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Samanci Y, Aydin S, Düzkalir AH, Askeroglu MO, Peker S. Upfront frameless hypofractionated gamma knife radiosurgery for large posterior Fossa metastases. Neurosurg Rev 2025; 48:418. [PMID: 40372490 DOI: 10.1007/s10143-025-03572-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2025] [Revised: 04/23/2025] [Accepted: 05/06/2025] [Indexed: 05/16/2025]
Abstract
The management of large metastatic brain tumors (METs), particularly those in the posterior fossa (pf-METs), is challenging. While surgery can alleviate symptoms, it carries the risk of complications such as leptomeningeal disease (LMD). Upfront hypofractionated Gamma Knife radiosurgery (hf-GKRS) has shown promise as an alternative approach for managing large METs. This study assesses the efficacy and safety of upfront hf-GKRS for treatment-naïve large pf-METs. In this retrospective, single-center study, 40 patients with 42 pf-METs received hf-GKRS from October 2017 to June 2024. Patients eligible for the study were 18 years or older, had histologically confirmed malignancy, large pf-METs (> 4 cm3), and a minimum of two follow-up MRI scans. The primary outcome was local control (LC), with secondary assessments of distant intracranial failure (DICF), intracranial progression-free survival (PFS), overall survival (OS), and toxicity. LC was achieved in 88.1% of pf-METs over a median follow-up of 6 months (mean: 13.7 months). LC rates at 6, 12, and 24 months were 95.8%, 95.8%, and 74.5%, respectively. Local failure (LF) occurred in 11.9% of cases, with a median recurrence time of 12 months. DICF was noted in 35% of patients, while no cases of LMD were reported. Intracranial PFS rates at 6, 12, and 24 months were 54.1%, 39.0%, and 16.7%, respectively, with a median PFS of 8 months. Symptomatic hydrocephalus developed in one patient (2.5%). Controlled primary tumor status (HR: 0.17, p = 0.036) was significantly associated with lower risk of death, while no other parameters were predictive of LC, DICF, or intracranial PFS. hf-GKRS demonstrates strong efficacy and safety as a primary treatment for selected, treatment-naïve large pf-METs over a relatively short follow-up duration. Further studies are warranted to refine patient selection, fractionation, and dosing strategies for this challenging population.
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Affiliation(s)
- Yavuz Samanci
- Department of Neurosurgery, Koç University School of Medicine, Türkiye Davutpasa Caddesi No:4, Zeytinburnu/İstanbul, 34010, Türkiye
- Department of Neurosurgery, Gamma Knife Center, Koç University Hospital, Istanbul, Türkiye
| | - Serhat Aydin
- Koç University School of Medicine, Istanbul, Türkiye
| | - Ali Haluk Düzkalir
- Department of Neurosurgery, Gamma Knife Center, Koç University Hospital, Istanbul, Türkiye
- Department of Neurosurgery, Koç University Hospital, Istanbul, Türkiye
| | - M Orbay Askeroglu
- Department of Neurosurgery, Gamma Knife Center, Koç University Hospital, Istanbul, Türkiye
| | - Selcuk Peker
- Department of Neurosurgery, Koç University School of Medicine, Türkiye Davutpasa Caddesi No:4, Zeytinburnu/İstanbul, 34010, Türkiye.
- Department of Neurosurgery, Gamma Knife Center, Koç University Hospital, Istanbul, Türkiye.
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Lee JH, Kim IY, Jung S, Jung TY, Moon KS, Kim YJ, Park SJ, Lim SH. Two-Day Fraction Gamma Knife Radiosurgery for Large Brain Metastasis. J Korean Neurosurg Soc 2024; 67:560-567. [PMID: 38124366 PMCID: PMC11375075 DOI: 10.3340/jkns.2023.0214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/19/2023] [Accepted: 12/16/2023] [Indexed: 12/23/2023] Open
Abstract
OBJECTIVE We investigated how treating large brain metastasis (LBM) using 2-day fraction Gamma Knife radiosurgery (GKRS) affects tumor control and patient survival. A prescription dose of 10.3 Gy was applied for 2 consecutive days, with a biologically effective dose equivalent to a tumor single-fraction dose of 16.05 Gy and a brain single-fraction dose of 15.12 Gy. METHODS Between November 2017 and December 2021, 42 patients (mean age, 68.3 years; range, 50-84 years; male, 29 [69.1%]; female, 13 [30.9%]) with 44 tumors underwent 2-day fraction GKRS to treat large volume brain metastasis. The main cancer types were non-small cell lung cancer (n=16), small cell lung cancer (n=7), colorectal cancer (n=7), breast cancer (n=3), gastric cancer (n=2), and other cancers (n=7). Twenty-one patients (50.0%) had a single LBM, 19 (46.3%) had a single LBM and other metastases, and two had two (4.7%) large brain metastases. At the time of the 2-day fraction GKRS, the tumors had a mean volume of 23.1 mL (range, 12.5-67.4). On each day, radiation was administered at a dose of 10.3 Gy, mainly using a 50% isodose-line. RESULTS We obtained clinical and magnetic resonance imaging follow-up data for 34 patients (81%) with 35 tumors, who had undergone 2-day fraction GKRS. These patients did not experience acute or late radiation-induced complications during follow-up. The median and mean progression-free survival (PFS) periods were 188 and 194 days, respectively. The local control rates at 6, 9, and 12 months were 77%, 40%, and 34%, respectively. The prognostic factors related to PFS were prior radiotherapy (p=0.019) and lung cancer origin (p=0.041). Other factors such as tumor volumes, each isodose volumes, and peri-GKRS systemic treatment were not significantly related to PFS. The overall survival period of the 44 patients following repeat stereotactic radiosurgery (SRS) ranged from 15-878 days (median, 263±38 days; mean, 174±43 days) after the 2-day fraction GKRS. Eight patients (18.2%) were still alive. CONCLUSION Considering the unsatisfactory tumor control, a higher prescription dose should be needed in this procedure as a salvage management. Moreover, in the treatment for LBM with fractionated SRS, using different isodoses and prescription doses at the treatment planning for LBMs should be important. However, this report might be a basic reference with the same fraction number and prescription dose in the treatment for LBMs with frame-based SRS.
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Affiliation(s)
- Joo-Hwan Lee
- Brain Tumor Clinic & Gamma Knife Center, Department of Neurosurgery, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - In-Young Kim
- Brain Tumor Clinic & Gamma Knife Center, Department of Neurosurgery, Chonnam National University Hwasun Hospital, Hwasun, Korea
- Department of Neurosurgery, Chonnam National University Medical School, Hwasun, Korea
| | - Shin Jung
- Brain Tumor Clinic & Gamma Knife Center, Department of Neurosurgery, Chonnam National University Hwasun Hospital, Hwasun, Korea
- Department of Neurosurgery, Chonnam National University Medical School, Hwasun, Korea
| | - Tae-Young Jung
- Brain Tumor Clinic & Gamma Knife Center, Department of Neurosurgery, Chonnam National University Hwasun Hospital, Hwasun, Korea
- Department of Neurosurgery, Chonnam National University Medical School, Hwasun, Korea
| | - Kyung-Sub Moon
- Brain Tumor Clinic & Gamma Knife Center, Department of Neurosurgery, Chonnam National University Hwasun Hospital, Hwasun, Korea
- Department of Neurosurgery, Chonnam National University Medical School, Hwasun, Korea
| | - Yeong-Jin Kim
- Brain Tumor Clinic & Gamma Knife Center, Department of Neurosurgery, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Sue-Jee Park
- Brain Tumor Clinic & Gamma Knife Center, Department of Neurosurgery, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Sa-Hoe Lim
- Brain Tumor Clinic & Gamma Knife Center, Department of Neurosurgery, Chonnam National University Hwasun Hospital, Hwasun, Korea
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Mangesius J, Seppi T, Arnold CR, Mangesius S, Kerschbaumer J, Demetz M, Minasch D, Vorbach SM, Sarcletti M, Lukas P, Nevinny-Stickel M, Ganswindt U. Prognosis versus Actual Outcomes in Stereotactic Radiosurgery of Brain Metastases: Reliability of Common Prognostic Parameters and Indices. Curr Oncol 2024; 31:1739-1751. [PMID: 38668035 PMCID: PMC11049204 DOI: 10.3390/curroncol31040132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/11/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
This study aims to evaluate the clinical outcome of stereotactic radiosurgery as the sole treatment for brain metastases and to assess prognostic factors influencing survival. A total of 108 consecutive patients with 213 metastases were retrospectively analyzed. Treatment was determined with close-meshed MRI follow-up. Various prognostic factors were assessed, and several prognostic indices were compared regarding their reliability to estimate overall survival. Median overall survival was 15 months; one-year overall survival was 50.5%. Both one- and two-year local controls were 90.9%. The rate of new metastases after SRS was 49.1%. Multivariate analysis of prognostic factors revealed that the presence of extracranial metastases, male sex, lower KPI, and progressive extracranial disease were significant risk factors for decreased survival. Of all evaluated prognostic indices, the Basic Score for Brain Metastases (BSBMs) showed the best correlation with overall survival. A substantial survival advantage was found for female patients after SRS when compared to male patients (18 versus 9 months, p = 0.003). SRS of brain metastasis is a safe and effective treatment option when frequent monitoring for new metastases with MRI is performed. Common prognostic scores lack reliable estimation of survival times. Female sex should be considered as an additional independent positive prognostic factor influencing survival.
