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Kaur M, Cassinelli Petersen G, Jekel L, von Reppert M, Varghese S, Dixe de Oliveira Santo I, Avesta A, Aneja S, Omuro A, Chiang V, Aboian M. PACS-Integrated Tools for Peritumoral Edema Volumetrics Provide Additional Information to RANO-BM-Based Assessment of Lung Cancer Brain Metastases after Stereotactic Radiotherapy: A Pilot Study. Cancers (Basel) 2023; 15:4822. [PMID: 37835516 PMCID: PMC10571649 DOI: 10.3390/cancers15194822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
Stereotactic radiotherapy (SRT) is the standard of care treatment for brain metastases (METS) today. Nevertheless, there is limited understanding of how posttreatment lesional volumetric changes may assist prediction of lesional outcome. This is partly due to the paucity of volumetric segmentation tools. Edema alone can cause significant clinical symptoms and, therefore, needs independent study along with standard measurements of contrast-enhancing tumors. In this study, we aimed to compare volumetric changes of edema to RANO-BM-based measurements of contrast-enhancing lesion size. Patients with NSCLC METS ≥10 mm on post-contrast T1-weighted image and treated with SRT had measurements for up to seven follow-up scans using a PACS-integrated tool segmenting the peritumoral FLAIR hyperintense volume. Two-dimensional contrast-enhancing and volumetric edema changes were compared by creating treatment response curves. Fifty NSCLC METS were included in the study. The initial median peritumoral edema volume post-SRT relative to pre-SRT baseline was 37% (IQR 8-114%). Most of the lesions with edema volume reduction post-SRT experienced no increase in edema during the study. In over 50% of METS, the pattern of edema volume change was different than the pattern of contrast-enhancing lesion change at different timepoints, which was defined as incongruent. Lesions demonstrating incongruence at the first follow-up were more likely to progress subsequently. Therefore, edema assessment of METS post-SRT provides critical additional information to RANO-BM.
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Affiliation(s)
- Manpreet Kaur
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT 06510, USA; (M.K.); (L.J.)
- Medical Faculty, Ludwig-Maximilians-University of Munich, 80336 Munich, Germany
| | - Gabriel Cassinelli Petersen
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT 06510, USA; (M.K.); (L.J.)
| | - Leon Jekel
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT 06510, USA; (M.K.); (L.J.)
| | - Marc von Reppert
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT 06510, USA; (M.K.); (L.J.)
| | - Sunitha Varghese
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Irene Dixe de Oliveira Santo
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT 06510, USA; (M.K.); (L.J.)
| | - Arman Avesta
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT 06510, USA (S.A.)
| | - Sanjay Aneja
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT 06510, USA (S.A.)
| | - Antonio Omuro
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Veronica Chiang
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06510, USA
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT 06510, USA (S.A.)
| | - Mariam Aboian
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT 06510, USA; (M.K.); (L.J.)
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Kanayama N, Ikawa T, Ohira S, Hirata T, Morimoto M, Ogawa K, Teshima T, Konishi K. Volumetric reduction of brain metastases after stereotactic radiotherapy: Prognostic factors and effect on local control. Cancer Med 2022; 11:4806-4815. [PMID: 35535485 PMCID: PMC9761087 DOI: 10.1002/cam4.4809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/11/2022] [Accepted: 04/25/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND AND PURPOSE Few reports include volumetric measurements as endpoints after stereotactic radiotherapy (SRT) despite the importance of such measurements. This study aimed to (1) investigate the impact of the volumetric response (specifically, an over 65% and over 90% volume reduction in brain metastases) at 6 months post-SRT on local control and (2) identify the predictive factors for a volumetric response of over 65% and over 90%. MATERIALS AND METHODS This study included 250 unresected brain metastases (>0.3 cc) treated with SRT. Doses were stratified according to the biological effective dose (BED). The BED was calculated using four models: linear-quadratic (LQ): α/β = 10; LQ: α/β = 20; LQ cubic: α/β = 12; and LQ linear: α/β = 10. The median prescription dose was 30 Gy/3 fractions (BED20, 45). The median follow-up time after SRT was 18.6 months (range, 6.4-81.8 months). RESULTS In the multivariate analysis, over 65% volume reduction and over 90% volume reduction were prognostic factors for local control (hazard ratio: 2.370, p = 0.011 and hazard ratio: 3.161, p = 0.014, respectively). A dose of 80% of the gross tumor volume (GTV) D80 > BED20 58 was a predictive factor for over 65% and over 90% volume reductions (odds ratio: 1.975, p = 0.023; odds ratio: 3.204, p < 0.001, respectively). CONCLUSION Robust volume reduction of brain metastases at 6 months post-SRT can predict local control. GTV D80 in the LQ model: α/β = 20 may be warranted for good volume reduction.
