcomes, and proliferation of primary meningioma cells. In summary, we find that multiple molecular mechanisms converge on a FOXM1/Wnt signaling axis in aggressive meningioma. Using multiplatform molecular profiling, Vasudevan et al. comprehensively define the molecular profile of aggressive meningioma. They identify genomic, epigenomic, and transcriptomic mechanisms that converge on a FOXM1/Wnt signaling axis in aggressive meningioma that is associated with meningioma cell proliferation and is a marker of poor clinical outcomes across molecular subgroups.
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Affiliation(s)
- Harish N Vasudevan
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Joanna J Phillips
- Department of Pathology, University of California, San Francisco, San Francisco, CA, USA; Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Melike Pekmezci
- Department of Pathology, University of California, San Francisco, San Francisco, CA, USA; Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA
| | - Bryan A Tomlin
- Department of Economics, California State University Channel Islands, Camarillo, CA, USA
| | - Ashley Wu
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Gerald F Reis
- Department of Pathology, University of California, San Francisco, San Francisco, CA, USA
| | - Stephen T Magill
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Jie Zhang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Felix Y Feng
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Theodore Nicholaides
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Susan M Chang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Penny K Sneed
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Michael W McDermott
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Arie Perry
- Department of Pathology, University of California, San Francisco, San Francisco, CA, USA; Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - David R Raleigh
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA; Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA.
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24
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Morin O, Chen WC, Nassiri F, Susko M, Magill ST, Vasudevan HN, Wu A, Vallières M, Gennatas ED, Valdes G, Pekmezci M, Alcaide-Leon P, Choudhury A, Interian Y, Mortezavi S, Turgutlu K, Bush NAO, Solberg TD, Braunstein SE, Sneed PK, Perry A, Zadeh G, McDermott MW, Villanueva-Meyer JE, Raleigh DR. Integrated models incorporating radiologic and radiomic features predict meningioma grade, local failure, and overall survival. Neurooncol Adv 2019; 1:vdz011. [PMID: 31608329 PMCID: PMC6777505 DOI: 10.1093/noajnl/vdz011] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [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] [Indexed: 02/06/2023] Open
Abstract
Background We investigated prognostic models based on clinical, radiologic, and radiomic feature to preoperatively identify meningiomas at risk for poor outcomes. Methods Retrospective review was performed for 303 patients who underwent resection of 314 meningiomas (57% World Health Organization grade I, 35% grade II, and 8% grade III) at two independent institutions, which comprised primary and external datasets. For each patient in the primary dataset, 16 radiologic and 172 radiomic features were extracted from preoperative magnetic resonance images, and prognostic features for grade, local failure (LF) or overall survival (OS) were identified using the Kaplan–Meier method, log-rank tests and recursive partitioning analysis. Regressions and random forests were used to generate and test prognostic models, which were validated using the external dataset. Results Multivariate analysis revealed that apparent diffusion coefficient hypointensity (HR 5.56, 95% CI 2.01–16.7, P = .002) was associated with high grade meningioma, and low sphericity was associated both with increased LF (HR 2.0, 95% CI 1.1–3.5, P = .02) and worse OS (HR 2.94, 95% CI 1.47–5.56, P = .002). Both radiologic and radiomic predictors of adverse meningioma outcomes were significantly associated with molecular markers of aggressive meningioma biology, such as somatic mutation burden, DNA methylation status, and FOXM1 expression. Integrated prognostic models combining clinical, radiologic, and radiomic features demonstrated improved accuracy for meningioma grade, LF, and OS (area under the curve 0.78, 0.75, and 0.78, respectively) compared to models based on clinical features alone. Conclusions Preoperative radiologic and radiomic features such as apparent diffusion coefficient and sphericity can predict tumor grade, LF, and OS in patients with meningioma.
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Affiliation(s)
- Olivier Morin
- Department of Radiation Oncology, University of California San Francisco, California
| | - William C Chen
- Department of Radiation Oncology, University of California San Francisco, California
| | - Farshad Nassiri
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Matthew Susko
- Department of Radiation Oncology, University of California San Francisco, California
| | - Stephen T Magill
- Department of Neurological Surgery, University of California San Francisco, California
| | - Harish N Vasudevan
- Department of Radiation Oncology, University of California San Francisco, California
| | - Ashley Wu
- Department of Radiation Oncology, University of California San Francisco, California
| | - Martin Vallières
- Department of Radiation Oncology, University of California San Francisco, California
| | - Efstathios D Gennatas
- Department of Radiation Oncology, University of California San Francisco, California
| | - Gilmer Valdes
- Department of Radiation Oncology, University of California San Francisco, California
| | - Melike Pekmezci
- Department of Pathology, University of California San Francisco, California
| | - Paula Alcaide-Leon
- Department of Radiology and Biomedical Imaging, University of California San Francisco, California
| | - Abrar Choudhury
- Department of Radiation Oncology, University of California San Francisco, California.,Department of Neurological Surgery, University of California San Francisco, California
| | - Yannet Interian
- Department of Radiation Oncology, University of California San Francisco, California
| | - Siavash Mortezavi
- Department of Radiation Oncology, University of California San Francisco, California
| | - Kerem Turgutlu
- Department of Radiation Oncology, University of California San Francisco, California
| | | | - Timothy D Solberg
- Department of Radiation Oncology, University of California San Francisco, California
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San Francisco, California
| | - Penny K Sneed
- Department of Radiation Oncology, University of California San Francisco, California
| | - Arie Perry
- Department of Pathology, University of California San Francisco, California.,Department of Neurological Surgery, University of California San Francisco, California
| | - Gelareh Zadeh
- Department of Radiation Oncology, University of California San Francisco, California
| | - Michael W McDermott
- Department of Neurological Surgery, University of California San Francisco, California
| | | | - David R Raleigh
- Department of Radiation Oncology, University of California San Francisco, California.,Department of Neurological Surgery, University of California San Francisco, California
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25
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Langfitt JT, Quigg M, Yan G, Yu W, Ward MM, Barbaro NM, Chang EF, Broshek DK, Laxer KD, Cole AJ, Sneed PK, Hess C, Tripathi M, Heck CN, Miller JW, Garcia PA, McEvoy A, Fountain NB, Salanova V, Knowlton RC, Bagić A, Henry T, Kapoor S, McKhann G, Palade AE, Reuber M, Tecoma E. Direct and indirect costs associated with stereotactic radiosurgery or open surgery for medial temporal lobe epilepsy: Results from the ROSE trial. Epilepsia 2019; 60:1453-1461. [PMID: 31185129 DOI: 10.1111/epi.16072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/01/2019] [Accepted: 05/22/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To determine whether a less-invasive approach to surgery for medically refractory temporal lobe epilepsy is associated with lower health care costs and costs of lost productivity over time, compared to open surgery. METHODS We compared direct medical costs and indirect productivity costs associated with treatment with stereotactic radiosurgery (SRS) or anterior temporal lobectomy (ATL) in the ROSE (Radiosurgery or Open Surgery for Epilepsy) trial. Health care use was abstracted from hospital bills, the study database, and diaries in which participants recorded health care use and time lost from work while seeking care. Costs of use were calculated using a Medicare costing approach used in a prior study of the costs of ATL. The power of many analyses was limited by the sample size and data skewing. RESULTS Combined treatment and follow-up costs (in thousands of US dollars) did not differ between SRS (n = 20, mean = $76.6, 95% confidence interval [CI] = 50.7-115.6) and ATL (n = 18, mean = $79.0, 95% CI = 60.09-103.8). Indirect costs also did not differ. More ATL than SRS participants were free of consciousness-impairing seizures in each year of follow-up (all P < 0.05). Costs declined following ATL (P = 0.005). Costs tended to increase over the first 18 months following SRS (P = 0.17) and declined thereafter (P = 0.06). This mostly reflected hospitalizations for SRS-related adverse events in the second year of follow-up. SIGNIFICANCE Lower initial costs of SRS for medial temporal lobe epilepsy were largely offset by hospitalization costs related to adverse events later in the course of follow-up. Future studies of less-invasive alternatives to ATL will need to assess adverse events and major costs systematically and prospectively to understand the economic implications of adopting these technologies.