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Affiliation(s)
- Julian Mangesius
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Thomas Seppi
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | | | - Stephanie Mangesius
- Department of Neuroradiology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Johannes Kerschbaumer
- Department of Neurosurgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Matthias Demetz
- Department of Neurosurgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Danijela Minasch
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Samuel Moritz Vorbach
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Manuel Sarcletti
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Peter Lukas
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | | | - Ute Ganswindt
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
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Calderon B, Vazquez L, Belkacemi M, Pourel N. Stereotactic radiotherapy for brain metastases: predictive factors of radionecrosis. Eur J Med Res 2023; 28:233. [PMID: 37443046 DOI: 10.1186/s40001-023-01178-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
PURPOSE Stereotactic radiotherapy (SRT) is a highly effective approach and represents the current standard of treatment for patients with limited number of brain metastasis (BM). SRT is generally well tolerated but can sometimes lead to radionecrosis (RN). The aim of this study was to identify predictive factors of radionecrosis related to SRT for brain metastasis. METHODS This retrospective observational cohort study included patients who underwent SRT in the Institut Sainte Catherine between January 1st, 2017 and December 31st, 2020 for the treatment of brain metastasis from any cancer. Individual data and particularly signs of radionecrosis (clinical, imaging, anatomopathological) were collected from electronic medical records. Radionecrosis was defined as the occurrence on MRI of contrast-enhancing necrotic lesions, surrounded by edema, occurring at least 6 months after SRT and localized within fields of irradiation. RESULTS 123 patients were included; median age was 66 years. 17 patients (11.8%) developed radionecrosis after a median follow up of 418.5 days [63;1498]. Predictive factors of radionecrosis in multivariate analysis were age under 66 years with a sensitivity of 77% and a specificity of 56%. No other factor as the presence of comorbidities, the number of irradiated metastases, the PTV volume or the volume of irradiated healthy brain were predictive of radionecrosis. CONCLUSION Age at treatment initiation and tumor location seems to be correlated with radionecrosis in patients with brain metastasis treated with SRT. These elements could be useful to adapted radiation therapy.
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Affiliation(s)
- Benoît Calderon
- Institut Sainte Catherine, 250 Chemin Des Baigne-Pieds, 84000, Avignon, France
| | - Léa Vazquez
- Institut Sainte Catherine, 250 Chemin Des Baigne-Pieds, 84000, Avignon, France.
| | | | - Nicolas Pourel
- Institut Sainte Catherine, 250 Chemin Des Baigne-Pieds, 84000, Avignon, France
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Johannwerner L, Werner EM, Blanck O, Janssen S, Cremers F, Yu NY, Rades D. Radiation Necrosis Following Stereotactic Radiosurgery or Fractionated Stereotactic Radiotherapy with High Biologically Effective Doses for Large Brain Metastases. BIOLOGY 2023; 12:biology12050655. [PMID: 37237469 DOI: 10.3390/biology12050655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023]
Abstract
In Radiation Therapy Oncology Group 90-05, the maximum tolerated dose of single-fraction radiosurgery (SRS) for brain metastases of 21-30 mm was 18 Gy (biologically effective dose (BED) 45 Gy12). Since the patients in this study received prior brain irradiation, tolerable BED may be >45 Gy12 for de novo lesions. We investigated SRS and fractionated stereotactic radiotherapy (FSRT) with a higher BED for radiotherapy-naive lesions. Patients receiving SRS (19-20 Gy) and patients treated with FSRT (30-48 Gy in 3-12 fractions) with BED > 49 Gy12 for up to 4 brain metastases were compared for grade ≥ 2 radiation necrosis (RN). In the entire cohort (169 patients with 218 lesions), 1-year and 2-year RN rates were 8% after SRS vs. 2% and 13% after FSRT (p = 0.73) in per-patient analyses, and 7% after SRS vs. 7% and 10% after FSRT (p = 0.59) in per-lesion analyses. For lesions ≤ 20 mm (137 patients with 185 lesions), the RN rates were 4% (SRS) vs. 0% and 15%, respectively, (FSRT) (p = 0.60) in per-patient analyses, and 3% (SRS) vs. 0% and 11%, respectively, (FSRT) (p = 0.80) in per-lesion analyses. For lesions > 20 mm (32 patients with 33 lesions), the RN rates were 50% (SRS) vs. 9% (FSRT) (p = 0.012) in both per-patient and per-lesion analyses. In the SRS group, a lesion size > 20 mm was significantly associated with RN; in the FSRT group, lesion size had no impact on RN. Given the limitations of this study, FSRT with BED > 49 Gy12 was associated with low RN risk and may be safer than SRS for brain metastases > 20 mm.
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Affiliation(s)
- Leonie Johannwerner
- Department of Radiation Oncology, University of Lubeck, 23562 Lubeck, Germany
| | - Elisa M Werner
- Department of Radiation Oncology, University of Lubeck, 23562 Lubeck, Germany
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany
- Saphir Radiosurgery Center Northern Germany, 24105 Kiel, Germany
| | - Stefan Janssen
- Department of Radiation Oncology, University of Lubeck, 23562 Lubeck, Germany
- Medical Practice for Radiotherapy and Radiation Oncology, 30161 Hannover, Germany
| | - Florian Cremers
- Department of Radiation Oncology, University of Lubeck, 23562 Lubeck, Germany
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Dirk Rades
- Department of Radiation Oncology, University of Lubeck, 23562 Lubeck, Germany
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Shiue K, Sahgal A, Lo SS. Precision Radiation for Brain Metastases With a Focus on Hypofractionated Stereotactic Radiosurgery. Semin Radiat Oncol 2023; 33:114-128. [PMID: 36990629 DOI: 10.1016/j.semradonc.2023.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
There are multiple published randomized controlled trials supporting single-fraction stereotactic radiosurgery (SF-SRS) for patients presenting with 1 to 4 brain metastases, with the benefit of minimizing radiation-induced neurocognitive sequelae as compared to whole brain radiotherapy . More recently, the dogma of SF-SRS as the only means of delivering an SRS treatment has been challenged by hypofractionated SRS (HF-SRS). The ability to deliver 25-35 Gy in 3-5 HF-SRS fractions is a direct consequence of the evolution of radiation technologies to allow image guidance, specialized treatment planning, robotic delivery and/or patient positioning corrections in all 6 degrees-of-freedom, and frameless head immobilization. The intent is to mitigate the potentially devastating complication of radiation necrosis and improve rates of local control for larger metastases. This narrative review provides an overview of outcomes specific to HF-SRS in addition to the more recent developments of staged SRS, preoperative SRS, and hippocampal avoidance-whole brain radiotherapy with simultaneous integrated boost.
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Loo M, Clavier JB, Attal Khalifa J, Moyal E, Khalifa J. Dose-Response Effect and Dose-Toxicity in Stereotactic Radiotherapy for Brain Metastases: A Review. Cancers (Basel) 2021; 13:cancers13236086. [PMID: 34885193 PMCID: PMC8657210 DOI: 10.3390/cancers13236086] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 11/29/2022] Open
Abstract
Simple Summary Brain metastases are one of the most frequent complications for cancer patients. Stereotactic radiosurgery is considered a cornerstone treatment for patients with limited brain metastases and the ideal dose and fractionation schedule still remain unknown. The aim of this literature review is to discuss the dose-effect relation in brain metastases treated by stereotactic radiosurgery, accounting for fractionation and technical considerations. Abstract For more than two decades, stereotactic radiosurgery has been considered a cornerstone treatment for patients with limited brain metastases. Historically, radiosurgery in a single fraction has been the standard of care but recent technical advances have also enabled the delivery of hypofractionated stereotactic radiotherapy for dedicated situations. Only few studies have investigated the efficacy and toxicity profile of different hypofractionated schedules but, to date, the ideal dose and fractionation schedule still remains unknown. Moreover, the linear-quadratic model is being debated regarding high dose per fraction. Recent studies shown the radiation schedule is a critical factor in the immunomodulatory responses. The aim of this literature review was to discuss the dose–effect relation in brain metastases treated by stereotactic radiosurgery accounting for fractionation and technical considerations. Efficacy and toxicity data were analyzed in the light of recent published data. Only retrospective and heterogeneous data were available. We attempted to present the relevant data with caution. A BED10 of 40 to 50 Gy seems associated with a 12-month local control rate >70%. A BED10 of 50 to 60 Gy seems to achieve a 12-month local control rate at least of 80% at 12 months. In the brain metastases radiosurgery series, for single-fraction schedule, a V12 Gy < 5 to 10 cc was associated to 7.1–22.5% radionecrosis rate. For three-fractions schedule, V18 Gy < 26–30 cc, V21 Gy < 21 cc and V23 Gy < 5–7 cc were associated with about 0–14% radionecrosis rate. For five-fractions schedule, V30 Gy < 10–30 cc, V 28.8 Gy < 3–7 cc and V25 Gy < 16 cc were associated with about 2–14% symptomatic radionecrosis rate. There are still no prospective trials comparing radiosurgery to fractionated stereotactic irradiation.