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Affiliation(s)
- Naoyuki Kanayama
- Department of Radiation Oncology, Osaka International Center InstituteOsakaJapan
| | - Toshiki Ikawa
- Department of Radiation Oncology, Osaka International Center InstituteOsakaJapan
| | - Shingo Ohira
- Department of Radiation Oncology, Osaka International Center InstituteOsakaJapan
| | - Takero Hirata
- Department of Radiation OncologyOsaka University Graduate School of MedicineOsakaJapan
| | - Masahiro Morimoto
- Department of Radiation Oncology, Osaka International Center InstituteOsakaJapan
| | - Kazuhiko Ogawa
- Department of Radiation OncologyOsaka University Graduate School of MedicineOsakaJapan
| | | | - Koji Konishi
- Department of Radiation Oncology, Osaka International Center InstituteOsakaJapan
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Gutsche R, Lohmann P, Hoevels M, Ruess D, Galldiks N, Visser-Vandewalle V, Treuer H, Ruge M, Kocher M. Radiomics outperforms semantic features for prediction of response to stereotactic radiosurgery in brain metastases. Radiother Oncol 2021; 166:37-43. [PMID: 34801629 DOI: 10.1016/j.radonc.2021.11.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/03/2021] [Accepted: 11/10/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Brain metastases show different patterns of contrast enhancement, potentially reflecting hypoxic and necrotic tumor regions with reduced radiosensitivity. An objective evaluation of these patterns might allow a prediction of response to radiotherapy. We therefore investigated the potential of MRI radiomics in comparison with the visual assessment of semantic features to predict early response to stereotactic radiosurgery in patients with brain metastases. PATIENTS AND METHODS In this retrospective study, 150 patients with 308 brain metastases from solid tumors (NSCLC in 53% of patients) treated by stereotactic radiosurgery (single dose of 17-20 Gy) were evaluated. The response of each metastasis (partial or complete remission vs. stabilization or progression) was assessed within 180 days after radiosurgery. Patterns of contrast enhancement in the pre-treatment T1-weighted MR images were either visually classified (homogenous, heterogeneous, necrotic ring-like) or subjected to a radiomics analysis. Random forest models were optimized by cross-validation and evaluated in a hold-out test data set (30% of metastases). RESULTS In total, 221/308 metastases (72%) responded to radiosurgery. The optimal radiomics model comprised 10 features and outperformed the model solely based on semantic features in the test data set (AUC, 0.71 vs. 0.56; accuracy, 69% vs. 54%). The diagnostic performance could be further improved by combining semantic and radiomics features resulting in an AUC of 0.74 and an accuracy of 75% in the test data set. CONCLUSION The developed radiomics model allowed prediction of early response to radiosurgery in patients with brain metastases and outperformed the visual assessment of patterns of contrast enhancement.
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Affiliation(s)
- Robin Gutsche
- Inst. of Neuroscience and Medicine (INM-3, -4), Research Center Juelich, Germany; RWTH Aachen University, Germany; Dept. of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany.
| | - Philipp Lohmann
- Inst. of Neuroscience and Medicine (INM-3, -4), Research Center Juelich, Germany; Dept. of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Mauritius Hoevels
- Dept. of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Daniel Ruess
- Dept. of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Norbert Galldiks
- Inst. of Neuroscience and Medicine (INM-3, -4), Research Center Juelich, Germany; Center for Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne and Duesseldorf, Germany; Dept. of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Veerle Visser-Vandewalle
- Dept. of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Harald Treuer
- Dept. of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Maximilian Ruge
- Dept. of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Center for Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne and Duesseldorf, Germany
| | - Martin Kocher
- Inst. of Neuroscience and Medicine (INM-3, -4), Research Center Juelich, Germany; Dept. of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
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Abstract
A significant proportion of metastatic renal cell carcinoma (mRCC) patients present with oligometastatic disease. Retrospective and limited prospective data suggests that a subgroup of patients with oligometastatic mRCC benefits from aggressive local therapy. With the emerging data of high local control efficacy with low toxicity of stereotactic ablative radiation (SAbR) for both CNS and extra-cranial mRCC, SAbR may play a critical role in the multi-modality management of mRCC patients with oligometastatic disease. In addition to local control benefit, the benefit of SAbR in this patient population can range from longitudinal disease control, maintaining quality of life, deferring systemic therapy, immune-modulation and even improving survival. A review of the retrospective data suggests that SAbR benefits oligometastatic mRCC patients with metachronous metastases, and perhaps those with indolent biology. Large prospective trials are indicated to successfully integrate SAbR of oligometastatic mRCC with the available systemic therapies to harness the optimal benefit of SAbR for this patient population.
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Affiliation(s)
- Sean All
- Department of Radiation Oncology, University of Texas at Southwestern Medical Center, Dallas, TX
| | - Aurelie Garant
- Department of Radiation Oncology, University of Texas at Southwestern Medical Center, Dallas, TX
| | - Raquibul Hannan
- Department of Radiation Oncology, University of Texas at Southwestern Medical Center, Dallas, TX.
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Poon DMC, Chan CK, Chan K, Chu WH, Kwong PWK, Lam W, Law KS, Lee EKC, Liu PL, Sze HCK, Wong JHM, Chan ESY. Consensus statements on the management of metastatic renal cell carcinoma from the Hong Kong Urological Association and the Hong Kong Society of Uro-Oncology 2019. Asia Pac J Clin Oncol 2021; 17 Suppl 3:27-38. [PMID: 33860644 DOI: 10.1111/ajco.13581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND To establish a set of consensus statements for the management of metastatic renal cell carcinoma, a total of 12 urologists and clinical oncologists from two professional associations in Hong Kong formed an expert consensus panel. METHODS Through a series of meetings and using the modified Delphi method, the panelists presented recent evidence, discussed clinical experiences, and drafted consensus statements on several areas of focus regarding the management of metastatic renal cell carcinoma. Each statement was eventually voted upon by every panelist based on the practicability of recommendation. RESULTS A total of 46 consensus statements were ultimately accepted and established by panel voting. CONCLUSIONS Derived from recent evidence and expert insights, these consensus statements were aimed at providing practical guidance to optimize metastatic renal cell carcinoma management and promote a higher standard of clinical care.