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Affiliation(s)
| | - Mark Quigg
- University of Virginia, Charlottesville, Virginia
| | - Guofen Yan
- University of Virginia, Charlottesville, Virginia
| | - Wei Yu
- University of Virginia, Charlottesville, Virginia
| | - Mariann M Ward
- University of California, San Francisco, San Francisco, California
| | | | - Edward F Chang
- University of California, San Francisco, San Francisco, California
| | | | - Kenneth D Laxer
- California Pacific Medical Center, San Francisco, California
| | - Andrew J Cole
- Massachusetts General Hospital, Boston, Massachusetts
| | - Penny K Sneed
- University of California, San Francisco, San Francisco, California
| | - Christopher Hess
- University of California, San Francisco, San Francisco, California
| | | | | | | | - Paul A Garcia
- University of California, San Francisco, San Francisco, California
| | | | | | | | | | - Anto Bagić
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | | | | | - Evelyn Tecoma
- University of California, San Diego, San Diego, California
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26
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Chapman CH, Hara JH, Molinaro AM, Clarke JL, Oberheim Bush NA, Taylor JW, Butowski NA, Chang SM, Fogh SE, Sneed PK, Nakamura JL, Raleigh DR, Braunstein SE. Reirradiation of recurrent high-grade glioma and development of prognostic scores for progression and survival. Neurooncol Pract 2019; 6:364-374. [PMID: 31555451 DOI: 10.1093/nop/npz017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/25/2019] [Accepted: 03/04/2019] [Indexed: 12/17/2022] Open
Abstract
Background Optimal techniques and patient selection for salvage reirradiation of high-grade glioma (HGG) are unclear. In this study, we identify prognostic factors for freedom from progression (FFP) and overall survival (OS) after reirradiation, risk factors for high-grade toxicity, and validate clinical prognostic scores. Methods A total of 116 patients evaluated between 2000 and 2018 received reirradiation for HGG (99 WHO grade IV, 17 WHO grade III). Median time to first progression after initial therapy was 10.6 months. Salvage therapies before reirradiation included surgery (31%) and systemic therapy (41%). Sixty-five patients (56%) received single-fraction stereotactic radiosurgery (SRS) as reirradiation. The median biologically effective dose (BED) was 47.25 Gy, and the median planning target volume (PTV) was 4.8 cc for SRS and 95.0 cc for non-SRS treatments. Systemic therapy was given concurrently to 52% and adjuvantly to 74% of patients. Results Median FFP was 4.9 months, and median OS was 11.0 months. Significant multivariable prognostic factors for FFP were performance status, time to initial progression, and BED; for OS they were age, time to initial progression, and PTV volume at recurrence. High-grade toxicity was correlated to PTV size at recurrence. Three-level prognostic scores were generated for FFP and OS, with cross-validated receiver operating characteristic area under the curve (AUC) of 0.640 and 0.687, respectively. Conclusions Clinical variables at the time of reirradiation for HGG can be used to prognosticate FFP and OS.
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Affiliation(s)
| | - Jared H Hara
- John A. Burns School of Medicine, University of Hawaii, Honolulu
| | - Annette M Molinaro
- Department of Neurological Surgery, University of California San Francisco, USA.,Department of Epidemiology & Biostatistics, University of California San Francisco
| | - Jennifer L Clarke
- Department of Neurological Surgery, University of California San Francisco, USA.,Department of Neurology, University of California San Francisco
| | - Nancy Ann Oberheim Bush
- Department of Neurological Surgery, University of California San Francisco, USA.,Department of Neurology, University of California San Francisco
| | - Jennie W Taylor
- Department of Neurological Surgery, University of California San Francisco, USA.,Department of Neurology, University of California San Francisco
| | - Nicholas A Butowski
- Department of Neurological Surgery, University of California San Francisco, USA
| | - Susan M Chang
- Department of Neurological Surgery, University of California San Francisco, USA
| | - Shannon E Fogh
- Department of Radiation Oncology, University of California San Francisco
| | - Penny K Sneed
- Department of Radiation Oncology, University of California San Francisco
| | - Jean L Nakamura
- Department of Neurology, University of California San Francisco
| | - David R Raleigh
- Department of Radiation Oncology, University of California San Francisco
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San Francisco
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27
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Susko M, Yu Y, Ma L, Nakamura J, Fogh S, Raleigh DR, Golden E, Theodosopoulos PV, McDermott MW, Sneed PK, Braunstein SE. Preoperative Dural Contact and Recurrence Risk After Surgical Cavity Stereotactic Radiosurgery for Brain Metastases: New Evidence in Support of Consensus Guidelines. Adv Radiat Oncol 2019; 4:458-465. [PMID: 31360800 PMCID: PMC6639748 DOI: 10.1016/j.adro.2019.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 02/28/2019] [Accepted: 03/03/2019] [Indexed: 11/19/2022] Open
Abstract
Purpose The incidence of brain metastases is increasing as a result of more routine diagnostic imaging and improved extracranial systemic treatment strategies. As noted in recent consensus guidelines, postoperative stereotactic radiosurgery (SRS) to the resection cavity has lower rates of local control than whole brain radiation therapy but improved cognitive outcomes. Further analyses are needed to improve local control and minimize toxicity. Methods and materials Patients receiving SRS to a resection cavity between 2006 and 2016 were retrospectively analyzed. Presurgical variables, including tumor location, diameter, dural/meningeal contact, and histology, were collected, as were SRS treatment parameters. Patients had routine follow-up with magnetic resonance imaging, and those noted to have local failure were further assessed for the recurrence location, distance from the target volume, and dosimetric characteristics. Results Overall, 82 patients and 85 resection cavities underwent postoperative SRS during the study period. Of these, 58 patients with 60 resection cavities with available follow-up magnetic resonance imaging scans were included in this analysis. With a median follow-up of 19.8 months, local recurrence occurred in 12 of the resection cavities for a 15% 1-year and 18% 2-year local recurrence rate. Pretreatment tumor volume contacted the dura/meninges in 100% of cavities with recurrence versus 67% of controlled cavities (P = .025). A total of 5 infield, 5 marginal, and 4 out-of-field recurrences were found, with a median distance to the centroid from the target volume of 3 mm. The addition of a 10-mm dural margin increased the target volume overlap with the recurrence contours for 10 of the 14 recurrences. Conclusions Dural contact was associated with an increased rate of recurrence for patients who received SRS to a surgical cavity, and the median distance of marginal recurrences from the target volume was 3 mm. These results provide evidence in support of recent consensus guidelines suggesting that additional dural margin on SRS volumes may benefit local control.
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Affiliation(s)
- Matthew Susko
- Department of Radiation Oncology, San Francisco, California
- Corresponding author. University of California – San Francisco, Department of Radiation Oncology, 1600 Divisadero Street, Basement Level, San Francisco, CA 94115.
| | - Yao Yu
- Department of Radiation Oncology, San Francisco, California
| | - Lijun Ma
- Department of Radiation Oncology, San Francisco, California
| | - Jean Nakamura
- Department of Radiation Oncology, San Francisco, California
| | - Shannon Fogh
- Department of Radiation Oncology, San Francisco, California
| | | | - Encouse Golden
- Department of Radiation Oncology, San Francisco, California
| | | | | | - Penny K. Sneed
- Department of Radiation Oncology, San Francisco, California
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28
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Chang J, Breshears JD, Molinaro AM, Sneed PK, McDermott MW, Theodosopoulos PV, Tward AD. Impact of pretreatment growth on Tumor control for vestibular schwannomas following gamma knife. Laryngoscope 2018; 129:743-747. [PMID: 30408172 DOI: 10.1002/lary.27427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 06/07/2018] [Accepted: 06/14/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine if volumetric growth prior to gamma knife (GK) radiosurgery predicts long-term tumor control. STUDY DESIGN Retrospective cohort study. METHODS Sporadic vestibular schwannomas (VS) treated with GK between 2002 and 2014 at a single tertiary care center were identified. Patients were included if they had over 6 months of pretreatment observation and over 1.5 years of posttreatment follow-up. Volumetric tumor analysis was performed on T1 postcontrast imaging. Pretreatment and posttreatment volume change was calculated. Tumors with over 20% volume increase were classified as growing. RESULTS There were 62 patients included in this study; 48 had pretreatment growth and 14 had no pretreatment growth. Median tumor volume was 0.58 ± 1.8 cm3 and median follow-up was 3.3 ± 2.0 years. For tumors with and without pretreatment growth, salvage treatment rates were 2% and 7% (P = .35), and posttreatment radiologic stability rates were 73% and 86%, respectively (P = .33). Median pretreatment growth was 27 ± 33% per year for tumors with posttreatment radiographic growth and 18 ± 26% per year for tumors without posttreatment radiographic growth (P = .99). CONCLUSIONS Pretreatment growth was not associated with increased salvage treatment or posttreatment radiographic progression rates in VS following GK. LEVEL OF EVIDENCE 4 Laryngoscope, 129:743-747, 2019.