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Affiliation(s)
- Maxime Loo
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
- Correspondence:
| | - Jean-Baptiste Clavier
- Radiotherapy Department, Strasbourg Europe Cancer Institute (ICANS), 67033 Strasbourg, France;
| | - Justine Attal Khalifa
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
| | - Elisabeth Moyal
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
| | - Jonathan Khalifa
- Radiotherapy Department, University Cancer Institute of Toulouse—Oncopôle, 31100 Toulouse, France; (J.A.K.); (E.M.); (J.K.)
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Lee EJ, Choi KS, Park ES, Cho YH. Single- and hypofractionated stereotactic radiosurgery for large (> 2 cm) brain metastases: a systematic review. J Neurooncol 2021; 154:25-34. [PMID: 34268640 DOI: 10.1007/s11060-021-03805-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 07/05/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Since frameless stereotactic radiosurgery (SRS) techniques have been recently introduced, hypofractionated SRS (HF-SRS) for large brain metastases (BMs) is gradually increasing. To verify the efficacy and safety of HF-SRS for large BMs, we aimed to perform a systematic review and compared them with SF-SRS. METHODS We systematically searched the studies regarding SF-SRS or HF-SRS for large (> 2 cm) BM from databases including PubMed, Embase, and the Cochrane Library on July 31, 2018. Biologically effective dose with the α/β ratio of 10 (BED10), 1-year local control (LC), and radiation necrosis (RN) were compared between the two groups, with the studies being weighted by the sample size. RESULTS The 15 studies with 1049 BMs that described 1-year LC and RN were included. HF-SRS tended to be performed in larger tumors; however, higher mean BED10 (50.1 Gy10 versus 40.4 Gy10, p < 0.0001) was delivered in the HF-SRS group, which led to significantly improved 1-year LC (81.6 versus 69.0%, p < 0.0001) and 1-year overall survival (55.1 versus 47.2%, p < 0.0001) in the HF-SRS group compared to the SF-SRS group. In contrast, the incidence of radiation toxicity was significantly decreased in the HF-SRS group compared to the SF-SRS group (8.0 versus 15.6%, p < 0.0001). CONCLUSION HF-SRS results in better LC of large BMs while simultaneously reducing RN compared to SF-SRS. Thus, HF-SRS should be considered a priority for SF-SRS in patients with large BMs who are not suitable to undergo surgical resection.
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Affiliation(s)
- Eun Jung Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, College of Medicine, Hanyang University, 222, Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea
| | - Eun Suk Park
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, 877, Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, Republic of Korea
| | - Young Hyun Cho
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympicro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Samanci Y, Karakose F, Senyurek S, Peker S. Single-fraction versus hypofractionated gamma knife radiosurgery for small metastatic brain tumors. Clin Exp Metastasis 2021; 38:305-320. [PMID: 33733707 DOI: 10.1007/s10585-021-10086-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/08/2021] [Indexed: 12/31/2022]
Abstract
Stereotactic radiosurgery (SRS) has become a standard of care for the treatment of metastatic brain tumors (METs). Although a better balance of tumor control and toxicity of hypofractionated SRS (hfSRS) compared with single-fraction SRS (sfSRS) was demonstrated in large METs, there is no data comparing two approaches for small METs (< 4 cm3). It was aimed to compare clinical outcomes between sfSRS versus hfSRS Gamma Knife radiosurgery (GKRS) in a series of patients with unresected, small METs. Patients (n = 208) treated with sfGKRS or hfGKRS between June 2017 and May 2020 were retrospectively examined in a single center. The co-primary endpoints of local control (LC) and toxicity were estimated by applying the Kaplan-Meier method. Multivariate analysis using Cox proportional hazards (HR) modeling was used to assess the effect of independent variables on the outcomes. The actuarial LC rate was 99.7% at six months and 98.8% at 18 months in the sfGKRS group, and 99.4% and 94.3% in the hfGKRS group (p = 0.089), respectively. In multivariate analysis, MET volume (p = 0.023, HR 2.064) and biologically effective dose (BED10) (p < 0.0001, HR 0.753) was associated with LC. In total, treatment-related toxicity was observed in 13 (8.7%) patients during a median period of 10 weeks (range 1-31). Radiation necrosis was observed in four patients (1.9%), and all patients were in the sfGKRS group (p = 0.042). Only the maximum dose was associated with toxicity (p = 0.032, HR 1.047). Our current results suggest that hfGKRS is advantageous and beneficial also in patients with unresected, small METs.
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Affiliation(s)
- Yavuz Samanci
- Department of Neurosurgery, Koç University Hospital, Istanbul, Turkey
| | - Fatih Karakose
- Department of Radiation Oncology, Koç University Hospital, Istanbul, Turkey
| | - Sukran Senyurek
- Department of Radiation Oncology, Koç University Hospital, Istanbul, Turkey
| | - Selcuk Peker
- Department of Neurosurgery, School of Medicine, Koç University, Istanbul, Turkey.
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Samanci Y, Sisman U, Altintas A, Sarioglu S, Sharifi S, Atasoy Aİ, Bolukbasi Y, Peker S. Hypofractionated frameless gamma knife radiosurgery for large metastatic brain tumors. Clin Exp Metastasis 2021; 38:31-46. [PMID: 33389335 DOI: 10.1007/s10585-020-10068-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/29/2020] [Indexed: 12/30/2022]
Abstract
Hypofractionated stereotactic radiosurgery has become an alternative for metastatic brain tumors (METs). We aimed to analyze the efficacy and safety of frameless hypofractionated Gamma Knife radiosurgery (hfGKRS) in the management of unresected, large METs. All patients who were managed with hfGKRS for unresected, large METs (> 4 cm3) between June 2017 and June 2020 at a single center were reviewed in this retrospective study. Local control (LC), progression-free survival (PFS), overall survival (OS), and toxicities were investigated. A total of 58 patients and 76 METs with regular follow-up were analyzed. LC rate was 98.5% at six months, 96.0% at one year, and 90.6% at 2 years during a median follow-up of 12 months (range, 2-37). The log-rank test indicated no difference in the distribution of LC for any clinical or treatment variable. PFS was 86.7% at 6 months, 66.6% at 1 year, and 58.5% at 2 years. OS was 81% at 6 months, 63.6% at one year, and 50.7% at 2 years. On the log-rank test, clinical parameters such as control status of primary cancer, presence of extracranial metastases, RTOG-RPA class, GPA group, and ds-GPA group were significantly associated with PFS and OS. Patients presented with grade 1 (19.0%), grade 2 (3.5%) and grade 3 (5.2%) side effects. Radiation necrosis was not observed in any patients. Our current results suggest that frameless hfGKRS for unresected, large METs is a rational alternative in selected patients with promising results.
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Affiliation(s)
- Yavuz Samanci
- Department of Neurosurgery, Koç University Hospital, Istanbul, Turkey
| | - Uluman Sisman
- School of Medicine, Koç University, Istanbul, Turkey
| | | | | | | | - Ali İhsan Atasoy
- Department of Radiation Oncology, Koç University Hospital, Istanbul, Turkey
| | - Yasemin Bolukbasi
- Department of Radiation Oncology, School of Medicine, Koç University, Istanbul, Turkey
| | - Selcuk Peker
- Department of Neurosurgery, School of Medicine, Koç University, Davutpasa Caddesi No:4, 34010, Zeytinburnu/İstanbul, Turkey.
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11
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Redmond KJ, Gui C, Benedict S, Milano MT, Grimm J, Vargo JA, Soltys SG, Yorke E, Jackson A, El Naqa I, Marks LB, Xue J, Heron DE, Kleinberg LR. Tumor Control Probability of Radiosurgery and Fractionated Stereotactic Radiosurgery for Brain Metastases. Int J Radiat Oncol Biol Phys 2020; 110:53-67. [PMID: 33390244 DOI: 10.1016/j.ijrobp.2020.10.034] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/25/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE As part of the American Association of Physicists in Medicine Working Group on Stereotactic Body Radiotherapy, tumor control probability (TCP) after stereotactic radiosurgery (SRS) and fractionated stereotactic radiosurgery (fSRS) for brain metastases was modeled based on pooled dosimetric and clinical data from published English-language literature. METHODS AND MATERIALS PubMed-indexed studies published between January 1995 and September 2017 were used to evaluate dosimetric and clinical predictors of TCP after SRS or fSRS for brain metastases. Eligible studies had ≥10 patients and included detailed dose-fractionation data with corresponding ≥1-year local control (LC) data, typically evaluated as a >20% increase in diameter of the targeted lesion using the pre-SRS diameter as a reference. RESULTS Of 2951 potentially eligible manuscripts, 56 included sufficient dose-volume data for analyses. Accepting that necrosis and pseudoprogression can complicate the assessment of LC, for tumors ≤20 mm, single-fraction doses of 18 and 24 Gy corresponded with >85% and 95% 1-year LC rates, respectively. For tumors 21 to 30 mm, an 18 Gy single-fraction dose was associated with 75% LC. For tumors 31 to 40 mm, a 15 Gy single-fraction dose yielded ∼69% LC. For 3- to 5-fraction fSRS using doses in the range of 27 to 35 Gy, 80% 1-year LC has been achieved for tumors of 21 to 40 mm in diameter. CONCLUSIONS TCP for SRS and fSRS are presented. For small lesions ≤20 mm, single doses of ≈18 Gy appear generally associated with excellent rates of LC; for melanoma, higher doses seem warranted. For larger lesions >20 mm, local control rates appear to be ≈ 70% to 75% with usual doses of 15 to 18 Gy, and in this setting, fSRS regimens should be considered. Greater consistency in reporting of dosimetric and LC data is needed to facilitate future pooled analyses. As systemic and biologic therapies evolve, updated analyses will be needed to further assess the necessity, efficacy, and toxicity of SRS and fSRS.