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Affiliation(s)
- Darren Ming-Chun Poon
- Comprehensive Oncology Centre, Hong Kong Sanatorium & Hospital, Happy Valley, Hong Kong.,Department of Clinical Oncology, The Chinese University of Hong Kong, Prince of Wales Hospital, New Territories, Hong Kong
| | - Chun-Ki Chan
- Division of Urology, Department of Surgery, Princess Margaret Hospital, New Territories, Hong Kong
| | - Kuen Chan
- Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | - Wing-Hong Chu
- Suite 418, Central Building, 1 Pedder Street, Central, Hong Kong
| | | | - Wayne Lam
- Department of Surgery, Queen Mary Hospital, University of Hong Kong, Hong Kong Island, Hong Kong
| | - Ka-Suet Law
- Department of Oncology, Princess Margaret Hospital, New Territories, Hong Kong
| | - Eric Ka-Chai Lee
- Department of Clinical Oncology, Tuen Mun Hospital, New Territories, Hong Kong
| | - Pak-Ling Liu
- Department of Surgery, Caritas Medical Centre, Kowloon, Hong Kong
| | | | - Joseph Hon-Ming Wong
- Division of Urology, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, New Territories, Hong Kong
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Oft D, Schmidt MA, Weissmann T, Roesch J, Mengling V, Masitho S, Bert C, Lettmaier S, Frey B, Distel LV, Fietkau R, Putz F. Volumetric Regression in Brain Metastases After Stereotactic Radiotherapy: Time Course, Predictors, and Significance. Front Oncol 2021; 10:590980. [PMID: 33489888 PMCID: PMC7820888 DOI: 10.3389/fonc.2020.590980] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 11/26/2020] [Indexed: 11/13/2022] Open
Abstract
Background There is insufficient understanding of the natural course of volumetric regression in brain metastases after stereotactic radiotherapy (SRT) and optimal volumetric criteria for the assessment of response and progression in radiotherapy clinical trials for brain metastases are currently unknown. Methods Volumetric analysis via whole-tumor segmentation in contrast-enhanced 1 mm³-isotropic T1-Mprage sequences before SRT and during follow-up. A total of 3,145 MRI studies of 419 brain metastases from 189 patients were segmented. Progression was defined using a volumetric extension of the RANO-BM criteria. A subset of 205 metastases without progression/radionecrosis during their entire follow-up of at least 3 months was used to study the natural course of volumetric regression after SRT. Predictors for volumetric regression were investigated. A second subset of 179 metastases was used to investigate the prognostic significance of volumetric response at 3 months (defined as ≥20% and ≥65% volume reduction, respectively) for subsequent local control. Results Median relative metastasis volume post-SRT was 66.9% at 6 weeks, 38.6% at 3 months, 17.7% at 6 months, 2.7% at 12 months and 0.0% at 24 months. Radioresistant histology and FSRT vs. SRS were associated with reduced tumor regression for all time points. In multivariate linear regression, radiosensitive histology (p=0.006) was the only significant predictor for metastasis regression at 3 months. Volumetric regression ≥20% at 3 months post-SRT was the only significant prognostic factor for subsequent control in multivariate analysis (HR 0.63, p=0.023), whereas regression ≥65% was no significant predictor. Conclusions Volumetric regression post-SRT does not occur at a constant rate but is most pronounced in the first 6 weeks to 3 months. Despite decreasing over time, volumetric regression continues beyond 6 months post-radiotherapy and may lead to complete resolution of controlled lesions by 24 months. Radioresistant histology is associated with slower regression. We found that a cutoff of ≥20% regression for the volumetric definition of response at 3 months post-SRT was predictive for subsequent control whereas the currently proposed definition of ≥65% was not. These results have implications for standardized volumetric criteria in future radiotherapy trials for brain metastases.
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Affiliation(s)
- Dominik Oft
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Manuel Alexander Schmidt
- Department of Neuroradiology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas Weissmann
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Johannes Roesch
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Veit Mengling
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Siti Masitho
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sebastian Lettmaier
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Benjamin Frey
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Luitpold Valentin Distel
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Florian Putz
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Miccio JA, Oladeru OT, Jun Ma S, Johung KL. Radiation Therapy for Patients with Advanced Renal Cell Carcinoma. Urol Clin North Am 2020; 47:399-411. [PMID: 32600541 DOI: 10.1016/j.ucl.2020.04.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Stereotactic radiosurgery and stereotactic body radiation therapy (SBRT) have led to a resurgence of the use of radiotherapy in the management of advanced renal cell carcinoma (RCC). These techniques provide excellent local control and palliation of metastatic sites of disease with minimal toxicity. Additionally, SBRT to the primary tumor may be efficacious and well tolerated in select patients that are not surgical candidates. Emerging data suggest that SBRT may potentiate the immune response, and current and future study will evaluate if SBRT can improve survival outcomes in patients with metastatic RCC.
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Affiliation(s)
- Joseph A Miccio
- Department of Therapeutic Radiology, Yale School of Medicine, 35 Park Street, New Haven, CT 06519, USA
| | | | - Sung Jun Ma
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263, USA
| | - Kimberly L Johung
- Department of Therapeutic Radiology, Yale School of Medicine, 35 Park Street, New Haven, CT 06519, USA.