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Affiliation(s)
- Joseph Chang
- Department of Otolaryngology-Head and Neck Surgery, San Francisco, San Francisco, California, U.S.A
| | - Jonathan D Breshears
- Department of Neurological Surgery, San Francisco, San Francisco, California, U.S.A
| | - Annette M Molinaro
- Department of Neurological Surgery, San Francisco, San Francisco, California, U.S.A
| | - Penny K Sneed
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California, U.S.A
| | - Michael W McDermott
- Department of Neurological Surgery, San Francisco, San Francisco, California, U.S.A
| | | | - Aaron D Tward
- Department of Otolaryngology-Head and Neck Surgery, San Francisco, San Francisco, California, U.S.A
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Garcia MA, Anwar M, Yu Y, Duriseti S, Merritt B, Nakamura J, Hess C, Theodosopoulos PV, McDermott M, Sneed PK, Braunstein SE. Brain metastasis growth on preradiosurgical magnetic resonance imaging. Pract Radiat Oncol 2018; 8:e369-e376. [DOI: 10.1016/j.prro.2018.06.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/16/2018] [Accepted: 06/04/2018] [Indexed: 12/01/2022]
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Barbaro NM, Quigg M, Ward MM, Chang EF, Broshek DK, Langfitt JT, Yan G, Laxer KD, Cole AJ, Sneed PK, Hess CP, Yu W, Tripathi M, Heck CN, Miller JW, Garcia PA, McEvoy A, Fountain NB, Salanova V, Knowlton RC, Bagić A, Henry T, Kapoor S, McKhann G, Palade AE, Reuber M, Tecoma E. Radiosurgery versus open surgery for mesial temporal lobe epilepsy: The randomized, controlled ROSE trial. Epilepsia 2018; 59:1198-1207. [PMID: 29600809 DOI: 10.1111/epi.14045] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare stereotactic radiosurgery (SRS) versus anterior temporal lobectomy (ATL) for patients with pharmacoresistant unilateral mesial temporal lobe epilepsy (MTLE). METHODS This randomized, single-blinded, controlled trial recruited adults eligible for open surgery among 14 centers in the USA, UK, and India. Treatment was either SRS at 24 Gy to the 50% isodose targeting mesial structures, or standardized ATL. Outcomes were seizure remission (absence of disabling seizures between 25 and 36 months), verbal memory (VM), and quality of life (QOL) at 36-month follow-up. RESULTS A total of 58 patients (31 in SRS, 27 in ATL) were treated. Sixteen (52%) SRS and 21 (78%) ATL patients achieved seizure remission (difference between ATL and SRS = 26%, upper 1-sided 95% confidence interval = 46%, P value at the 15% noninferiority margin = .82). Mean VM changes from baseline for 21 English-speaking, dominant-hemisphere patients did not differ between groups; consistent worsening occurred in 36% of SRS and 57% of ATL patients. QOL improved with seizure remission. Adverse events were anticipated cerebral edema and related symptoms for some SRS patients, and cerebritis, subdural hematoma, and others for ATL patients. SIGNIFICANCE These data suggest that ATL has an advantage over SRS in terms of proportion of seizure remission, and both SRS and ATL appear to have effectiveness and reasonable safety as treatments for MTLE. SRS is an alternative to ATL for patients with contraindications for or with reluctance to undergo open surgery.
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Affiliation(s)
- Nicholas M Barbaro
- Department of Neurological Surgery, Indiana University, Indianapolis, IN, USA
| | - Mark Quigg
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
| | - Mariann M Ward
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - Edward F Chang
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - Donna K Broshek
- Department of Psychiatry, University of Virginia, Charlottesville, VA, USA
| | - John T Langfitt
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | - Guofen Yan
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Kenneth D Laxer
- Department of Neurology, California Pacific Medical Center, San Francisco, CA, USA
| | - Andrew J Cole
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Penny K Sneed
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Christopher P Hess
- Department of Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Wei Yu
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Science, New Delhi, India
| | - Christianne N Heck
- Department of Neurology, University of Southern California, Los Angeles, CA, USA
| | - John W Miller
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Paul A Garcia
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Andrew McEvoy
- Department of Clinical and Experimental Epilepsy, University College London, London, UK
| | - Nathan B Fountain
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
| | | | - Robert C Knowlton
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Anto Bagić
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas Henry
- Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - Siddharth Kapoor
- Department of Neurology, University of Kentucky, Lexington, KY, USA
| | - Guy McKhann
- Department of Neurosurgery, Columbia University, New York, NY, USA
| | - Adriana E Palade
- Department of Neurology, University of Louisville, Louisville, KY, USA
| | - Markus Reuber
- Department of Neuroscience, University of Sheffield, Sheffield, UK
| | - Evelyn Tecoma
- Department of Neurology, University of California San Diego, San Diego, CA, USA
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Chen WC, Magill ST, Wu A, Vasudevan HN, Morin O, Aghi MK, Theodosopoulos PV, Perry A, McDermott MW, Sneed PK, Braunstein SE, Raleigh DR. Histopathological features predictive of local control of atypical meningioma after surgery and adjuvant radiotherapy. J Neurosurg 2018; 130:443-450. [PMID: 29624151 DOI: 10.3171/2017.9.jns171609] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 09/05/2017] [Indexed: 01/04/2023]
Abstract
OBEJECTIVE The goal of this study was to investigate the impact of adjuvant radiotherapy (RT) on local recurrence and overall survival in patients undergoing primary resection of atypical meningioma, and to identify predictive factors to inform patient selection for adjuvant RT. METHODS One hundred eighty-two patients who underwent primary resection of atypical meningioma at a single institution between 1993 and 2014 were retrospectively identified. Patient, meningioma, and treatment data were extracted from the medical record and compared using the Kaplan-Meier method, log-rank tests, multivariate analysis (MVA) Cox proportional hazards models with relative risk (RR), and recursive partitioning analysis. RESULTS The median patient age and imaging follow-up were 57 years (interquartile range [IQR] 45–67 years) and 4.4 years (IQR 1.8–7.5 years), respectively. Gross-total resection (GTR) was achieved in 114 cases (63%), and 42 patients (23%) received adjuvant RT. On MVA, prognostic factors for death from any cause included GTR (RR 0.4, 95% CI 0.1–0.9, p = 0.02) and MIB1 labeling index (LI) ≤ 7% (RR 0.4, 95% CI 0.1–0.9, p = 0.04). Prognostic factors on MVA for local progression included GTR (RR 0.2, 95% CI 0.1–0.5, p = 0.002), adjuvant RT (RR 0.2, 95% CI 0.1–0.4, p < 0.001), MIB1 LI ≤ 7% (RR 0.2, 95% CI 0.1–0.5, p < 0.001), and a remote history of prior cranial RT (RR 5.7, 95% CI 1.3–18.8, p = 0.03). After GTR, adjuvant RT (0 of 10 meningiomas recurred, p = 0.01) and MIB1 LI ≤ 7% (RR 0.1, 95% CI 0.003–0.3, p < 0.001) were predictive for local progression on MVA. After GTR, 2.2% of meningiomas with MIB1 LI ≤ 7% recurred (1 of 45), compared with 38% with MIB1 LI > 7% (13 of 34; p < 0.001). Recursive partitioning analysis confirmed the existence of a cohort of patients at high risk of local progression after GTR without adjuvant RT, with MIB1 LI > 7%, and evidence of brain or bone invasion. After subtotal resection, adjuvant RT (RR 0.2, 95% CI 0.04–0.7, p = 0.009) and ≤ 5 mitoses per 10 hpf (RR 0.1, 95% CI 0.03–0.4, p = 0.002) were predictive on MVA for local progression. CONCLUSIONS Adjuvant RT improves local control of atypical meningioma irrespective of extent of resection. Although independent validation is required, the authors’ results suggest that MIB1 LI, the number of mitoses per 10 hpf, and brain or bone invasion may be useful guides to the selection of patients who are most likely to benefit from adjuvant RT after resection of atypical meningioma.
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Affiliation(s)
| | | | | | | | | | | | | | - Arie Perry
- 2Neurological Surgery, and
- 3Pathology, University of California, San Francisco, California
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Magill ST, Lau D, Raleigh DR, Sneed PK, Fogh SE, McDermott MW. Surgical Resection and Interstitial Iodine-125 Brachytherapy for High-Grade Meningiomas: A 25-Year Series. Neurosurgery 2017; 80:409-416. [PMID: 27258768 DOI: 10.1227/neu.0000000000001262] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 02/29/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Atypical and malignant meningiomas can recur despite resection and radiation. OBJECTIVE To determine outcomes of patients with recurrent atypical or malignant meningioma treated with repeat resection and permanent iodine-125 ( 125 I) brachy-therapy. METHODS Charts of patients who underwent surgical resection and 125 I brachyther-apy implantation for atypical and malignant meningiomas between 1988 and 2013 were retrospectively reviewed. The Kaplan-Meier actuarial method was used to calculate progression-free and overall survival. The log-rank test was used to compare groups. Significance was set at P < .05. RESULTS Forty-two patients underwent 50 resections with 125 I brachytherapy im-plantations. All patients had undergone previous resections and 85% had previously undergone radiation. Median follow-up was 7.5 years after diagnosis and 2.3 years after brachytherapy. Median time to progression after resection with 125 I brachytherapy was 20.9 months for atypical meningioma, 11.4 months for malignant meningioma, and 11.4 months for the combined groups. Median survival after re-resection and 125 I brachytherapy was 3.5 years for atypical meningioma, 2.3 years for malignant menin-gioma, and 3.3 years for all subjects. Median overall survival after diagnosis was 11.1 years for atypical meningioma, 9.1 years for malignant meningioma, and 9.4 years for all subjects. Complications occurred in 17 patients and included radiation necrosis (n = 8, 16%), wound breakdown (n = 6, 12%), hydrocephalus (n = 4, 8%), infection (n = 3, 6%), and a pseudomeningocele (n = 2, 5%). CONCLUSION This is the largest experience with adjuvant 125 I brachytherapy for recurrent high-grade meningiomas. The outcomes support the use of adjuvant brachytherapy as an option for these aggressive tumors.