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Affiliation(s)
- Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Chengcheng Gui
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stanley Benedict
- Department of Radiation Oncology, University of California at Davis Comprehensive Cancer Center, Sacramento, California
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Jimm Grimm
- Department of Radiation Oncology, Geisinger Medical Center, Danville, Pennsylvania
| | - J Austin Vargo
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Ellen Yorke
- Medical Physics Department, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Jackson
- Medical Physics Department, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Issam El Naqa
- Department of Machine Learning and Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Lawrence B Marks
- Department of Radiation Oncology and the Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Jinyu Xue
- Department of Radiation Oncology, New York University, New York, New York
| | - Dwight E Heron
- Department of Radiation Oncology, Bon Secours Mercy Health System, Youngstown, Ohio
| | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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12
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Matsuda R, Tamamoto T, Sugimoto T, Hontsu S, Yamaki K, Miura S, Takeshima Y, Tamura K, Yamada S, Nishimura F, Nakagawa I, Motoyama Y, Park YS, Nakase H, Hasegawa M. Linac-based fractionated stereotactic radiotherapy with a micro-multileaf collimator for large brain metastasis unsuitable for surgical resection. JOURNAL OF RADIATION RESEARCH 2020; 61:546-553. [PMID: 32548618 PMCID: PMC7336818 DOI: 10.1093/jrr/rraa038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/27/2020] [Indexed: 05/21/2023]
Abstract
The aim of this study was to assess clinical outcomes using linac-based, fractionated, stereotactic radiotherapy (fSRT) with a micro-multileaf collimator for large brain metastasis (LBM) unsuitable for surgical resection. Between January 2009 and October 2018 we treated 21 patients with LBM using linac-based fSRT. LBM was defined as a tumor with ≥30 mm maximal diameter in gadolinium-enhanced magnetic resonance images. LBMs originated from the lung (n = 17, 81%), ovary (n = 2, 9.5%), rectum (n = 1, 4.8%) and esophagus (n = 1, 4.8%). The median pretreatment Karnofsky performance status was 50 (range: 50-80). Recursive partition analysis (RPA) was as follows: Classes 2 and 3 were 7 and 14 patients, respectively. The median follow-up was 5 months (range: 1-86 months). The range of tumor volume was 8.7-26.5 cm3 (median: 17.1 cm3). All patients were basically treated with 35Gy in 5 fractions, except in three cases. The progression-free survival was 3.0 months. The median survival time was 7.0 months. There was no permanent radiation injury in any of the patients. Radiation-caused central nervous system necrosis, according to the Common Terminology Criteria for Adverse Events version 4.0, occurred in one patient (grade 3). One patients received bevacizumab for radiation necrosis. Two patients underwent additional surgical resection due to local progression and cyst formation. For patients with LBM unsuitable for surgical resection, linac-based fSRT is a promising therapeutic alternative.
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Affiliation(s)
- Ryosuke Matsuda
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
| | - Tetsuro Tamamoto
- Department of Radiation Oncology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
- Corresponding author. Department of Radiation Oncology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan. Tel: +81-744-22-3051; Fax: +81-744-29-0818;
| | - Tadashi Sugimoto
- Department of Neurosurgery, Osaka General Medical Center, 3-1-56 Mandaihigashi, Sumiyoshi-ku, Osaka, Osaka 558-8558, Japan
| | - Shigeto Hontsu
- Department of Respiratory medicine, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
| | - Kaori Yamaki
- Department of Radiation Oncology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
| | - Sachiko Miura
- Department of Radiation Oncology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
| | - Yasuhiro Takeshima
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
| | - Kentaro Tamura
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
| | - Shuichi Yamada
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
| | - Fumihiko Nishimura
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
| | - Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
| | - Yasushi Motoyama
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
| | - Young-Su Park
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
| | - Masatoshi Hasegawa
- Department of Radiation Oncology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
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13
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Dumont Lecomte D, Lequesne J, Geffrelot J, Lesueur P, Barraux V, Loiseau C, Lacroix J, Leconte A, Émery É, Thariat J, Stefan D. Hypofractionated stereotactic radiotherapy for challenging brain metastases using 36 Gy in six fractions. Cancer Radiother 2019; 23:860-866. [DOI: 10.1016/j.canrad.2019.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/10/2019] [Accepted: 06/13/2019] [Indexed: 10/25/2022]
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14
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Chao ST, De Salles A, Hayashi M, Levivier M, Ma L, Martinez R, Paddick I, Régis J, Ryu S, Slotman BJ, Sahgal A. Stereotactic Radiosurgery in the Management of Limited (1-4) Brain Metasteses: Systematic Review and International Stereotactic Radiosurgery Society Practice Guideline. Neurosurgery 2019; 83:345-353. [PMID: 29126142 DOI: 10.1093/neuros/nyx522] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 09/19/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Guidelines regarding stereotactic radiosurgery (SRS) for brain metastases are missing recently published evidence. OBJECTIVE To conduct a systematic review and provide an objective summary of publications regarding SRS in managing patients with 1 to 4 brain metastases. METHODS Using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, a systematic review was conducted using PubMed and Medline up to November 2016. A separate search was conducted for SRS for larger brain metastases. RESULTS Twenty-seven prospective studies, critical reviews, meta-analyses, and published consensus guidelines were reviewed. Four key points came from these studies. First, there is no detriment to survival by withholding whole brain radiation (WBRT) in the upfront management of brain metastases with SRS. Second, while SRS on its own provides a high rate of local control (LC), WBRT may provide further increase in LC. Next, WBRT does provide distant brain control with less need for salvage therapy. Finally, the addition of WBRT does affect neurocognitive function and quality of life more than SRS alone. For larger brain metastases, surgical resection should be considered, especially when factoring lower LC with single-session radiosurgery. There is emerging data showing good LC and/or decreased toxicity with multisession radiosurgery. CONCLUSION A number of well-conducted prospective and meta-analyses studies demonstrate good LC, without compromising survival, using SRS alone for patients with a limited number of brain metastases. Some also demonstrated less impact on neurocognitive function with SRS alone. Practice guidelines were developed using these data with International Stereotactic Radiosurgery Society consensus.
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Affiliation(s)
- Samuel T Chao
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neurooncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Antonio De Salles
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California.,HCor Neuroscience, Sao Paulo, Brazil
| | - Motohiro Hayashi
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Marc Levivier
- Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lijun Ma
- Division Physics, Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Roberto Martinez
- Department Neurosurgery, Ruber International Hospital, Madrid, Spain
| | - Ian Paddick
- Division Physics, National Hospital for Neurology and Neurosurgery, London, UK
| | - Jean Régis
- Department of Functional Neurosurgery, Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Samuel Ryu
- Department of Radiation Oncology and Neurosurgery, Stony Brook University, Stony Brook, New York
| | - Ben J Slotman
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Arjun Sahgal
- Department of Radiation Oncology, University of Toronto, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
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15
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Improved effectiveness of stereotactic radiosurgery in large brain metastases by individualized isotoxic dose prescription: an in silico study. Strahlenther Onkol 2018; 194:560-569. [PMID: 29349605 PMCID: PMC5959984 DOI: 10.1007/s00066-018-1262-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 01/05/2018] [Indexed: 12/25/2022]
Abstract
INTRODUCTION In large brain metastases (BM) with a diameter of more than 2 cm there is an increased risk of radionecrosis (RN) with standard stereotactic radiosurgery (SRS) dose prescription, while the normal tissue constraint is exceeded. The tumor control probability (TCP) with a single dose of 15 Gy is only 42%. This in silico study tests the hypothesis that isotoxic dose prescription (IDP) can increase the therapeutic ratio (TCP/Risk of RN) of SRS in large BM. MATERIALS AND METHODS A treatment-planning study with 8 perfectly spherical and 46 clinically realistic gross tumor volumes (GTV) was conducted. The effects of GTV size (0.5-4 cm diameter), set-up margins (0, 1, and 2 mm), and beam arrangements (coplanar vs non-coplanar) on the predicted TCP using IDP were assessed. For single-, three-, and five-fraction IDP dose-volume constraints of V12Gy = 10 cm3, V19.2 Gy = 10 cm3, and a V20Gy = 20 cm3, respectively, were used to maintain a low risk of radionecrosis. RESULTS In BM of 4 cm in diameter, the maximum achievable single-fraction IDP dose was 14 Gy compared to 15 Gy for standard SRS dose prescription, with respective TCPs of 32 and 42%. Fractionated SRS with IDP was needed to improve the TCP. For three- and five-fraction IDP, a maximum predicted TCP of 55 and 68% was achieved respectively (non-coplanar beams and a 1 mm GTV-PTV margin). CONCLUSIONS Using three-fraction or five-fraction IDP the predicted TCP can be increased safely to 55 and 68%, respectively, in large BM with a diameter of 4 cm with a low risk of RN. Using IDP, the therapeutic ratio of SRS in large BM can be increased compared to current SRS dose prescription.