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8
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Dengina N, Mitin T, Gamayunov S, Safina S, Kreinina Y, Tsimafeyeu I. Stereotactic body radiation therapy in combination with systemic therapy for metastatic renal cell carcinoma: a prospective multicentre study. ESMO Open 2019; 4:e000535. [PMID: 31673426 PMCID: PMC6802957 DOI: 10.1136/esmoopen-2019-000535] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 08/29/2019] [Accepted: 08/31/2019] [Indexed: 01/05/2023] Open
Abstract
Background Tyrosine kinase inhibitors (TKIs) and checkpoint inhibitors have been established as effective treatment for metastatic renal cell carcinoma (mRCC), but only a minority of patients achieve complete response. Additional strategies are necessary to improve these agents’ efficacy. Methods Patients with stable disease for at least 4 months on TKI or checkpoint inhibitors were included. Stereotactic body radiotherapy (SBRT) was delivered to an organ with comparable lesions, where one lesion was in the treatment target and the other one was intentionally left untreated (control lesion). Response in both lesions was scored using the Response Evaluation Criteria in Solid Tumors V.1.1 criteria 2 months after completion of SBRT. The primary endpoint was the rate of SBRT adverse events, and the secondary endpoints included the rate of reduction in target lesion size. Results 17 patients were enrolled (14 men and 3 women, median age: 54.5 years old). SBRT was delivered to the lungs (n=5), bones (n=4), lymph nodes (n=4), liver (n=1), primary renal cell carcinoma (RCC) (n=1) and locally recurrent RCC (n=2). The equivalent dose in 2 Gy with an alpha to beta ratio of 2.6 was 114 Gy. With a median follow-up of 8 months, the cumulative rate of SBRT-related toxicity (grade 1) was 12% (n=2), consisting of oesophagitis and skin erythema. No grade 2 or higher toxicity was detected. Radiographic response in the target lesion was seen in 13 patients (76%), with complete response in 5 (29%) patients and partial response in 8 (47%), including abscopal effect in 1 patient. Control lesions remained stable in 16 patients. The difference between response in the target and control lesions as judged by the mean sizes of these lesions before and at 2 months after SBRT was statistically significant (p<0.01). Fraction size of 10 Gy or greater was associated with complete response (p<0.01). Conclusion Extracranial SBRT in patients with mRCC treated with TKI or checkpoint inhibitors is well tolerated and could be effective. Trial registration number NCT02864615
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Affiliation(s)
- Natalia Dengina
- Department of Radiotherapy, Ulyanovsk Regional Clinical Cancer Center, Ulyanovsk, Russian Federation
| | - Timur Mitin
- Department of Radiation Medicine, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Sergey Gamayunov
- Department of Thoracic and Abdominal Surgery, Republic Clinical Cancer Center, Cheboksary, Russian Federation
| | - Sufia Safina
- Department of Medical Oncology, Republic Clinical Cancer Center, Kazan, Russian Federation
| | - Yuliya Kreinina
- Department of Brachytherapy, Russian Scientific Center of Roentgen Radiology, Moscow, Russian Federation
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9
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Stereotactic ablative radiation therapy for oligometastatic renal cell carcinoma (SABR ORCA): a meta-analysis of 28 studies. Eur Urol Oncol 2019; 2:515-523. [DOI: 10.1016/j.euo.2019.05.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 05/28/2019] [Indexed: 12/24/2022]
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10
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Mehrabian H, Detsky J, Soliman H, Sahgal A, Stanisz GJ. Advanced Magnetic Resonance Imaging Techniques in Management of Brain Metastases. Front Oncol 2019; 9:440. [PMID: 31214496 PMCID: PMC6558019 DOI: 10.3389/fonc.2019.00440] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 05/08/2019] [Indexed: 01/18/2023] Open
Abstract
Brain metastases are the most common intracranial tumors and occur in 20–40% of all cancer patients. Lung cancer, breast cancer, and melanoma are the most frequent primary cancers to develop brain metastases. Treatment options include surgical resection, whole brain radiotherapy, stereotactic radiosurgery, and systemic treatment such as targeted or immune therapy. Anatomical magnetic resonance imaging (MRI) of the tumor (in particular post-Gadolinium T1-weighted and T2-weighted FLAIR) provide information about lesion morphology and structure, and are routinely used in clinical practice for both detection and treatment response evaluation for brain metastases. Advanced MRI biomarkers that characterize the cellular, biophysical, micro-structural and metabolic features of tumors have the potential to improve the management of brain metastases from early detection and diagnosis, to evaluating treatment response. Magnetic resonance spectroscopy (MRS), chemical exchange saturation transfer (CEST), quantitative magnetization transfer (qMT), diffusion-based tissue microstructure imaging, trans-membrane water exchange mapping, and magnetic susceptibility weighted imaging (SWI) are advanced MRI techniques that will be reviewed in this article as they pertain to brain metastases.
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Affiliation(s)
- Hatef Mehrabian
- Physical Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Radiology and Biomedical Imaging, University of California, San Francisco (UCSF), San Francisco, CA, United States
| | - Jay Detsky
- Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Hany Soliman
- Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Arjun Sahgal
- Physical Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Greg J Stanisz
- Physical Sciences, Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Neurosurgery and Pediatric Neurosurgery, Medical University, Lublin, Poland
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Klausner G, Troussier I, Biau J, Jacob J, Schernberg A, Canova CH, Simon JM, Borius PY, Malouf G, Spano JP, Roupret M, Cornu P, Mazeron JJ, Valéry C, Feuvret L, Maingon P. Stereotactic Radiation Therapy for Renal Cell Carcinoma Brain Metastases in the Tyrosine Kinase Inhibitors Era: Outcomes of 120 Patients. Clin Genitourin Cancer 2019; 17:191-200. [PMID: 30926219 DOI: 10.1016/j.clgc.2019.02.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 01/11/2019] [Accepted: 02/13/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The objective of the study was to evaluate the outcomes in terms of efficacy and safety of a large consecutive series of 362 patients with renal cell carcinoma (RCC) brain metastases treated using stereotactic radiosurgery (SRS) in the tyrosine kinase inhibitor (TKI) era. PATIENTS AND METHODS From 2005 to 2015, 362 consecutive patients with brain metastases from RCC were treated using SRS in 1 fraction: 226 metastases (61 patients) using Gamma-Knife at a median of 18 Gy (50% isodose line); 136 metastases (63 patients) using linear accelerator at a median of 16 Gy (70% isodose line). The median patient age was 58 years. At the first SRS, 37 patients (31%) received a systemic treatment. Among systemic therapies, TKIs were the most common (65%). RESULTS The local control rates were 94% and 92% at 12 and 36 months, respectively. In multivariate analysis, a minimal dose >17 Gy and concomitant TKI treatment were associated with higher rates of local control. The overall survival rates at 12 and 36 months were 52% and 29%, respectively. In multivariate analysis, factors associated with poor survival included age ≥65 years, lower score index for SRS, concomitant lung metastases, time between RCC diagnosis and first systemic metastasis ≤4 months, occurrence during treatment with a systemic therapy, no history of neurosurgery, and persistence or occurrence of neurological symptoms at 3 months after SRS. Seventeen patients had Grade III/IV adverse effects of whom 3 patients presented a symptomatic radionecrosis. CONCLUSION SRS is highly effective in patients with brain metastases from RCC. Its association with TKIs does not suggest higher risk of neurologic toxicity.