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Affiliation(s)
- Stephen T Magill
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Darryl Lau
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - David R Raleigh
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Penny K Sneed
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Shannon E Fogh
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Michael W McDermott
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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Imber BS, Kanungo I, Braunstein S, Barani IJ, Fogh SE, Nakamura JL, Berger MS, Chang EF, Molinaro AM, Cabrera JR, McDermott MW, Sneed PK, Aghi MK. Indications and Efficacy of Gamma Knife Stereotactic Radiosurgery for Recurrent Glioblastoma: 2 Decades of Institutional Experience. Neurosurgery 2017; 80:129-139. [PMID: 27428784 DOI: 10.1227/neu.0000000000001344] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 05/23/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The role of stereotactic radiosurgery (SRS) for recurrent glioblastoma and the radionecrosis risk in this setting remain unclear. OBJECTIVE To perform a large retrospective study to help inform proper indications, efficacy, and anticipated complications of SRS for recurrent glioblastoma. METHODS We retrospectively analyzed patients who underwent Gamma Knife SRS between 1991 and 2013. We used the partitioning deletion/substitution/addition algorithm to identify potential predictor covariate cut points and Kaplan-Meier and proportional hazards modeling to identify factors associated with post-SRS and postdiagnosis survival. RESULTS One hundred seventy-four glioblastoma patients (median age, 54.1 years) underwent SRS a median of 8.7 months after initial diagnosis. Seventy-five percent had 1 treatment target (range, 1-6), and median target volume and prescriptions were 7.0 cm 3 (range, 0.3-39.0 cm 3 ) and 16.0 Gy (range, 10-22 Gy), respectively. Median overall survival was 10.6 months after SRS and 19.1 months after diagnosis. Kaplan-Meier and multivariable modeling revealed that younger age at SRS, higher prescription dose, and longer interval between original surgery and SRS are significantly associated with improved post-SRS survival. Forty-six patients (26%) underwent salvage craniotomy after SRS, with 63% showing radionecrosis or mixed tumor/necrosis vs 35% showing purely recurrent tumor. The necrosis/mixed group had lower mean isodose prescription compared with the tumor group (16.2 vs 17.8 Gy; P = .003) and larger mean treatment volume (10.0 vs 5.4 cm 3 ; P = .009). CONCLUSION Gamma Knife may benefit a subset of focally recurrent patients, particularly those who are younger with smaller recurrences. Higher prescriptions are associated with improved post-SRS survival and do not seem to have greater risk of symptomatic treatment effect.
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Affiliation(s)
- Brandon S Imber
- University of California, San Francisco School of Medicine, San Francisco, California
| | | | - Steve Braunstein
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Igor J Barani
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Shannon E Fogh
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Jean L Nakamura
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | | | | | | | | | | | - Penny K Sneed
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
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Wu A, Braunstein SE, Garcia MA, Theodosopoulos PV, Sneed PK, Perry A, McDermott MW, Raleigh DR. (P021) Central Nervous System Edema, Brain Invasion and Prior Radiotherapy Are Negative Predictive Factors for Symptomatic Improvement Following Surgery for Meningioma. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.02.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chiu J, Pierce M, Braunstein SE, Theodosopoulos PV, McDermott MW, Sneed PK, Ma L. Sharpening peripheral dose gradient via beam number enhancement from patient head tilt for stereotactic brain radiosurgery. Phys Med Biol 2016; 61:N532-N541. [DOI: 10.1088/0031-9155/61/20/n532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ma L, Braunstein SE, Theodosopoulos PV, McDermott MW, Sneed PK. Inherent functional dependence among cochlear dose surrogates for stereotactic radiosurgery of vestibular schwannomas. Pract Radiat Oncol 2016; 7:e1-e7. [PMID: 27742557 DOI: 10.1016/j.prro.2016.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 07/25/2016] [Accepted: 08/15/2016] [Indexed: 12/31/2022]
Abstract
PURPOSE Various cochlear dose surrogates have been reported as associated with hearing outcome in studies of stereotactic radiosurgery (SRS) for vestibular schwannomas. In this study, we investigated whether an inherent functional relationship exists among these reported surrogates. METHODS AND MATERIALS A cohort of 85 serial patient cases treated with single-fraction stereotactic radiosurgery from 1997 through 2013 at our institution was analyzed. For all the cases, the mean prescription dose was 12.5 ± 0.3 Gy (range, 12-13 Gy) and mean target volume 1.32 ± 1.51 mL (range, 0.80-8.77 mL). The mean cochlea volume was 0.078 ± 0.016 mL (range, 0.048-0.131 mL; median, 0.076 mL). Correlation analysis among mean cochlear dose, point maximum dose and modiolus dose was performed and also parameterized with new variables such as the effective dose radius (EDR) as derived from a general dose fall-off model. RESULTS Weak correlation via linear regression was found between the point maximum dose and the mean cochlear dose (R2 = 0.719) as well as the modiolus dose (R2 = 0.568). However, when parameterized with EDR, a near-perfect correlation (P < .0001) via linear regression was found between the EDR for the point maximum dose and the EDR for the mean cochlear dose (R2 = 0.996), and with the EDR for the modiolus dose (R2 = 0.993). Such a result led to a functional formula relating these dose surrogates, yielding dose equivalence results such as: 12-Gy point maximum dose is equivalent to mean cochlear dose of 5.6 ± 0.1 Gy (95% confidence level), or modiolus dose of 6.0 ± 0.2 Gy (95% confidence level). CONCLUSIONS An inherent functional relationship was found among point maximum, modiolus, and mean cochlear doses for SRS of vestibular schwannomas. As such, clinical hearing outcome can be interchangeably analyzed or reported via any of these dose surrogates.
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Affiliation(s)
- Lijun Ma
- Department of Radiation Oncology, University of California, San Francisco, California.
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California, San Francisco, California
| | | | - Michael W McDermott
- Department of Neurosurgery, University of California, San Francisco, California
| | - Penny K Sneed
- Department of Radiation Oncology, University of California, San Francisco, California
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Chang JS, Ma L, Barani IJ, McDermott MW, Sneed PK, Larson DA. Hippocampal Dose With Radiosurgery for Multiple Intracranial Targets. Technol Cancer Res Treat 2016; 15:555-9. [DOI: 10.1177/1533034615590934] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 04/29/2015] [Indexed: 11/15/2022] Open
Abstract
Stereotactic radiosurgery provides conformal treatment of intracranial lesions, but when multiple lesions are treated, cumulative dose to structures such as the hippocampi may be increased. We analyzed hippocampal dose for patients treated with radiosurgery for multiple brain metastases. We then investigated a means to minimize hippocampal dose. We randomly selected 8 patients treated with single-session, frame-based radiosurgery for 6 to 12 intracranial metastases. Standard planning was employed to deliver 16 to 20 Gy to each lesion without hippocampal avoidance. Each case was replanned using the software’s dynamic shaping function to minimize direct beam hippocampal irradiation, while maintaining conformality and target coverage. With standard planning, the maximum hippocampal dose varied from 0.8 to 9.0 Gy but was >3 Gy only when a lesion was <10 mm from the hippocampus. There was no clear correlation between hippocampal dose and the number or the total volume of lesions. Replanning with direct beam avoidance decreased the mean hippocampal dose by an average of 35% but increased treatment time by a mean of 20%. Sparing was most pronounced when the closest lesion was in close proximity to the hippocampus. This is the first study reporting hippocampal dose for multilesion intracranial radiosurgery. It illustrates that when multiple intracranial targets are treated with radiosurgery, substantial hippocampal dose can result. Active beam shielding and optimization can lower hippocampal dose, especially with lesions <10 mm from the hippocampus. These results raise the prospect that the risk of neurocognitive side effects may be further decreased with a hippocampal-sparing approach.
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Affiliation(s)
- Jennifer S. Chang
- Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | - Lijun Ma
- Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | - Igor J. Barani
- Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | | | - Penny K. Sneed
- Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | - David A. Larson
- Department of Radiation Oncology, University of California, San Francisco, CA, USA
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Raleigh DR, Seymour ZA, Tomlin B, Theodosopoulos PV, Berger MS, Aghi MK, Geneser SE, Krishnamurthy D, Fogh SE, Sneed PK, McDermott MW. Resection and brain brachytherapy with permanent iodine-125 sources for brain metastasis. J Neurosurg 2016; 126:1749-1755. [PMID: 27367240 DOI: 10.3171/2016.4.jns152530] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) with or without whole-brain radiotherapy can be used to achieve local control (> 90%) for small brain metastases after resection. However, many brain metastases are unsuitable for SRS because of their size or previous treatment, and whole-brain radiotherapy is associated with significant neurocognitive morbidity. The purpose of this study was to investigate the efficacy and toxicity of surgery and iodine-125 (125I) brachytherapy for brain metastases. METHODS A total of 95 consecutive patients treated for 105 brain metastases at a single institution between September 1997 and July 2013 were identified for this analysis retrospectively. Each patient underwent MRI followed by craniotomy with resection of metastasis and placement of 125I sources as permanent implants. The patients were followed with serial surveillance MRIs. The relationships among local control, overall survival, and necrosis were estimated by using the Kaplan-Meier method and compared with results of log-rank tests and multivariate regression models. RESULTS The median age at surgery was 59 years (range 29.9-81.6 years), 53% of the lesions had been treated previously, and the median preoperative metastasis volume was 13.5 cm3 (range 0.21-76.2 cm3). Gross-total resection was achieved in 81% of the cases. The median number of 125I sources implanted per cavity was 28 (range 4-93), and the median activity was 0.73 mCi (range 0.34-1.3 mCi) per source. A total of 476 brain MRIs were analyzed (median MRIs per patient 3; range 0-22). Metastasis size was the strongest predictor of cavity volume and shrinkage (p < 0.0001). Multivariable regression modeling failed to predict the likelihood of local progression or necrosis according to metastasis volume, cavity volume, or the rate of cavity remodeling regardless of source activity or previous SRS. The median clinical follow-up time in living patients was 14.4 months (range 0.02-13.6 years), and crude local control was 90%. Median overall survival extended from 2.1 months in the shortest quartile to 62.3 months in the longest quartile (p < 0.0001). The overall risk of necrosis was 15% and increased significantly for lesions with a history of previous SRS (p < 0.05). CONCLUSIONS Therapeutic options for patients with large or recurrent brain metastases are limited. Data from this study suggest that resection with permanent 125I brachytherapy is an effective strategy for achieving local control of brain metastasis. Although metastasis volume significantly influences resection cavity size and remodeling, volumetric parameters do not seem to influence local control or necrosis. With careful patient selection, this treatment regimen is associated with minimal toxicity and can result in long-term survival for some patients. ▪ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: retrospective case series; evidence: Class IV.