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16
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Angelov L, Mohammadi AM, Bennett EE, Abbassy M, Elson P, Chao ST, Montgomery JS, Habboub G, Vogelbaum MA, Suh JH, Murphy ES, Ahluwalia MS, Nagel SJ, Barnett GH. Impact of 2-staged stereotactic radiosurgery for treatment of brain metastases ≥ 2 cm. J Neurosurg 2017; 129:366-382. [PMID: 28937324 DOI: 10.3171/2017.3.jns162532] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) is the primary modality for treating brain metastases. However, effective radiosurgical control of brain metastases ≥ 2 cm in maximum diameter remains challenging and is associated with suboptimal local control (LC) rates of 37%-62% and an increased risk of treatment-related toxicity. To enhance LC while limiting adverse effects (AEs) of radiation in these patients, a dose-dense treatment regimen using 2-staged SRS (2-SSRS) was used. The objective of this study was to evaluate the efficacy and toxicity of this treatment strategy. METHODS Fifty-four patients (with 63 brain metastases ≥ 2 cm) treated with 2-SSRS were evaluated as part of an institutional review board-approved retrospective review. Volumetric measurements at first-stage stereotactic radiosurgery (first SSRS) and second-stage SRS (second SSRS) treatments and on follow-up imaging studies were determined. In addition to patient demographic data and tumor characteristics, the study evaluated 3 primary outcomes: 1) response at first follow-up MRI, 2) time to local progression (TTP), and 3) overall survival (OS) with 2-SSRS. Response was analyzed using methods for binary data, TTP was analyzed using competing-risks methods to account for patients who died without disease progression, and OS was analyzed using conventional time-to-event methods. When needed, analyses accounted for multiple lesions in the same patient. RESULTS Among 54 patients, 46 (85%) had 1 brain metastasis treated with 2-SSRS, 7 patients (13%) had 2 brain metastases concurrently treated with 2-SSRS, and 1 patient underwent 2-SSRS for 3 concurrent brain metastases ≥ 2 cm. The median age was 63 years (range 23-83 years), 23 patients (43%) had non-small cell lung cancer, and 14 patients (26%) had radioresistant tumors (renal or melanoma). The median doses at first and second SSRS were 15 Gy (range 12-18 Gy) and 15 Gy (range 12-15 Gy), respectively. The median duration between stages was 34 days, and median tumor volumes at the first and second SSRS were 10.5 cm3 (range 2.4-31.3 cm3) and 7.0 cm3 (range 1.0-29.7 cm3). Three-month follow-up imaging results were available for 43 lesions; the median volume was 4.0 cm3 (range 0.1-23.1 cm3). The median change in volume compared with baseline was a decrease of 54.9% (range -98.2% to 66.1%; p < 0.001). Overall, 9 lesions (14.3%) demonstrated local progression, with a median of 5.2 months (range 1.3-7.4 months), and 7 (11.1%) demonstrated AEs (6.4% Grade 1 and 2 toxicity; 4.8% Grade 3). The estimated cumulative incidence of local progression at 6 months was 12% ± 4%, corresponding to an LC rate of 88%. Shorter TTP was associated with greater tumor volume at baseline (p = 0.01) and smaller absolute (p = 0.006) and relative (p = 0.05) decreases in tumor volume from baseline to second SSRS. Estimated OS rates at 6 and 12 months were 65% ± 7% and 49% ± 8%, respectively. CONCLUSIONS 2-SSRS is an effective treatment modality that resulted in significant reduction of brain metastases ≥ 2 cm, with excellent 3-month (95%) and 6-month (88%) LC rates and an overall AE rate of 11%. Prospective studies with larger cohorts and longer follow-up are necessary to assess the durability and toxicities of 2-SSRS.
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Affiliation(s)
- Lilyana Angelov
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,2Department of Neurosurgery, Neurological Institute
| | - Alireza M Mohammadi
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,2Department of Neurosurgery, Neurological Institute
| | | | - Mahmoud Abbassy
- 4Department of Neurosurgery, Alexandria University, Alexandria, Egypt
| | - Paul Elson
- 3Quantitative Health Sciences, Taussig Cancer Institute, and
| | - Samuel T Chao
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,5Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; and
| | - Joshua S Montgomery
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute
| | | | - Michael A Vogelbaum
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,2Department of Neurosurgery, Neurological Institute
| | - John H Suh
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,5Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; and
| | - Erin S Murphy
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,5Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; and
| | - Manmeet S Ahluwalia
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute
| | - Sean J Nagel
- 2Department of Neurosurgery, Neurological Institute
| | - Gene H Barnett
- 1Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute.,2Department of Neurosurgery, Neurological Institute
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17
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Bahig H, Simard D, Létourneau L, Wong P, Roberge D, Filion E, Donath D, Sahgal A, Masucci L. A Study of Pseudoprogression After Spine Stereotactic Body Radiation Therapy. Int J Radiat Oncol Biol Phys 2016; 96:848-856. [PMID: 27788956 DOI: 10.1016/j.ijrobp.2016.07.034] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 07/25/2016] [Accepted: 07/26/2016] [Indexed: 12/18/2022]
Abstract
PURPOSE To determine the incidence of pseudoprogression (PP) after spine stereotactic body radiation therapy based on a detailed and quantitative assessment of magnetic resonance imaging (MRI) morphologic tumor alterations, and to identify predictive factors distinguishing PP from local recurrence (LR). METHODS AND MATERIALS A retrospective analysis of 35 patients with 49 spinal segments treated with spine stereotactic body radiation therapy, from 2009 to 2014, was conducted. The median number of follow-up MRI studies was 4 (range, 2-7). The gross tumor volumes (GTVs) within each of the 49 spinal segments were contoured on the pretreatment and each subsequent follow-up T1- and T2-weighted MRI sagittal sequence. T2 signal intensity was reported as the mean intensity of voxels constituting each volume. LR was defined as persistent GTV enlargement on ≥2 serial MRI studies for ≥6 months or on pathologic confirmation. PP was defined as a GTV enlargement followed by stability or regression on subsequent imaging within 6 months. Kaplan-Meier analysis was used for estimation of actuarial local control, disease-free survival, and overall survival. RESULTS The median follow-up was 23 months (range, 1-39 months). PP was identified in 18% of treated segments (9 of 49) and LR in 29% (14 of 49). Earlier volume enlargement (5 months for PP vs 15 months for LR, P=.005), greater GTV to reference nonirradiated vertebral body T2 intensity ratio (+30% for PP vs -10% for LR, P=.005), and growth confined to 80% of the prescription isodose line (80% IDL) (8 of 9 PP cases vs 1 of 14 LR cases, P=.002) were associated with PP on univariate analysis. Multivariate analysis confirmed an earlier time to volume enlargement and growth within the 80% IDL as significant predictors of PP. LR involved the epidural space in all but 1 lesion, whereas PP was confined to the vertebral body in 7 of 9 cases. CONCLUSIONS PP was observed in 18% of treated spinal segments. Tumor growth confined to the 80% IDL and earlier time to tumor enlargement were predictive for PP.
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Affiliation(s)
- Houda Bahig
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Dany Simard
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Laurent Létourneau
- Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Philip Wong
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - David Roberge
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Edith Filion
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - David Donath
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Laura Masucci
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada.
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18
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Jeong WJ, Park JH, Lee EJ, Kim JH, Kim CJ, Cho YH. Efficacy and Safety of Fractionated Stereotactic Radiosurgery for Large Brain Metastases. J Korean Neurosurg Soc 2015; 58:217-24. [PMID: 26539264 PMCID: PMC4630352 DOI: 10.3340/jkns.2015.58.3.217] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 06/01/2015] [Accepted: 08/20/2015] [Indexed: 01/19/2023] Open
Abstract
Objective To investigate the efficacy and safety of fractionated stereotactic radiosurgery for large brain metastases (BMs). Methods Between June 2011 and December 2013, a total of 38 large BMs >3.0 cm in 37 patients were treated with fractionated Cyberknife radiosurgery. These patients comprised 16 men (43.2%) and 21 women, with a median age of 60 years (range, 38-75 years). BMs originated from the lung (n=19, 51.4%), the gastrointestinal tract (n=10, 27.0%), the breast (n=5, 13.5%), and other tissues (n=3, 8.1%). The median tumor volume was 17.6 cc (range, 9.4-49.6 cc). For Cyberknife treatment, a median peripheral dose of 35 Gy (range, 30-41 Gy) was delivered in 3 to 5 fractions. Results With a median follow-up of 10 months (range, 1-37 months), the crude local tumor control (LTC) rate was 86.8% and the estimated LTC rates at 12 and 24 months were 87.0% and 65.2%, respectively. The median overall survival (OS) and progression-free survival (PFS) rates were 16 and 11 months, respectively. The estimated OS and PFS rates at 6, 12, and 18 months were 81.1% and 65.5%, 56.8% and 44.9%, and 40.7% and 25.7%, respectively. Patient performance status and preoperative focal neurologic deficits improved in 20 of 35 (57.1%) and 12 of 17 patients (70.6%), respectively. Radiation necrosis with a toxicity grade of 2 or 3 occurred in 6 lesions (15.8%). Conclusion These results suggest a promising role of fractionated stereotactic radiosurgery in treating large BMs in terms of both efficacy and safety.