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Affiliation(s)
- Guillaume Klausner
- Radiation Oncology Department, La Pitié-Salpêtrière Universitary Hospital, Paris, France.
| | - Idriss Troussier
- Radio-Oncology Department, Hopital Universitary of Geneva, Geneva, Switzerland
| | - Julian Biau
- Radio-Oncology Department, Lausanne Universitary Hospital (CHUV), Lausanne, Switzerland
| | - Julian Jacob
- Radiation Oncology Department, La Pitié-Salpêtrière Universitary Hospital, Paris, France
| | - Antoine Schernberg
- Radiation Oncology Department, Gustave Roussy Institut, Villejuif, France
| | - Charles-Henri Canova
- Radiation Oncology Department, La Pitié-Salpêtrière Universitary Hospital, Paris, France
| | - Jean-Marc Simon
- Radiation Oncology Department, La Pitié-Salpêtrière Universitary Hospital, Paris, France
| | - Pierre-Yves Borius
- Neurosurgery Department, La Pitié-Salpêtrière Universitary Hospital, Paris, France
| | - Gabriel Malouf
- Medical Oncology Department, La Pitié-Salpêtrière Universitary Hospital, Paris, France
| | - Jean-Philippe Spano
- Medical Oncology Department, La Pitié-Salpêtrière Universitary Hospital, Paris, France
| | - Morgan Roupret
- Urology Department, La Pitié-Salpêtrière Universitary Hospital, Paris, France
| | - Philippe Cornu
- Neurosurgery Department, La Pitié-Salpêtrière Universitary Hospital, Paris, France
| | - Jean-Jacques Mazeron
- Radiation Oncology Department, La Pitié-Salpêtrière Universitary Hospital, Paris, France
| | - Charles Valéry
- Neurosurgery Department, La Pitié-Salpêtrière Universitary Hospital, Paris, France
| | - Loïc Feuvret
- Radiation Oncology Department, La Pitié-Salpêtrière Universitary Hospital, Paris, France
| | - Philippe Maingon
- Radiation Oncology Department, La Pitié-Salpêtrière Universitary Hospital, Paris, France
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Freifeld Y, Margulis V, Woldu SL, Timmerman R, Brugarolas J, Hannan R. Stereotactic Body Radiation Therapy for Renal Cell Carcinoma with Inferior Vena Cava Thrombus – Initial Experience Report and Literature Review. KIDNEY CANCER 2019. [DOI: 10.3233/kca-180044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Yuval Freifeld
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vitaly Margulis
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Solomon L. Woldu
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert Timmerman
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James Brugarolas
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Division of Hematology/Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Raquibul Hannan
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
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13
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Haque W, Verma V, Butler E, Teh BS. Utilization of Stereotactic Radiosurgery for Renal Cell Carcinoma Brain Metastases. Clin Genitourin Cancer 2018; 16:e935-e943. [DOI: 10.1016/j.clgc.2018.03.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 03/23/2018] [Indexed: 11/16/2022]
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Overall survival after stereotactic radiotherapy or surgical metastasectomy in oligometastatic renal cell carcinoma patients treated at two Swedish centres 2005–2014. Radiother Oncol 2018; 127:501-506. [DOI: 10.1016/j.radonc.2018.04.028] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/18/2018] [Accepted: 04/21/2018] [Indexed: 11/21/2022]
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Current management of metastatic renal cell carcinoma: evolving new therapies. Curr Opin Support Palliat Care 2018; 11:231-237. [PMID: 28590313 DOI: 10.1097/spc.0000000000000277] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Targeted therapies have recently replaced cytokine treatments as the gold standard for management of metastatic renal cell carcinoma (mRCC). Currently approved treatments include the tyrosine kinase inhibitors sunitinib, pazopanib, axitinib, sorafenib, cabozantinib and lenvatinib; the vascular endothelial growth factor (VEGF) inhibitor bevacizumab; the mammalian target of rapamycin (mTOR) inhibitors everolimus and temsirolimus; and the immunologic nivolumab. The purpose of this review is to provide an updated analysis of the clinical data supporting the use of these agents in the first-line and second-line setting. RECENT FINDINGS In the first-line setting, pazopanib may be better tolerated than sunitinib, an individualized dosing sunitinib regimen based on toxicity might improve survival and cabozantinib appears to be an emerging option. In the second-line setting, three new therapies (cabozantinib, lenvatinib/everolimus and nivolumab) have shown superiority against everolimus, the previous standard therapy. The International Metastatic RCC Database Consortium prognostic model may be useful in guiding the selection of subsequent therapy and patients eligible for metastasectomy. SUMMARY Targeted therapies are the standard treatment for mRCC. Despite advancements in survival, progression-free survival and tolerability, these targeted therapies remain largely noncurative. Further characterization of the RCC oncogenic pathway, and the ongoing clinical trials should help optimize the management of mRCC.
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Improving the Prognostic Value of Disease-Specific Graded Prognostic Assessment Model for Renal Cell Carcinoma by Incorporation of Cumulative Intracranial Tumor Volume. World Neurosurg 2017; 108:151-156. [PMID: 28754641 DOI: 10.1016/j.wneu.2017.07.109] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 07/17/2017] [Accepted: 07/18/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND We tested the prognostic value of cumulative intracranial tumor volume (CITV) in the context of a disease-specific Graded Prognostic Assessment (ds-GPA) model for renal cell carcinoma (RCC) patients with brain metastasis (BM) treated with stereotactic radiosurgery (SRS). METHODS Patient and tumor characteristics were collected from RCC cohorts with new BM who underwent SRS. Univariable and multivariable logistic regression model was used to test the prognostic value of CITV, Karnofsky Performance Score (KPS), and the number of BM. Net reclassification index (NRI) and integrated discrimination improvement (IDI) were used to assess whether CITV improved the prognostic utility of RCC ds-GPA. RESULTS In univariable logistic regression models, CITV, KPS, and the number of BM were independently associated with RCC patient survival. In a multivariable Cox proportional hazard model, the association between CITV and survival remained robust after controlling for KPS and the number of BM (P = 0.042). The incorporation of the CITV into the RCC ds-GPA model (consisting of KPS and number of BM) improved prognostic accuracy with NRI >0 of 0.3156 (95% confidence interval [CI], 0.0883-0.5428; P = 0.0065) and IDI of 0.0151 (95% CI, 0.0036-0.0277; P = 0.0183). These findings were validated in an independent cohort of 107 SRS-treated RCC BM patients. CONCLUSION CITV is an important prognostic variable in SRS-treated RCC patients with BM. The prognostic value of the ds-GPA scale for RCC brain metastasis was enhanced by the incorporation of CITV.