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Affiliation(s)
| | - Zachary A Seymour
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan
| | - Bryan Tomlin
- Department of Economics, California State University Chanel Islands, Camarillo; and
| | | | | | - Manish K Aghi
- Neurological Surgery, University of California San Francisco
| | - Sarah E Geneser
- Department of Therapeutic Radiology, Yale University, New Haven, Connecticut
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Garcia MA, Lazar A, Duriseti S, Raleigh DR, Hess CP, Fogh SE, Barani IJ, Nakamura JL, Larson DA, Theodosopoulos P, McDermott M, Sneed PK, Braunstein S. Discovery of additional brain metastases on the day of stereotactic radiosurgery: risk factors and outcomes. J Neurosurg 2016; 126:1756-1763. [PMID: 27367235 DOI: 10.3171/2016.4.jns152319] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE High-resolution double-dose gadolinium-enhanced Gamma Knife (GK) radiosurgery-planning MRI (GK MRI) on the day of GK treatment can detect additional brain metastases undiagnosed on the prior diagnostic MRI scan (dMRI), revealing increased intracranial disease burden on the day of radiosurgery, and potentially necessitating a reevaluation of appropriate management. The authors identified factors associated with detecting additional metastases on GK MRI and investigated the relationship between detection of additional metastases and postradiosurgery patient outcomes. METHODS The authors identified 326 patients who received GK radiosurgery at their institution from 2010 through 2013 and had a prior dMRI available for comparison of numbers of brain metastases. Factors predictive of additional brain metastases on GK MRI were investigated using logistic regression analysis. Overall survival was estimated by Kaplan-Meier method, and postradiosurgery distant intracranial failure was estimated by cumulative incidence measures. Multivariable Cox proportional hazards model and Fine-Gray regression modeling assessed potential risk factors of overall survival and distant intracranial failure, respectively. RESULTS The mean numbers of brain metastases (SD) on dMRI and GK MRI were 3.4 (4.2) and 5.8 (7.7), respectively, and additional brain metastases were found on GK MRI in 48.9% of patients. Frequencies of detecting additional metastases for patients with 1, 2, 3-4, and more than 4 brain metastases on dMRI were 29.5%, 47.9%, 55.9%, and 79.4%, respectively (p < 0.001). An index brain metastasis with a diameter greater than 1 cm on dMRI was inversely associated with detecting additional brain metastases, with an adjusted odds ratio of 0.57 (95% CI 0.4-0.9, p = 0.02). The median time between dMRI and GK MRI was 22 days (range 1-88 days), and time between scans was not associated with detecting additional metastases. Patients with additional brain metastases did not have larger total radiosurgery target volumes, and they rarely had an immediate change in management (abortion of radiosurgery or addition of whole-brain radiation therapy) due to detection of additional metastases. Patients with additional metastases had a higher incidence of distant intracranial failure than those without additional metastases (p = 0.004), with an adjusted subdistribution hazard ratio of 1.4 (95% CI 1.0-2.0, p = 0.04). Significantly worse overall survival was not detected for patients with additional brain metastases on GK MRI (log-rank p = 0.07), with the relative adjusted hazard ratio of 1.07, (95% CI 0.81-1.41, p = 0.65). CONCLUSIONS Detecting additional brain metastases on GK MRI is strongly associated with the number of brain metastases on dMRI and inversely associated with the size of the index brain metastasis. The discovery of additional brain metastases at time of GK radiosurgery is very unlikely to lead to aborting radiosurgery but is associated with a higher incidence of distant intracranial failure. However, there is not a significant difference in survival. ▪ CLASSIFICATION OF EVIDENCE Type of question: prognostic; study design: retrospective cohort trial; evidence: Class IV.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Michael McDermott
- Neurological Surgery, University of California, San Francisco, California
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Raleigh DR, Solomon DA, Lloyd SA, Lazar A, Garcia MA, Sneed PK, Clarke JL, McDermott MW, Berger MS, Tihan T, Haas-Kogan DA. Histopathologic review of pineal parenchymal tumors identifies novel morphologic subtypes and prognostic factors for outcome. Neuro Oncol 2016; 19:78-88. [PMID: 27282397 DOI: 10.1093/neuonc/now105] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Pineal parenchymal tumors (PPTs) are rare neoplasms of the central nervous system, and data concerning clinical outcomes are limited. The purpose of this study was to define the clinical behavior of PPT according to current histopathologic criteria and identify prognostic factors to guide therapeutic decisions. METHODS Seventy-five patients treated for PPT at a single institution between 1992 and 2015 were retrospectively identified. Forty-five resection specimens were available and re-reviewed. Freedom from progression (FFP) and overall survival (OS) were estimated using the Kaplan-Meier method and compared using log-rank tests. RESULTS Median follow-up was 4.1 years. All patients initially underwent surgery; 78% of patients with PPT of intermediate differentiation (PPTID) and all patients with pineoblastoma received adjuvant therapy. Pathologic re-review refined classification in 27% of cases, with the majority of these being adult patients with pineal tumors originally classified as pineoblastomas that more accurately resembled PPTID based on the 2007 WHO classification. CLASSIFICATION Our histologic review also identified that PPTIDs can be classified into small-cell and large-cell morphologic subtypes, which have distinct clinical outcomes. Tumor grade, extent of resection, and neuraxis spread were prognostic for FFP. PPTID subtype, extent of resection, and neuraxis spread were prognostic for OS. Genetic analysis of a pineoblastoma case identified somatic mutations of DICER1, ARID1A, and KDM5C genes. CONCLUSIONS PPTIDs can be classified into 1 of 2 novel morphologic subtypes that are associated with distinct clinical outcomes. Tumor grade, neuraxis spread, and extent of resection also influence outcome for patients with PPT.
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Affiliation(s)
- David R Raleigh
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - David A Solomon
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - Shane A Lloyd
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - Ann Lazar
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - Michael A Garcia
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - Penny K Sneed
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - Jennifer L Clarke
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - Michael W McDermott
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - Mitchel S Berger
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - Tarik Tihan
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
| | - Daphne A Haas-Kogan
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California (D.R.R., S.A.L., A.L., M.A.G., P.K.S., D.A.H.-K.); Division of Neuropathology, Department of Pathology, University of California San Francisco, San Francisco, California (D.A.S., T.T.); Department of Neurology, University of California San Francisco, San Francisco, California (J.L.C.); Department of Neurologic Surgery, University of California San Francisco, San Francisco, California (J.L.C., M.W.M., M.S.B.)
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Shah JK, Potts MB, Sneed PK, Aghi MK, McDermott MW. Surgical Cavity Constriction and Local Progression Between Resection and Adjuvant Radiosurgery for Brain Metastases. Cureus 2016; 8:e575. [PMID: 27226936 PMCID: PMC4873317 DOI: 10.7759/cureus.575] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [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] [Indexed: 11/05/2022] Open
Abstract
Stereotactic radiosurgery (SRS) to a surgical cavity after brain metastasis resection is a promising treatment for improving local control. The optimal timing of adjuvant SRS, however, has yet to be determined. Changes in resection cavity volume and local progression in the interval between surgery and SRS are likely important factors in deciding when to proceed with adjuvant SRS. We conducted a retrospective review of patients with a brain metastasis treated with surgical resection followed by SRS to the resection cavity. Post-operative and pre-radiosurgery magnetic resonance imaging (MRI) was reviewed for evidence of cavity volume changes, amount of edema, and local tumor progression. Resection cavity volume and edema volume were measured using volumetric analysis. We identified 21 consecutive patients with a brain metastasis treated with surgical resection and radiosurgery to the resection cavity. Mean age was 57 yrs. The most common site of metastasis was the frontal lobe (38%), and the most common primary neoplasms were lung adenocarcinoma and melanoma (24% each). The mean postoperative resection cavity volume was 7.8 cm(3) and shrank to a mean of 4.5 cm(3) at the time of repeat imaging for radiosurgical planning (median 41 days after initial post-operative MRI), resulting in a mean reduction in cavity volume of 43%. Patients who underwent pre-SRS imaging within 1 month of their initial post-operative MRI had a mean volume reduction of 13% compared to 61% in those whose pre-SRS imaging was ≥1 month (p=0.0003). Post-resection edema volume was not related to volume reduction (p=0.59). During the interval between MRIs, 52% of patients showed evidence of tumor progression within the resection cavity wall. There was no significant difference in local recurrence if the interval between resection and radiosurgery was <1 month (n=8) versus ≥1 month (n=13, p=0.46). These data suggest that the surgical cavity after brain metastasis resection constricts over time with greater constriction seen in patients whose pre-SRS imaging is ≥1 month after initial post-operative imaging. Given that there was no difference in local recurrence rate, the data suggest there is benefit in waiting in order to treat a smaller resection cavity.