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Affiliation(s)
- Won Joo Jeong
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Hong Park
- Radiosurgery Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Jung Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Jin Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Hyun Cho
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Abstract
OBJECTIVE The goal of this study was to investigate the treatment results of Gamma Knife radiosurgery (GKRS) for cystic brain metastases and relevant factors associated with local tumor control. MATERIALS AND METHODS We retrospectively reviewed the clinical, radiological, and dosimetry data of 37 cystic brain metastases of 28 patients who were treated with GKRS. Cyst drainage was performed in 8 large lesions before GKRS to decrease the target volume. The mean target volume was 4.8 (range, 0.3-15.8) cc at the time of GKRS, and the mean prescription dose was 16.6 (range, 13-22) Gy. RESULTS The actuarial median survival time was 17.7 ± 10.2 months, and the primary tumor status was a significant prognostic factor for survival. The actuarial local tumor control rate at 6 and 12 months was 93.1 and 82.3%, respectively. Among the various factors, only prescription dose (>15 Gy) was a significant factor related to local tumor control after multivariate analysis (p = 0.049). Cyst volume or cyst/total tumor volume ratio did not influence local control after GKRS, when the target volume was reduced to about 15 cc after cyst drainage. CONCLUSION According to our results, we suggest that stereotactic radiosurgery should be considered as one of the treatment options for cystic brain metastases, when large tumor volume can be reduced by surgical drainage before radiosurgery, especially for patients with a controlled primary tumor.
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Affiliation(s)
- Sang Ryul Lee
- a Gamma Knife Center, Department of Neurosurgery , Ajou University School of Medicine , Suwon , Korea
| | - Ji Young Oh
- a Gamma Knife Center, Department of Neurosurgery , Ajou University School of Medicine , Suwon , Korea
| | - Se-Hyuk Kim
- a Gamma Knife Center, Department of Neurosurgery , Ajou University School of Medicine , Suwon , Korea
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Pinkham MB, Whitfield GA, Brada M. New developments in intracranial stereotactic radiotherapy for metastases. Clin Oncol (R Coll Radiol) 2015; 27:316-23. [PMID: 25662094 DOI: 10.1016/j.clon.2015.01.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 12/16/2014] [Accepted: 01/22/2015] [Indexed: 11/19/2022]
Abstract
Brain metastases are common and the prognosis for patients with multiple brain metastases treated with whole brain radiotherapy is limited. As systemic disease control continues to improve, the expectations of radiotherapy for brain metastases are growing. Stereotactic radiosurgery (SRS) as a high precision localised irradiation given in a single fraction prolongs survival in patients with a single brain metastasis and functional independence in those with up to three brain metastases. SRS technology has become commonplace and is available in many radiation oncology and neurosurgery departments. With increasing use there is a need for appropriate patient selection, refinement of dose-fractionation and safe integration of SRS with other treatment modalities. We review the evidence for current practice and new developments in the field, with a specific focus on patient-relevant outcomes.
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Affiliation(s)
- M B Pinkham
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK; School of Medicine, University of Queensland, Brisbane, Australia
| | - G A Whitfield
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK; The University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - M Brada
- University of Liverpool, Department of Clinical and Molecular Cancer Medicine and Academic Radiotherapy Unit, Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK.
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Zimmerman AL, Murphy ES, Suh JH, Vogelbaum MA, Barnett GH, Angelov L, Ahluwalia M, Reddy CA, Chao ST. Treatment of Large Brain Metastases With Stereotactic Radiosurgery. Technol Cancer Res Treat 2015; 15:186-95. [DOI: 10.1177/1533034614568097] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 12/22/2014] [Indexed: 01/09/2023] Open
Abstract
Introduction: We report our series of patients with large brain metastases, >3 cm in diameter, who received stereotactic radiosurgery (SRS) as a component of their treatment, focusing on survival and intracranial recurrence rates. Materials and Methods: The brain tumor database was queried for patients treated with SRS for large brain metastases. Local recurrence (LR) and distant brain recurrence (DBR) rates were calculated using cumulative incidence analysis, and overall survival (OS) was calculated using Kaplan-Meier analysis. Patients were classified into 1 of the 4 groups based on treatment strategy: SRS alone, surgery plus SRS, SRS plus whole-brain radiation therapy (WBRT), and salvage SRS from more remote WBRT and/or surgery. Results: A total of 153 patients with 164 lesions were evaluated. The SRS alone was the treatment approach in 62 lesions, surgery followed by SRS to the resection bed (S + SRS) in 33, SRS + WBRT in 19, and salvage SRS in 50. There was no statistically significant difference in OS between the 4 treatment groups ( P = .06). Median survival was highest in patients receiving surgery + SRS (12.2 months) followed by SRS + WBRT (6.9 months), SRS alone (6.6 months), and salvage SRS (6.1 months). There was also no significant difference for LR rates between the groups at 12 months. No significant variables on univariate analysis were noted for LR. The 12-month DBR rates were highest in the S + SRS group (52%), followed by salvage SRS (31%), SRS alone (28%), and SRS + WBRT (13%; P = .03). Conclusion: There were no significant predictors for local control. Keeping in mind that patient numbers in the SRS + WBRT group are small, the addition of WBRT to SRS did not appear to significantly improve survival or local control, supporting the delayed use of WBRT for some patients to prevent potential side effects provided regular imaging surveillance and salvage therapy are utilized. Prospective studies are needed to optimize SRS treatment regimens for patients with large brain metastases.
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Affiliation(s)
- Amy L. Zimmerman
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Erin S. Murphy
- Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic, Cleveland, OH, USA
- Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John H. Suh
- Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic, Cleveland, OH, USA
- Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Michael A. Vogelbaum
- Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic, Cleveland, OH, USA
- Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gene H. Barnett
- Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic, Cleveland, OH, USA
- Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lilyana Angelov
- Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic, Cleveland, OH, USA
- Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Manmeet Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic, Cleveland, OH, USA
- Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Chandana A. Reddy
- Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Samuel T. Chao
- Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic, Cleveland, OH, USA
- Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
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Whole brain irradiation with hippocampal sparing and dose escalation on multiple brain metastases: Local tumour control and survival. Strahlenther Onkol 2015; 191:461-9. [PMID: 25592907 DOI: 10.1007/s00066-014-0808-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 12/19/2014] [Indexed: 01/27/2023]
Abstract
PURPOSE Hippocampal-avoidance whole brain radiotherapy (HA-WBRT) for multiple brain metastases may prevent treatment-related cognitive decline, compared to standard WBRT. Additionally, simultaneous integrated boost (SIB) on individual metastases may further improve the outcome. Here, we present initial data concerning local tumour control (LTC), intracranial progression-free survival (PFS), overall survival (OS), toxicity and safety for this new irradiation technique. METHODS AND MATERIALS Twenty patients, enrolled between 2011 and 2013, were treated with HA-WBRT (30 Gy in 12 fractions, D98% to hippocampus ≤ 9 Gy) and a SIB (51 Gy) on multiple (2-13) metastases using a volumetric modulated arc therapy (VMAT) approach based on 2-4 arcs. Metastases were evaluated bidimensionally along the two largest diameters in contrast-enhanced three-dimensional T1-weighed MRI. RESULTS Median follow-up was 40 weeks. The median time to progression of boosted metastases has not been reached yet, corresponding to a LTC rate of 73%. Median intracranial PFS was 40 weeks, corresponding to a 1-year PFS of 45.3%. Median OS was 71.5 weeks, corresponding to a 1-year OS of 60%. No obvious acute or late toxicities grade > 2 (NCI CTCAE v4.03) were observed. Dmean to the bilateral hippocampi was 6.585 Gy ± 0.847 (α/β = 2 Gy). Two patients developed a new metastasis in the area of hippocampal avoidance. CONCLUSION HA-WBRT (simultaneous integrated protection, SIP) with SIB to metastases is a safe and tolerable regime that shows favorable LTC for patients with multiple brain metastases, while it has the potential to minimize the side-effect of cognitive deterioration.