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Siva S, Kothari G, Muacevic A, Louie AV, Slotman BJ, Teh BS, Lo SS. Radiotherapy for renal cell carcinoma: renaissance of an overlooked approach. Nat Rev Urol 2017. [PMID: 28631740 DOI: 10.1038/nrurol.2017.87] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Conventional radiotherapy previously had a limited role in the definitive treatment of renal cell carcinoma (RCC), owing to the disappointing outcomes of several trials and the perceived radioresistance of this type of cancer. In this context, radiotherapy has been relegated largely to the palliation of symptoms in patients with metastatic disease, with variable rates of response. Following the availability of newer technologies that enable safe delivery of high-dose radiotherapy, stereotactic ablative radiotherapy (SABR) has become increasingly used in patients with RCC. Preclinical evidence demonstrates that RCC cells are sensitive to ablative doses of radiotherapy (≥8-10 Gy). Trials in the setting of intracranial and extracranial oligometastases, as well as primary RCC, have demonstrated excellent tumour control using this approach. Additionally, an awareness of the capacity of high-dose radiation to stimulate antitumour immunity has resulted in novel combinations of SABR with immunotherapies. Here we describe the historical application of conventional radiotherapy, the current biological understanding of the effects of radiation, and the clinical evidence supporting the use of ablative radiotherapy in RCC. We also explore emerging opportunities to combine systemic targeted agents or immunotherapies with radiation. Radiotherapy, although once an overlooked approach, is moving towards the forefront of RCC treatment.
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Affiliation(s)
- Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Grattan Street, Melbourne, Victoria 3000, Australia
| | - Gargi Kothari
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Grattan Street, Melbourne, Victoria 3000, Australia
| | - Alexander Muacevic
- European Cyberknife Center, Max-Lebsche-Platz 31, Munich D-81377, Germany
| | - Alexander V Louie
- Department of Radiation Oncology, London Health Sciences Centre, 800 Commissioners Road East, PO Box 5010, London, Ontario N6A 5W9, Canada
| | - Ben J Slotman
- Radiation Oncology, VU University Medical Center, De Boelelaan, PO Box 7057, Amsterdam, 1007 MB, Netherlands
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, 6565 Fannin, Ste#DB1-077, Houston, Texas 77030, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356043, Seattle, Washington 98195-6043, USA
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18
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Current Role of Radiotherapy for Renal-Cell Carcinoma: Review. Clin Genitourin Cancer 2017; 15:183-187. [DOI: 10.1016/j.clgc.2016.09.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 09/07/2016] [Accepted: 09/11/2016] [Indexed: 11/23/2022]
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Mehrabian H, Desmond KL, Soliman H, Sahgal A, Stanisz GJ. Differentiation between Radiation Necrosis and Tumor Progression Using Chemical Exchange Saturation Transfer. Clin Cancer Res 2017; 23:3667-3675. [PMID: 28096269 DOI: 10.1158/1078-0432.ccr-16-2265] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 12/15/2016] [Accepted: 01/06/2017] [Indexed: 11/16/2022]
Abstract
Purpose: Stereotactic radiosurgery (SRS) is a common treatment used in patients with brain metastases and is associated with high rates of local control, however, at the risk of radiation necrosis. It is difficult to differentiate radiation necrosis from tumor progression using conventional MRI, making it a major diagnostic dilemma for practitioners. This prospective study investigated whether chemical exchange saturation transfer (CEST) was able to differentiate these two conditions.Experimental Design: Sixteen patients with brain metastases who had been previously treated with SRS were included. Average time between SRS and evaluation was 12.6 months. Lesion type was determined by pathology in 9 patients and the other 7 were clinically followed. CEST imaging was performed on a 3T Philips scanner and the following CEST metrics were measured: amide proton transfer (APT), magnetization transfer (MT), magnetization transfer ratio (MTR), and area under the curve for CEST peaks corresponding to amide and nuclear Overhauser effect (NOE).Results: Five lesions were classified as progressing tumor and 11 were classified as radiation necrosis (using histopathologic confirmation and radiographic follow-up). The best separation was obtained by NOEMTR (NOEMTR,necrosis = 8.9 ± 0.9%, NOEMTR,progression = 12.6 ± 1.6%, P < 0.0001) and AmideMTR (AmideMTR,necrosis = 8.2 ± 1.0%, AmideMTR,progression = 12.0 ± 1.9%, P < 0.0001). MT (MTnecrosis = 4.7 ± 1.0%, MTprogression = 6.7 ± 1.7%, P = 0.009) and NOEAUC (NOEAUC,necrosis = 4.3 ± 2.0% Hz, NOEAUC,progression = 7.2 ± 1.9% Hz, P = 0.019) provided statistically significant separation but with higher P values.Conclusions: CEST was capable of differentiating radiation necrosis from tumor progression in brain metastases. Both NOEMTR and AmideMTR provided statistically significant separation of the two cohorts. However, APT was unable to differentiate the two groups. Clin Cancer Res; 23(14); 3667-75. ©2017 AACR.