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Affiliation(s)
- Jugal K Shah
- Department of Neurosurgery, New York University Langone Medical Center
| | - Matthew B Potts
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Penny K Sneed
- Department of Radiation Oncology , University of California, San Francisco
| | - Manish K Aghi
- Department of Neurological Surgery, University of California, San Francisco
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Held M, Cremers F, Sneed PK, Braunstein S, Fogh SE, Nakamura J, Barani I, Perez-Andujar A, Pouliot J, Morin O. Assessment of image quality and dose calculation accuracy on kV CBCT, MV CBCT, and MV CT images for urgent palliative radiotherapy treatments. J Appl Clin Med Phys 2016; 17:279-290. [PMID: 27074487 PMCID: PMC5874969 DOI: 10.1120/jacmp.v17i2.6040] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/27/2015] [Accepted: 11/18/2015] [Indexed: 12/03/2022] Open
Abstract
A clinical workflow was developed for urgent palliative radiotherapy treatments that integrates patient simulation, planning, quality assurance, and treatment in one 30‐minute session. This has been successfully tested and implemented clinically on a linac with MV CBCT capabilities. To make this approach available to all clinics equipped with common imaging systems, dose calculation accuracy based on treatment sites was assessed for other imaging units. We evaluated the feasibility of palliative treatment planning using on‐board imaging with respect to image quality and technical challenges. The purpose was to test multiple systems using their commercial setup, disregarding any additional in‐house development. kV CT, kV CBCT, MV CBCT, and MV CT images of water and anthropomorphic phantoms were acquired on five different imaging units (Philips MX8000 CT Scanner, and Varian TrueBeam, Elekta VersaHD, Siemens Artiste, and Accuray Tomotherapy linacs). Image quality (noise, contrast, uniformity, spatial resolution) was evaluated and compared across all machines. Using individual image value to density calibrations, dose calculation accuracies for simple treatment plans were assessed for the same phantom images. Finally, image artifacts on clinical patient images were evaluated and compared among the machines. Image contrast to visualize bony anatomy was sufficient on all machines. Despite a high noise level and low contrast, MV CT images provided the most accurate treatment plans relative to kV CT‐based planning. Spatial resolution was poorest for MV CBCT, but did not limit the visualization of small anatomical structures. A comparison of treatment plans showed that monitor units calculated based on a prescription point were within 5% difference relative to kV CT‐based plans for all machines and all studied treatment sites (brain, neck, and pelvis). Local dose differences >5% were found near the phantom edges. The gamma index for 3%/3 mm criteria was ≥95% in most cases. Best dose calculation results were obtained when the treatment isocenter was near the image isocenter for all machines. A large field of view and immediate image export to the treatment planning system were essential for a smooth workflow and were not provided on all devices. Based on this phantom study, image quality of the studied kV CBCT, MV CBCT, and MV CT on‐board imaging devices was sufficient for treatment planning in all tested cases. Treatment plans provided dose calculation accuracies within an acceptable range for simple, urgently planned palliative treatments. However, dose calculation accuracy was compromised towards the edges of an image. Feasibility for clinical implementation should be assessed separately and may be complicated by machine specific features. Image artifacts in patient images and the effect on dose calculation accuracy should be assessed in a separate, machine‐specific study. PACS number(s): 87.55.D‐, 87.57.C‐, 87.57.Q‐
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Seymour ZA, Sneed PK, Gupta N, Lawton MT, Molinaro AM, Young W, Dowd CF, Halbach VV, Higashida RT, McDermott MW. Volume-staged radiosurgery for large arteriovenous malformations: an evolving paradigm. J Neurosurg 2016; 124:163-74. [DOI: 10.3171/2014.12.jns141308] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Large arteriovenous malformations (AVMs) remain difficult to treat, and ideal treatment parameters for volume-staged stereotactic radiosurgery (VS-SRS) are still unknown. The object of this study was to compare VS-SRS treatment outcomes for AVMs larger than 10 ml during 2 eras; Era 1 was 1992-March 2004, and Era 2 was May 2004–2008. In Era 2 the authors prospectively decreased the AVM treatment volume, increased the radiation dose per stage, and shortened the interval between stages.
METHODS
All cases of VS-SRS treatment for AVM performed at a single institution were retrospectively reviewed.
RESULTS
Of 69 patients intended for VS-SRS, 63 completed all stages. The median patient age at the first stage of VS-SRS was 34 years (range 9–68 years). The median modified radiosurgery-based AVM score (mRBAS), total AVM volume, and volume per stage in Era 1 versus Era 2 were 3.6 versus 2.7, 27.3 ml versus 18.9 ml, and 15.0 ml versus 6.8 ml, respectively. The median radiation dose per stage was 15.5 Gy in Era 1 and 17.0 Gy in Era 2, and the median clinical follow-up period in living patients was 8.6 years in Era 1 and 4.8 years in Era 2. All outcomes were measured from the first stage of VS-SRS. Near or complete obliteration was more common in Era 2 (log-rank test, p = 0.0003), with 3- and 5-year probabilities of 5% and 21%, respectively, in Era 1 compared with 24% and 68% in Era 2. Radiosurgical dose, AVM volume per stage, total AVM volume, era, compact nidus, Spetzler-Martin grade, and mRBAS were significantly associated with near or complete obliteration on univariate analysis. Dose was a strong predictor of response (Cox proportional hazards, p < 0.001, HR 6.99), with 3- and 5-year probabilities of near or complete obliteration of 5% and 16%, respectively, at a dose < 17 Gy versus 23% and 74% at a dose ≥ 17 Gy. Dose per stage, compact nidus, and total AVM volume remained significant predictors of near or complete obliteration on multivariate analysis. Seventeen patients (25%) had salvage surgery, SRS, and/or embolization. Allowing for salvage therapy, the probability of cure was more common in Era 2 (log-rank test, p = 0.0007) with 5-year probabilities of 0% in Era 1 versus 41% in Era 2. The strong trend toward improved cure in Era 2 persisted on multivariate analysis even when considering mRBAS (Cox proportional hazards, p = 0.055, HR 4.01, 95% CI 0.97–16.59). The complication rate was 29% in Era 1 compared with 13% in Era 2 (Cox proportional hazards, not significant).
CONCLUSIONS
VS-SRS is an option to obliterate or downsize large AVMs. Decreasing the AVM treatment volume per stage to ≤ 8 ml with this technique allowed a higher dose per fraction and decreased time to response, as well as improved rates of near obliteration and cure without increasing complications. Reducing the volume of these very large lesions can facilitate a surgical approach for cure.
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Affiliation(s)
| | | | | | | | | | | | - Christopher F. Dowd
- 2Neurological Surgery,
- 6Radiology, University of California, San Francisco, California
| | - Van V. Halbach
- 2Neurological Surgery,
- 6Radiology, University of California, San Francisco, California
| | - Randall T. Higashida
- 2Neurological Surgery,
- 6Radiology, University of California, San Francisco, California
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Held M, Sneed PK, Fogh SE, Pouliot J, Morin O. Feasibility of MV CBCT-based treatment planning for urgent radiation therapy: dosimetric accuracy of MV CBCT-based dose calculations. J Appl Clin Med Phys 2015; 16:458-471. [PMID: 26699575 PMCID: PMC5690985 DOI: 10.1120/jacmp.v16i6.5625] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 08/18/2015] [Accepted: 08/25/2015] [Indexed: 11/23/2022] Open
Abstract
Unlike scheduled radiotherapy treatments, treatment planning time and resources are limited for emergency treatments. Consequently, plans are often simple 2D image‐based treatments that lag behind technical capabilities available for nonurgent radiotherapy. We have developed a novel integrated urgent workflow that uses onboard MV CBCT imaging for patient simulation to improve planning accuracy and reduce the total time for urgent treatments. This study evaluates both MV CBCT dose planning accuracy and novel urgent workflow feasibility for a variety of anatomic sites. We sought to limit local mean dose differences to less than 5% compared to conventional CT simulation. To improve dose calculation accuracy, we created separate Hounsfield unit–to–density calibration curves for regular and extended field‐of‐view (FOV) MV CBCTs. We evaluated dose calculation accuracy on phantoms and four clinical anatomical sites (brain, thorax/spine, pelvis, and extremities). Plans were created for each case and dose was calculated on both the CT and MV CBCT. All steps (simulation, planning, setup verification, QA, and dose delivery) were performed in one 30 min session using phantoms. The monitor units (MU) for each plan were compared and dose distribution agreement was evaluated using mean dose difference over the entire volume and gamma index on the central 2D axial plane. All whole‐brain dose distributions gave gamma passing rates higher than 95% for 2%/2 mm criteria, and pelvic sites ranged between 90% and 98% for 3%/3 mm criteria. However, thoracic spine treatments produced gamma passing rates as low as 47% for 3%/3 mm criteria. Our novel MV CBCT‐based dose planning and delivery approach was feasible and time‐efficient for the majority of cases. Limited MV CBCT FOV precluded workflow use for pelvic sites of larger patients and resulted in image clearance issues when tumor position was far off midline. The agreement of calculated MU on CT and MV CBCT was acceptable for all treatment sites. PACS numbers: 87.55.D‐, 87.57.Q‐
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Sneed PK, Mendez J, Vemer-van den Hoek JGM, Seymour ZA, Ma L, Molinaro AM, Fogh SE, Nakamura JL, McDermott MW. Adverse radiation effect after stereotactic radiosurgery for brain metastases: incidence, time course, and risk factors. J Neurosurg 2015; 123:373-86. [DOI: 10.3171/2014.10.jns141610] [Citation(s) in RCA: 187] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The authors sought to determine the incidence, time course, and risk factors for overall adverse radiation effect (ARE) and symptomatic ARE after stereotactic radiosurgery (SRS) for brain metastases.