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Pseudo-progression after stereotactic radiotherapy of brain metastases: lesion analysis using MRI cine-loops. J Neurooncol 2014; 119:437-43. [DOI: 10.1007/s11060-014-1519-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 06/22/2014] [Indexed: 01/13/2023]
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Inoue HK, Sato H, Seto KI, Torikai K, Suzuki Y, Saitoh JI, Noda SE, Nakano T. Five-fraction CyberKnife radiotherapy for large brain metastases in critical areas: impact on the surrounding brain volumes circumscribed with a single dose equivalent of 14 Gy (V14) to avoid radiation necrosis. JOURNAL OF RADIATION RESEARCH 2014; 55:334-42. [PMID: 24187332 PMCID: PMC3951086 DOI: 10.1093/jrr/rrt127] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 08/23/2013] [Accepted: 09/18/2013] [Indexed: 05/27/2023]
Abstract
The efficacy and toxicity of five-fraction CyberKnife radiotherapy were evaluated in patients with large brain metastases in critical areas. A total of 85 metastases in 78 patients, including tumors >30 cm(3) (4 cm in diameter) were treated with five-fraction CyberKnife radiotherapy with a median marginal dose of 31 Gy at a median prescribed isodose of 58%. Changes in the neurological manifestations, local tumor control, and adverse effects were investigated after treatment. The surrounding brain volumes circumscribed with 28.8 Gy (single dose equivalent to 14 Gy: V14) were measured to evaluate the risk of radiation necrosis. Neurological manifestations, such as motor weakness, visual disturbances and aphasia improved in 28 of 55 patients (50.9%). Local tumor control was obtained in 79 of 85 metastases (92.9%) during a median follow-up of eight months. Symptomatic edema occurred in 10 patients, and two of them (2.6%) required surgical resection because of radiation necrosis. The V14 of these patients was 3.0-19.7 cm(3). There were 16 lesions with a V14 of ≥7.0 cm(3), and two of these lesions developed extensive brain edema due to radiation necrosis. None of the patients with a V14 of <7.0 cm(3) exhibited edema requiring surgical intervention. We therefore conclude that a high rate of local tumor control and low rates of complications can be obtained after five-fraction CyberKnife radiotherapy for large metastases in critical areas. The V14 of the surrounding brain is therefore a useful indicator for the risk of radiation necrosis in patients with large metastases.
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Affiliation(s)
- Hiroshi K. Inoue
- Cyber Center, Kanto Neurosurgical Hospital, 1120 Dai, Kumagaya, Saitama, 360-0804, Japan
| | - Hiro Sato
- Cyber Center, Kanto Neurosurgical Hospital, 1120 Dai, Kumagaya, Saitama, 360-0804, Japan
| | - Ken-ichi Seto
- Cyber Center, Kanto Neurosurgical Hospital, 1120 Dai, Kumagaya, Saitama, 360-0804, Japan
| | - Kota Torikai
- Gunma University Heavy-ion Medical Research Center, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Yoshiyuki Suzuki
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Jun-ichi Saitoh
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Shin-ei Noda
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Takashi Nakano
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
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Minniti G, D'Angelillo RM, Scaringi C, Trodella LE, Clarke E, Matteucci P, Osti MF, Ramella S, Enrici RM, Trodella L. Fractionated stereotactic radiosurgery for patients with brain metastases. J Neurooncol 2014; 117:295-301. [PMID: 24488446 DOI: 10.1007/s11060-014-1388-3] [Citation(s) in RCA: 131] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 01/22/2014] [Indexed: 10/25/2022]
Abstract
Stereotactic radiosurgery (SRS) delivered in 2-5 fractions (multi-fraction SRS) has been employed in patients with brain metastases as an alternative to single-fraction SRS with the aim to reduce late radiation-induced toxicity while maintaining high local control rate. In the present study we have evaluated the efficacy and toxicity of multi-fraction SRS in patients with 1-3 brain metastases. Between March 2006 and October 2012, 135 patients (63 men and 72 women) with 171 brain metastases have been treated with multi-fraction SRS (3 × 9 Gy or 3 × 12 Gy). At a median follow-up of 11.4 months, 16 lesions recurred locally. The 1- and 2-year local control rates were 88 and 72 %, respectively. The 1- and 2-year survival rates were 57 and 25 %, and respective distant failure rates were 52 and 73 %. Seventy-eight percent of patients succumbed to their extracranial disease and 22 % died of progressive intracranial disease. Multivariate analysis showed that melanoma histology was predictive of local failure (p = 0.02; HR 6.1, 95 % CI 1.5-24). Specifically, the 1-year local control rates were 68 % for melanoma, 92 % for breast carcinoma, and 88 % for NSCLC, respectively. Stable extracranial disease (p = 0.004) and Karnofsky performance status (p = 0.01) were predictive of longer survival. Radiologic changes suggestive of radionecrosis occurred in 12 (7 %) out of 171 lesions, with an actuarial risk of 9 % at 1 year and 17 % at 2 years, respectively. In conclusion, multi-fraction SRS appears to be an effective and safe treatment modality for brain metastases. It may represent an alternative to single-dose SRS for patients with large lesions or lesions located near critical structures.
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Affiliation(s)
- Giuseppe Minniti
- Radiation Oncology Unit, Sant' Andrea Hospital, University "Sapienza", Via di Grottarossa 1035, 00189, Rome, Italy,
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Feuvret L, Vinchon S, Martin V, Lamproglou I, Halley A, Calugaru V, Chea M, Valéry CA, Simon JM, Mazeron JJ. Stereotactic radiotherapy for large solitary brain metastases. Cancer Radiother 2014; 18:97-106. [PMID: 24439342 DOI: 10.1016/j.canrad.2013.12.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 12/02/2013] [Accepted: 12/04/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE To assess effectiveness and toxicity levels of stereotactic radiation therapy without whole brain radiation therapy in patients with solitary brain metastases larger than 3cm. PATIENTS AND METHODS Between June 2007 and March 2009, 12 patients received fractionated stereotactic radiation therapy and 24 patients underwent stereotactic radiosurgery. For the fractionated stereotactic radiation therapy group, 3×7.7Gy were delivered to the planning target volume (PTV); median volume and diameter were 29.4 cm(3) and 4.4cm, respectively. For the stereotactic radiosurgery group, 14Gy were delivered to the PTV; median volume and diameter were 15.6 cm(3) and 3.7cm, respectively. RESULTS Median follow-up was 218 days. For the fractionated stereotactic radiation therapy group, local control rates were 100% at 360 days and 64% at 720 days; for the stereotactic radiosurgery group, rates were 58% at 360 days and 48% at 720 days (P=0.06). Median survival time was 504 days for the fractionated stereotactic radiation therapy group and 164 days for the stereotactic radiosurgery group (P=0.049). Two cases of grade 2 toxicity were observed in the fractionated stereotactic radiation therapy group, and 6 cases of grade 1-2 toxicity, in the stereotactic radiosurgery group. CONCLUSIONS This study provides data to support that fractionated stereotactic radiation therapy without whole brain radiation therapy with a margin dose of 3 fractions of 7.7Gy for treatment of solitary large brain metastases is efficient and well-tolerated. Because of the significant improvement in overall survival, this schedule should be assessed in a randomized trial.
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Affiliation(s)
- L Feuvret
- Centre des tumeurs, groupe Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France.
| | - S Vinchon
- Centre Paul-Papin, 2, rue Moll, 49100 Angers cedex, France
| | - V Martin
- Centre des tumeurs, groupe Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - I Lamproglou
- Centre des tumeurs, groupe Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - A Halley
- Centre des tumeurs, groupe Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - V Calugaru
- Centre de protonthérapie d'Orsay (CPO), institut Curie, bâtiment 101, campus universitaire, 91898 Orsay cedex, France
| | - M Chea
- Centre des tumeurs, groupe Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - C A Valéry
- Unité de Gamma-Knife, groupe Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - J-M Simon
- Centre des tumeurs, groupe Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - J-J Mazeron
- Centre des tumeurs, groupe Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France
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Gerdan L, Segedin B, Nagy V, Khoa MT, Trang NT, Schild SE, Rades D. The number of involved extracranial organs: a new predictor of survival in breast cancer patients with brain metastasis. Clin Neurol Neurosurg 2013; 115:2108-10. [PMID: 23954201 DOI: 10.1016/j.clineuro.2013.07.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 07/22/2013] [Accepted: 07/24/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study was performed to investigate the potential impact of the number of involved extracranial organs on survival in patients with brain metastasis from breast cancer. METHODS The data of 196 patients treated with whole-brain radiotherapy (WBRT) alone for brain metastases from breast cancer were retrospectively analyzed. Six potential prognostic factors were evaluated for associations with survival. These factors included WBRT regimen, age, Karnofsky performance score (KPS), number of brain metastases, interval from breast cancer diagnosis to WBRT, and the number of involved extracranial organs. RESULTS The 6-month survival rates of patients with involvement of 0, 1, 2, 3 and ≥4 extracranial organs were 59%, 49%, 26%, 26% and 13%, respectively, and the 12-month survival rates were 45%, 36%, 17%, 17% and 13%, respectively (p<0.001). On multivariate analysis, the number of involved extracranial organs (risk ratio 1.17; 95%-confidence interval 1.02-1.35; p=0.028) maintained significance, as did KPS (p<0.001), but not age (p=0.27). CONCLUSION The number of involved extracranial organs is an independent prognostic factor of survival in patients with brain metastasis from breast cancer.