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Affiliation(s)
- Hatef Mehrabian
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada. .,Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Kimberly L Desmond
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Hany Soliman
- Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Greg J Stanisz
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Neurosurgery and Pediatric Neurosurgery, Medical University, Lublin, Poland
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20
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Mehrabian H, Desmond KL, Chavez S, Bailey C, Rola R, Sahgal A, Czarnota GJ, Soliman H, Martel AL, Stanisz GJ. Water Exchange Rate Constant as a Biomarker of Treatment Efficacy in Patients With Brain Metastases Undergoing Stereotactic Radiosurgery. Int J Radiat Oncol Biol Phys 2017; 98:47-55. [PMID: 28258890 DOI: 10.1016/j.ijrobp.2017.01.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 12/12/2016] [Accepted: 01/02/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE This study was designed to evaluate whether changes in metastatic brain tumors after stereotactic radiosurgery (SRS) can be seen with quantitative MRI early after treatment. METHODS AND MATERIALS Using contrast-enhanced MRI, a 3-water-compartment tissue model consisting of intracellular (I), extracellular-extravascular (E), and vascular (V) compartments was used to assess the intra-extracellular water exchange rate constant (kIE), efflux rate constant (kep), and water compartment volume fractions (M0,I, M0,E, M0,V). In this prospective study, 19 patients were MRI-scanned before treatment and 1 week and 1 month after SRS. The change in model parameters between the pretreatment and 1-week posttreatment scans was correlated to the change in tumor volume between pretreatment and 1-month posttreatment scans. RESULTS At 1 week kIE differentiated (P<.001) tumors that had partial response from tumors with stable and progressive disease, and a high correlation (R=-0.76, P<.001) was observed between early changes in the kIE and tumor volume change 1 month after treatment. Other model parameters had lower correlation (M0,E) or no correlation (kep, M0,V). CONCLUSIONS This is the first study that measured kIE early after SRS, and it found that early changes in kIE (1 week after treatment) highly correlated with long-term tumor response and could predict the extent of tumor shrinkage at 1 month after SRS.
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Affiliation(s)
- Hatef Mehrabian
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada; Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.
| | - Kimberly L Desmond
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Sofia Chavez
- Research Imaging Centre, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Colleen Bailey
- Computer Science Department, University College London, London, United Kingdom
| | - Radoslaw Rola
- Neurosurgery and Pediatric Neurosurgery, Medical University, Lublin, Poland
| | - Arjun Sahgal
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada; Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Gregory J Czarnota
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada; Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada; Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Hany Soliman
- Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Anne L Martel
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada; Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Greg J Stanisz
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada; Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada; Neurosurgery and Pediatric Neurosurgery, Medical University, Lublin, Poland
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21
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Qian JM, Yu JB, Kluger HM, Chiang VLS. Timing and type of immune checkpoint therapy affect the early radiographic response of melanoma brain metastases to stereotactic radiosurgery. Cancer 2016; 122:3051-8. [PMID: 27285122 DOI: 10.1002/cncr.30138] [Citation(s) in RCA: 153] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 05/09/2016] [Accepted: 05/23/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Growing evidence suggests that immunotherapy and radiation therapy can be synergistic in the treatment of cancer. This study was performed to determine the effect of the relative timing and type of immune checkpoint therapy on the response of melanoma brain metastases (BrMets) to treatment with stereotactic radiosurgery (SRS). METHODS Seventy-five melanoma patients with 566 BrMets were treated with both SRS and immune checkpoint therapy between 2007 and 2015 at a single institution. Immunotherapy and radiosurgery treatment of any single lesion were considered concurrent if SRS was administered within 4 weeks of immunotherapy. The impact of the timing and type of immunotherapy on the lesional response was determined with the Wilcoxon rank-sum test, which was used to compare the median percent lesion volume change 1.5, 3, and 6 months after SRS treatment, with significance determined by P = .0167 according to the Bonferroni correction for multiple comparisons. RESULTS Concurrent use of immunotherapy and SRS resulted in a significantly greater median percent reduction in the lesion volume at 1.5 (-63.1% vs -43.2%, P < .0001), 3 (-83.0% vs -52.8%, P < .0001), and 6 months (-94.9% vs -66.2%, P < .0001) in comparison with nonconcurrent therapy. The median percent reduction in the lesion volume was also significantly greater for anti-programmed cell death protein 1 (anti-PD-1) than anti-cytotoxic T-lymphocyte-associated protein 4 (anti-CTLA-4) at 1.5 (-71.1% vs -48.2%, P < .0001), 3 (-89.3% vs -66.2%, P < .0001), and 6 months (-95.1% vs -75.9%, P = .0004). CONCLUSIONS The administration of immunotherapy within 4 weeks of SRS results in an improved lesional response of melanoma BrMets in comparison with treatment separated by longer than 4 weeks. Anti-PD-1 therapy also results in a greater lesional response than anti-CTLA-4 after SRS. Cancer 2016;122:3051-3058. © 2016 American Cancer Society.
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Affiliation(s)
- Jack M Qian
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - James B Yu
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Harriet M Kluger
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Veronica L S Chiang
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut. .,Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut.
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Stereotactic Radiosurgery for Renal Cancer Brain Metastasis: Prognostic Factors and the Role of Whole-Brain Radiation and Surgical Resection. JOURNAL OF ONCOLOGY 2015; 2015:636918. [PMID: 26681942 PMCID: PMC4668321 DOI: 10.1155/2015/636918] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 10/07/2015] [Accepted: 10/08/2015] [Indexed: 11/20/2022]
Abstract
Background. Renal cell carcinoma is a frequent source of brain metastasis. We present our consecutive series of patients treated with Stereotactic Radiosurgery (SRS) and analyse prognostic factors and the interplay of WBRT and surgical resection. Methods. This is a retrospective study of 66 patients with 207 lesions treated with the Cyberknife radiosurgery system in our institution. The patients were followed up with imaging and clinical examination 1 month and 2-3 months thereafter for the brain metastasis. Patient, treatment, and outcomes characteristics were analysed. Results. 51 male (77.3%) and 15 female (22.7%) patients, with a mean age of 58.9 years (range of 31–85 years) and a median Karnofsky Performance Status (KPS) of 90 (range of 60–100), were included in the study. The overall survival was 13.9 months, 21.9 months, and 5.9 months for the patients treated with SRS only, additional surgery, and WBRT, respectively. The actuarial 1-year Local Control rates were 84%, 94%, and 88% for SRS only, for surgery and SRS, and for WBRT and additional SRS, respectively. Conclusions. Stereotactic radiosurgery is a safe and effective treatment option in patients with brain metastases from RCC. In case of a limited number of brain metastases, surgery and SRS might be appropriate.