METHODS
All cases of brain metastases treated from 1998 through 2009 with Gamma Knife SRS at UCSF were considered. Cases with less than 3 months of follow-up imaging, a gap of more than 8 months in imaging during the 1st year, or inadequate imaging availability were excluded. Brain scans and pathology reports were reviewed to ensure consistent scoring of dates of ARE, treatment failure, or both; in case of uncertainty, the cause of lesion worsening was scored as indeterminate. Cumulative incidence of ARE and failure were estimated with the Kaplan-Meier method with censoring at last imaging. Univariate and multivariate Cox proportional hazards analyses were performed.
RESULTS
Among 435 patients and 2200 brain metastases evaluable, the median patient survival time was 17.4 months and the median lesion imaging follow-up was 9.9 months. Calculated on the basis of 2200 evaluable lesions, the rates of treatment failure, ARE, concurrent failure and ARE, and lesion worsening with indeterminate cause were 9.2%, 5.4%, 1.4%, and 4.1%, respectively. Among 118 cases of ARE, approximately 60% were symptomatic and 85% occurred 3–18 months after SRS (median 7.2 months). For 99 ARE cases managed without surgery or bevacizumab, the probabilities of improvement observed on imaging were 40%, 57%, and 76% at 6, 12, and 18 months after onset of ARE. The most important risk factors for ARE included prior SRS to the same lesion (with 20% 1-year risk of symptomatic ARE vs 3%, 4%, and 8% for no prior treatment, prior whole brain radiotherapy [WBRT], or concurrent WBRT) and any of these volume parameters: target, prescription isodose, 12-Gy, or 10-Gy volume. Excluding lesions treated with repeat SRS, the 1-year probabilities of ARE were < 1%, 1%, 3%, 10%, and 14% for maximum diameter 0.3–0.6 cm, 0.7–1.0 cm, 1.1–1.5 cm, 1.6–2.0 cm, and 2.1–5.1 cm, respectively. The 1-year probabilities of symptomatic ARE leveled off at 13%–14% for brain metastases maximum diameter > 2.1 cm, target volume > 1.2 cm3, prescription isodose volume > 1.8 cm3,12-Gy volume > 3.3 cm3, and 10-Gy volume > 4.3 cm3, excluding lesions treated with repeat SRS. On both univariate and multivariate analysis, capecitabine, but not other systemic therapy within 1 month of SRS, appeared to increase ARE risk. For the multivariate analysis considering only metastases with target volume > 1.0 cm3, risk factors for ARE included prior SRS, kidney primary tumor, connective tissue disorder, and capecitabine.
CONCLUSIONS
Although incidence of ARE after SRS was low overall, risk increased rapidly with size and volume, leveling off at a 1-year cumulative incidence of 13%–14%. This study describes the time course of ARE and provides risk estimates by various lesion characteristics and treatment parameters to aid in decision-making and patient counseling.
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Affiliation(s)
| | - Joe Mendez
- 2Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, Missouri; and
| | | | | | - Lijun Ma
- Departments of 1Radiation Oncology and
| | | | | | | | - Michael W. McDermott
- Departments of 1Radiation Oncology and
- 4Neurological Surgery, University of California, San Francisco, California
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Kano H, Sheehan J, Sneed PK, McBride HL, Young B, Duma C, Mathieu D, Seymour Z, McDermott MW, Kondziolka D, Iyer A, Lunsford LD. Skull base chondrosarcoma radiosurgery: report of the North American Gamma Knife Consortium. J Neurosurg 2015; 123:1268-75. [PMID: 26115468 DOI: 10.3171/2014.12.jns132580] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Stereotactic radiosurgery (SRS) is a potentially important option for patients with skull base chondrosarcomas. The object of this study was to analyze the outcomes of SRS for chondrosarcoma patients who underwent this treatment as a part of multimodality management. METHODS Seven participating centers of the North American Gamma Knife Consortium (NAGKC) identified 46 patients who underwent SRS for skull base chondrosarcomas. Thirty-six patients had previously undergone tumor resections and 5 had been treated with fractionated radiation therapy (RT). The median tumor volume was 8.0 cm3 (range 0.9-28.2 cm3), and the median margin dose was 15 Gy (range 10.5-20 Gy). Kaplan-Meier analysis was used to calculate progression-free and overall survival rates. RESULTS At a median follow-up of 75 months after SRS, 8 patients were dead. The actuarial overall survival after SRS was 89% at 3 years, 86% at 5 years, and 76% at 10 years. Local tumor progression occurred in 10 patients. The rate of progression-free survival (PFS) after SRS was 88% at 3 years, 85% at 5 years, and 70% at 10 years. Prior RT was significantly associated with shorter PFS. Eight patients required salvage resection, and 3 patients (7%) developed adverse radiation effects. Cranial nerve deficits improved in 22 (56%) of the 39 patients who deficits before SRS. Clinical improvement after SRS was noted in patients with abducens nerve paralysis (61%), oculomotor nerve paralysis (50%), lower cranial nerve dysfunction (50%), optic neuropathy (43%), facial neuropathy (38%), trochlear nerve paralysis (33%), trigeminal neuropathy (12%), and hearing loss (10%). CONCLUSIONS Stereotactic radiosurgery for skull base chondrosarcomas is an important adjuvant option for the treatment of these rare tumors, as part of a team approach that includes initial surgical removal of symptomatic larger tumors.
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Affiliation(s)
- Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Penny K Sneed
- Departments of Radiation Oncology and Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Heyoung L McBride
- Departments of Radiation Oncology and Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Byron Young
- Department of Neurological Surgery, University of Kentucky, Lexington, Kentucky
| | - Christopher Duma
- Department of Neurological Surgery, Hoag Memorial Hospital, Newport Beach, California
| | - David Mathieu
- Department of Neurological Surgery, Université de Sherbrooke, Centre de Recherche Clinique Étienne-LeBel, Sherbrooke, Quebec, Canada
| | - Zachary Seymour
- Departments of Radiation Oncology and Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Michael W McDermott
- Departments of Radiation Oncology and Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Douglas Kondziolka
- Department of Neurological Surgery, New York University Langone Medical Center, New York, New York; and
| | - Aditya Iyer
- Department of Neurological Surgery, Stanford University, Stanford, California
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Seymour ZA, Fogh SE, Westcott SK, Braunstein S, Larson DA, Barani IJ, Nakamura J, Sneed PK. Interval From Imaging to Treatment Delivery in the Radiation Surgery Age: How Long Is Too Long? Int J Radiat Oncol Biol Phys 2015; 93:126-32. [PMID: 26279030 DOI: 10.1016/j.ijrobp.2015.05.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 04/29/2015] [Accepted: 05/01/2015] [Indexed: 12/21/2022]
Abstract
PURPOSE The purpose of this study was to evaluate workflow and patient outcomes related to frameless stereotactic radiation surgery (SRS) for brain metastases. METHODS AND MATERIALS We reviewed all treatment demographics, clinical outcomes, and workflow timing, including time from magnetic resonance imaging (MRI), computed tomography (CT) simulation, insurance authorization, and consultation to the start of SRS for brain metastases. RESULTS A total of 82 patients with 151 brain metastases treated with SRS were evaluated. The median times from consultation, insurance authorization, CT simulation, and MRI for treatment planning were 15, 7, 6, and 11 days to SRS. Local freedom from progression (LFFP) was lower in metastases with MRI ≥ 14 days before treatment (P = .0003, log rank). The 6- and 12-month LFFP rate were 95% and 75% for metastasis with interval of <14 days from MRI to treatment compared to 56% and 34% for metastases with MRI ≥ 14 days before treatment. On multivariate analysis, LFFP remained significantly lower for lesions with MRI ≥ 14 days at SRS (P = .002, Cox proportional hazards; hazard ratio: 3.4, 95% confidence interval: 1.6-7.3). CONCLUSIONS Delay from MRI to SRS treatment delivery for brain metastases appears to reduce local control. Future studies should monitor the timing from imaging acquisition to treatment delivery. Our experience suggests that the time from MRI to treatment should be <14 days.