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Affiliation(s)
- Lavinia Gerdan
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany; Section of Nuclear Medicine, University of Lübeck, Lübeck, Germany
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Rades D, Dziggel L, Segedin B, Oblak I, Nagy V, Marita A, Schild SE. The first survival score for patients with brain metastases from small cell lung cancer (SCLC). Clin Neurol Neurosurg 2013; 115:2029-32. [PMID: 23871680 DOI: 10.1016/j.clineuro.2013.06.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 06/12/2013] [Accepted: 06/23/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Survival scores can help physicians select appropriate treatment for patients with brain metastasis. Primary tumors have different biological behavior justifying separate scoring systems for different tumors. In this study, a survival score was developed for patients with brain metastasis from SCLC. METHODS Data of 172 patients receiving whole-brain radiotherapy alone for brain metastasis from SCLC were included. Patients were assigned to a test (N=86) or a validation group (N=86). In the test group, Karnofsky Performance Score, number of brain metastases, and extracranial metastasis were associated with survival and included in the score. Scores for each factor were obtained from the 6-month survival rate divided by 10. According to the total scores, which represented the sum of the three scores, three prognostic groups were formed. RESULTS 6-Month survival rates in the test group were 3% for 5-8 points, 40% for 9-12 points, and 89% for 15 points (p<0.001). In the validation group, 6-month survival rates were 3%, 41%, and 89% (p<0.001). The comparisons between the three prognostic groups of the test group and the validation group did not show significant differences. CONCLUSIONS This new score appears valid and reproducible. It can be used to personalize the treatment to patients with brain metastasis from SCLC.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany.
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Martens K, Meyners T, Rades D, Tronnier V, Bonsanto MM, Petersen D, Dunst J, Dellas K. The prognostic value of tumor necrosis in patients undergoing stereotactic radiosurgery of brain metastases. Radiat Oncol 2013; 8:162. [PMID: 23822663 PMCID: PMC3707781 DOI: 10.1186/1748-717x-8-162] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 07/01/2013] [Indexed: 11/10/2022] Open
Abstract
Background This retrospective study investigated the outcome of patients with brain metastases after radiosurgery with special emphasis on prognostic impact of visible intratumoral necrosis on survival and local control. Methods From 1998 through 2008, 149 patients with brain metastases from solid tumors were treated with stereotactic radiotherapy at Luebeck University. Median age was 58.4 years with 11%, 78%, 10% in recursive partitioning analysis (RPA) classes I, II, III, respectively. 70% had 1 metastasis, 29% 2-3 metastases, 2 patients more than 3 metastases, 71% active extracranial disease. Median volume of metastatic lesions was 4.7 cm3, median radiosurgery dose 22 Gy (single fraction). 71% of patients received additional whole-brain irradiation (WBI). All patients were analyzed regarding survival, local, distant failure and prognostic factors, side effects and changes in neurologic symptoms after radiotherapy. The type of contrast-enhancement in MR imaging was also analyzed; metastatic lesions were classified as containing necrosis if they appeared as ring-enhancing with central areas of no or minimal contrast enhancement. Results Median survival was 7.0 months with 1-year and 5-year survival rates of 33% and 0.4%, respectively. Tumor necrosis (ring-enhancement) was visible on pretreatment MRI scans in 56% of all lesions and lesions with necrosis were larger than non-necrotic lesions (6.7 cm3 vs. 3.2 cm3, p = 0.01). Patients with tumor necrosis had a median survival of 5.4 months, patients without tumor necrosis 7.2 months. Local control rate in the irradiated volume was 70%, median survival without local failure 17.8 months. Control in the brain outside the irradiated volume was 60%, median survival without distant failure 14.0 months. Significant prognostic factors for overall survival were KPS (p = 0.001), presence of tumor necrosis on pretreatment MRI (p = 0.001) with RPA-class and WBI reaching marginal significance (each p = 0.05). Prognostic impact of tumor necrosis remained significant if only smaller tumors with a volume below 3.5 cm3 (p = 0.03). Side effects were rare, only one patient suffered from serious acute side effects. Conclusions Results of this retrospective study support that stereotactic radiotherapy is an effective treatment option for patients with metastatic brain lesions. The prognostic impact of visible tumor necrosis (ring-enhancement) on pretreatment MRI scans should be further investigated.
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Inoue HK, Seto KI, Nozaki A, Torikai K, Suzuki Y, Saitoh JI, Noda SE, Nakano T. Three-fraction CyberKnife radiotherapy for brain metastases in critical areas: referring to the risk evaluating radiation necrosis and the surrounding brain volumes circumscribed with a single dose equivalence of 14 Gy (V14). JOURNAL OF RADIATION RESEARCH 2013; 54:727-735. [PMID: 23404206 PMCID: PMC3709677 DOI: 10.1093/jrr/rrt006] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Revised: 12/28/2012] [Accepted: 01/08/2013] [Indexed: 05/31/2023]
Abstract
The efficacy and toxicity of three-fraction CyberKnife radiotherapy were evaluated in patients with brain metastases in critical areas. One hundred and fifty-nine metastases in 145 patients including tumors >10 cm(3) were treated with three-fraction CyberKnife radiotherapy with a median marginal dose of 27 Gy at a median prescribed isodose of 60%. Changes in the neurological manifestations, local tumor control and adverse effects were investigated after treatment. The surrounding brain volumes circumscribed with 23.1 Gy (single dose equivalence of 14 Gy: V14) were measured to evaluate the risk of adverse effects. Neurological manifestations, such as motor weakness, visual disturbances and aphasia improved in 26 of 97 patients (26.8%). Local tumor control was obtained in 137 of 143 metastases (95.8%) during a median follow-up of 7 months. Nine patients had symptomatic edema and three of them (2.1%) required surgical resection because of radiation necrosis. The V14 of these patients was 4.6-31.5 cm(3). There were 35 lesions with a V14 of 7 cm(3) or more and three of them developed extensive brain edema due to radiation necrosis. None of the patients with a V14 of <7 cm(3) exhibited edema requiring an operation. We therefore conclude that a high rate of local tumor control and low rates of complications are obtained after three-fraction CyberKnife radiotherapy for metastases in critical areas. The V14 of the surrounding brain therefore seems to be a useful indicator for the risk evaluation of radiation necrosis in patients with larger metastases.
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Affiliation(s)
- Hiroshi K Inoue
- Cyber Center, Kanto Neurosurgical Hospital, 1120 Dai, Kumagaya, Saitama, 360-0804, Japan.
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31
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Jereczek-Fossa BA, Bossi-Zanetti I, Mauro R, Beltramo G, Fariselli L, Bianchi LC, Fodor C, Fossati P, Baroni G, Orecchia R. CyberKnife robotic image-guided stereotactic radiotherapy for oligometastic cancer : A prospective evaluation of 95 patients/118 lesions. Strahlenther Onkol 2013; 189:448-55. [PMID: 23604189 DOI: 10.1007/s00066-013-0345-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 03/06/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate the outcome of robotic CyberKnife (Accuray Inc. Sunnyvale, USA)-based stereotactic radiotherapy (CBK-SRT) for oligometastic cancer patients. PATIENTS AND METHODS Between May 2007 and December 2009, 95 patients with a total of 118 lesions underwent CBK-SRT (median dose 24 Gy in 3 fractions). INCLUSION CRITERIA adult patients with limited volume cancer; suitability for SRT but not for other local therapies. Primary diagnoses included breast, lung, head and neck, gastrointestinal and other malignancies. Prostate cancer patients were excluded. Concomitant systemic therapy was given in 40 % of cases and median follow-up was 12 months. Toxicity and tumor response were evaluated using the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer (RTOG/EORTC) Scale and Response Evaluation Criteria in Solid Tumors RECIST. RESULTS Toxicity was rare and observed mainly in patients with comorbidities or uncontrolled cancer. Out of 87 evaluable lesions, complete radiological response, partial response, stabilization and progressive disease were observed in 15 (17 %), 25 (29 %), 34 (39 %) and 13 (15 %) lesions, respectively. Upon restricting the analysis to lesions treated with CBK-SRT alone (no concomitant therapy), response- and local control (LC) rates remained similar. Actuarial 3-year in-field progression-free survival- (i.e. LC), progression-free survival- (PFS) and overall-survival (OS) rates were 67.6, 18.4, and 31.2 %, respectively. LC was reduced in cases of early recurrence. OS- and cause-specific survival (CSS) rates were significantly lower in patients treated for visceral lesions. Failures were predominantly out-field. CONCLUSION CBK-SRT is a feasible therapeutic approach for oligometastastic cancer patients that provides long-term in-field tumor control with a low toxicity profile. Further investigations should focus on dose escalation and optimization of the combination with systemic therapies.
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Affiliation(s)
- B A Jereczek-Fossa
- Department of Radiotherapy, European Institute of Oncology, via Ripamonti 435, Milan, Italy.
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