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Affiliation(s)
- Zachary A Seymour
- Department of Radiation Oncology, University of California at San Francisco, San Francisco, California.
| | - Shannon E Fogh
- Department of Radiation Oncology, University of California at San Francisco, San Francisco, California
| | - Sarah K Westcott
- Department of Radiation Oncology, University of California at San Francisco, San Francisco, California
| | - Steve Braunstein
- Department of Radiation Oncology, University of California at San Francisco, San Francisco, California
| | - David A Larson
- Department of Radiation Oncology, University of California at San Francisco, San Francisco, California; Department of Neurological Surgery, University of California at San Francisco, San Francisco, California
| | - Igor J Barani
- Department of Radiation Oncology, University of California at San Francisco, San Francisco, California
| | - Jean Nakamura
- Department of Radiation Oncology, University of California at San Francisco, San Francisco, California
| | - Penny K Sneed
- Department of Radiation Oncology, University of California at San Francisco, San Francisco, California
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48
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Ma L, Mason E, Sneed PK, McDermott M, Polishchuk A, Larson DA, Sahgal A. Clinical realization of sector beam intensity modulation for Gamma Knife radiosurgery: a pilot treatment planning study. Int J Radiat Oncol Biol Phys 2015; 91:661-8. [PMID: 25542309 DOI: 10.1016/j.ijrobp.2014.10.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 10/16/2014] [Accepted: 10/22/2014] [Indexed: 11/27/2022]
Abstract
PURPOSE To demonstrate the clinical feasibility and potential benefits of sector beam intensity modulation (SBIM) specific to Gamma Knife stereotactic radiosurgery (GKSRS). METHODS AND MATERIALS SBIM is based on modulating the confocal beam intensities from individual sectors surrounding an isocenter in a nearly 2π geometry. This is in contrast to conventional GKSRS delivery, in which the beam intensities from each sector are restricted to be either 0% or 100% and must be identical for any given isocenter. We developed a SBIM solution based on available clinical planning tools, and we tested it on a cohort of 12 clinical cases as a proof of concept study. The SBIM treatment plans were compared with the original clinically delivered treatment plans to determine dosimetric differences. The goal was to investigate whether SBIM would improve the dose conformity for these treatment plans without prohibitively lengthening the treatment time. RESULTS A SBIM technique was developed. On average, SBIM improved the Paddick conformity index (PCI) versus the clinically delivered plans (clinical plan PCI = 0.68 ± 0.11 vs SBIM plan PCI = 0.74 ± 0.10, P=.002; 2-tailed paired t test). The SBIM plans also resulted in nearly identical target volume coverage (mean, 97 ± 2%), total beam-on times (clinical plan 58.4 ± 38.9 minutes vs SBIM 63.5 ± 44.7 minutes, P=.057), and gradient indices (clinical plan 3.03 ± 0.27 vs SBIM 3.06 ± 0.29, P=.44) versus the original clinical plans. CONCLUSION The SBIM method is clinically feasible with potential dosimetric gains when compared with conventional GKSRS.
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Affiliation(s)
- Lijun Ma
- Department of Radiation Oncology, University of California, San Francisco, California.
| | - Erica Mason
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Penny K Sneed
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Michael McDermott
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Alexei Polishchuk
- Department of Radiation Oncology, University of California, San Francisco, California
| | - David A Larson
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Center, University of Toronto, Toronto, Ontario, Canada
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Abla AA, Rutledge WC, Seymour ZA, Guo D, Kim H, Gupta N, Sneed PK, Barani IJ, Larson D, McDermott MW, Lawton MT. A treatment paradigm for high-grade brain arteriovenous malformations: volume-staged radiosurgical downgrading followed by microsurgical resection. J Neurosurg 2015; 122:419-32. [DOI: 10.3171/2014.10.jns1424] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The surgical treatment of many large arteriovenous malformations (AVMs) is associated with substantial risks, and many are considered inoperable. Furthermore, AVMs larger than 3 cm in diameter are not usually treated with conventional single-session radiosurgery encompassing the entire AVM volume. Volume-staged stereotactic radiosurgery (VS-SRS) is an option for large AVMs, but it has mixed results. The authors report on a series of patients with high-grade AVMs who underwent multiple VS-SRS sessions with resultant downgrading of the AVMs, followed by resection.
METHODS
A cohort of patients was retrieved from a single-institution AVM patient registry consisting of prospectively collected data. VS-SRS was performed as a planned intentional treatment. Surgery was considered as salvage therapy in select patients.
RESULTS
Sixteen AVMs underwent VS-SRS followed by surgery. Four AVMs presented with rupture. The mean patient age was 25.3 years (range 13–54 years). The average initial Spetzler-Martin grade before any treatment was 4, while the average supplemented Spetzler-Martin grade (Spetzler-Martin plus Lawton-Young) was 7.1. The average AVM size in maximum dimension was 5.9 cm (range 3.3–10 cm). All AVMs were supratentorial in location and all except one were in eloquent areas of the brain, with 7 involving primary motor cortex. The mean number of VS-SRS sessions was 2.7 (range 2–5 sessions). The mean interval between first VS-SRS session and resection was 5.7 years. There were 4 hemorrhages that occurred after VS-SRS. The average Spetzler-Martin grade was reduced to 2.5 (downgrade, −1.5) and the average supplemented Spetzler-Martin grade was reduced to 5.6 (downgrade, −1.5). The maximum AVM size was reduced to an average of 3.0 cm (downsize = −2.9 cm). The mean modified Rankin Scale (mRS) scores were 1.2, 2.3, and 2.2 before VS-SRS, before surgery, and at last follow-up, respectively (mean follow-up, 6.9 years). Fifteen AVMs were cured after surgery. Ten patients had good outcomes at last follow-up (7 with mRS Score 0 or 1, and 3 with mRS Score 2). There were 2 deaths (both mRS Score 1 before treatment) and 4 patients with mRS Score 3 outcome (from mRS Scores 0, 1, and 2 [n = 2]).
CONCLUSIONS
Volume-staged SRS can downgrade AVMs, transforming high-grade AVMs (initially considered inoperable) into operable AVMs with acceptable surgical risks. This treatment paradigm offers an alternative to conservative observation for young patients with unruptured AVMs and long life expectancy, where the risk of hemorrhage is substantial. Difficult AVMs were cured in 15 patients. Surgical morbidity associated with downgraded AVMs is reduced to that of postradiosurgical/preoperative supplemented Spetzler-Martin grades, not their initial AVM grades.
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Affiliation(s)
| | | | | | - Diana Guo
- 3Center for Cerebrovascular Research, University of California, San Francisco, California
| | - Helen Kim
- 3Center for Cerebrovascular Research, University of California, San Francisco, California
| | | | | | | | | | | | - Michael T. Lawton
- Departments of 1Neurological Surgery and
- 3Center for Cerebrovascular Research, University of California, San Francisco, California
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50
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Tempel ZJ, Chivukula S, Monaco EA, Bowden G, Kano H, Niranjan A, Chang EF, Sneed PK, Kaufmann AM, Sheehan J, Mathieu D, Lunsford LD. The results of a third Gamma Knife procedure for recurrent trigeminal neuralgia. J Neurosurg 2015; 122:169-79. [DOI: 10.3171/2014.9.jns132779] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Gamma Knife radiosurgery (GKRS) is the least invasive treatment option for medically refractory, intractable trigeminal neuralgia (TN) and is especially valuable for treating elderly, infirm patients or those on anticoagulation therapy. The authors reviewed pain outcomes and complications in TN patients who required 3 radiosurgical procedures for recurrent or persistent pain.
METHODS
A retrospective review of all patients who underwent 3 GKRS procedures for TN at 4 participating centers of the North American Gamma Knife Consortium from 1995 to 2012 was performed. The Barrow Neurological Institute (BNI) pain score was used to evaluate pain outcomes.
RESULTS
Seventeen patients were identified; 7 were male and 10 were female. The mean age at the time of last GKRS was 79.6 years (range 51.2–95.6 years). The TN was Type I in 16 patients and Type II in 1 patient. No patient suffered from multiple sclerosis. Eight patients (47.1%) reported initial complete pain relief (BNI Score I) following their third GKRS and 8 others (47.1%) experienced at least partial relief (BNI Scores II–IIIb). The average time to initial response was 2.9 months following the third GKRS. Although 3 patients (17.6%) developed new facial sensory dysfunction following primary GKRS and 2 patients (11.8%) experienced new or worsening sensory disturbance following the second GKRS, no patient sustained additional sensory disturbances after the third procedure. At a mean follow-up of 22.9 months following the third GKRS, 6 patients (35.3%) reported continued Score I complete pain relief, while 7 others (41.2%) reported pain improvement (BNI Scores II–IIIb). Four patients (23.5%) suffered recurrent TN following the third procedure at a mean interval of 19.1 months.
CONCLUSIONS
A third GKRS resulted in pain reduction with a low risk of additional complications in most patients with medically refractory and recurrent, intractable TN. In patients unsuitable for other microsurgical or percutaneous strategies, especially those receiving long-term oral anticoagulation or antiplatelet agents, GKRS repeated for a third time was a satisfactory, low risk option.
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Affiliation(s)
- Zachary J. Tempel
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center
| | | | - Edward A. Monaco
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center
| | - Greg Bowden
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center
| | - Hideyuki Kano
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center
| | - Ajay Niranjan
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center
| | | | - Penny K. Sneed
- 4Radiation Oncology, University of California, San Francisco, California
| | - Anthony M. Kaufmann
- 5Department of Neurological Surgery, University of Manitoba Health Sciences Centre, Winnipeg, Manitoba; and
| | - Jason Sheehan
- 6Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - David Mathieu
- 7Department of Neurological Surgery, Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada
| | - L. Dade Lunsford
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center
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