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23
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Bex A. Integrating metastasectomy and stereotactic radiosurgery in the treatment of metastatic renal cell carcinoma. EJC Suppl 2015. [PMID: 26217128 PMCID: PMC4041303 DOI: 10.1016/j.ejcsup.2013.07.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Axel Bex
- The Netherlands Cancer Institute, Department of Urology, Amsterdam, The Netherlands
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24
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Husillos Alonso A, Carbonero García M, González Enguita C. Is there a role for systemic targeted therapy after surgical treatment for metastases of renal cell carcinoma? World J Nephrol 2015; 4:254-262. [PMID: 25949939 PMCID: PMC4419135 DOI: 10.5527/wjn.v4.i2.254] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 01/18/2015] [Accepted: 02/09/2015] [Indexed: 02/06/2023] Open
Abstract
Metastatic renal cell carcinoma (mRCC) is a challenging disease. Despite the new targeted therapies, complete remissions occur only in 1%-3% of the cases, and the most effective first-line treatment drugs have reached a ceiling in overall survival (ranging from 9 to 49 mo). Metastasectomy remains to be the only curative option in most patients with mRCC. Prognostic nomograms have been recently published, so we have tools to classify patients in risk groups, allowing us to detect the cases with the higher risk of recurrence after metastasectomy. Although sparse, there is some evidence of effectiveness of neoadjuvant targeted therapy before metastasectomy; but with an increase in surgical complications due to the effects of these new drugs in tissue healing. We have aimed to answer the question: Is there a role for systemic targeted therapy after surgical treatment for metastases of renal cell carcinoma? We have made a search in Pubmed database. As far as we know, evidence is low and it’s based in case reports and small series of patients treated with adjuvant drugs after neoadjuvant therapy plus metastasectomy in cases of partial response to initial systemic treatment. Despite the limitations and high risk of bias, promising results and cases with long-term survival with this approach have been described. Two ongoing clinical trials may answer the question that concerns us.
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25
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Sharpton SR, Oermann EK, Moore DT, Schreiber E, Hoffman R, Morris DE, Ewend MG. The volumetric response of brain metastases after stereotactic radiosurgery and its post-treatment implications. Neurosurgery 2014; 74:9-15; discussion 16; quiz 16. [PMID: 24077581 DOI: 10.1227/neu.0000000000000190] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Changes in tumor volume are seen on magnetic resonance imaging within weeks after stereotactic radiosurgery (SRS), but it remains unclear what clinical outcomes early radiological changes portend. OBJECTIVE We hypothesized that rapid, early reduction in tumor volume post-SRS is associated with prolonged local control and favorable clinical outcome. METHODS A retrospective review of patients treated with CyberKnife SRS for brain metastases at the University of North Carolina from 2007 to 2009 was performed. Patients with at least 1 radiological follow-up, minimal initial tumor volume of 0.1 cm, no previous focal radiation, and no recent whole-brain radiation therapy were eligible for inclusion. RESULTS Fifty-two patients with 100 metastatic brain lesions were analyzed and had a median follow-up of 15.6 months (range, 2-33 months) and a median of 2 (range, 1-8) metastatic lesions. In treated metastases in which there was a significant tumor volume reduction by 6 or 12 weeks post-SRS, there was no local progression for the duration of the study. Furthermore, patients with metastases that did not reduce in volume by 6 or 12 weeks post-SRS were more likely to require corticosteroids (P = .01) and to experience progression of neurological symptoms (P = .003). CONCLUSION Significant volume reductions of brain metastases measured at either 6 or 12 weeks post-SRS were strongly associated with prolonged local control. Furthermore, early volume reduction was associated with less corticosteroid use and stable neurological symptoms.
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Affiliation(s)
- Suzanne R Sharpton
- *Department of Internal Medicine, University of California San Francisco, San Francisco, California; ‡Department of Neurological Surgery, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North California; §Department of Biostatistics, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North California; ¶Radiation Oncology, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North California
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Xu Q, Wu P, Feng Y, Ye K, Tong Y, Zhou Y. Gamma knife surgery for brain metastasis from hepatocellular carcinoma. PLoS One 2014; 9:e88317. [PMID: 24516635 PMCID: PMC3917852 DOI: 10.1371/journal.pone.0088317] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 01/06/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The authors evaluated the results of Gamma knife surgery (GKS) for the treatment of metastatic brain tumors from hepatocellular carcinoma (HCC). METHODS AND RESULTS The authors conducted a retrospective review of the clinical characteristics and treatment outcomes in 14 patients with metastatic brain tumors from HCC who underwent GKS. Twelve (85.7%) patients were male. The mean age of the patients was 53±12 years. There were totally 22 brain metastases in 14 patients and 8 patients (57.1%) presented with a single brain lesion. Intracranial hemorrhages occurred in 13 (59.1%) of the 22 lesions. The mean KPS score was 81±14 (range 50-100). Eleven (78.6%) patients were classified as RTOG RPA Class 2. The mean tumor volume was 8.16±8.15 cm(3) (range 0.59-27.0 cm(3)). The mean marginal dose prescribed was 18.7±3.2 Gy (range 10.0-22.0 Gy). The mean number of shots administered was 10±9 (range 1-27). The median overall survival time after GKS was 5.0±0.93 months (95% CI 3.2-6.8). No complications related to the radiosurgical treatment were identified. Multivariate analysis showed that the total volume of brain metastases, the RTOG RPA class and serum AFP level were significantly correlated with patients' survival time. CONCLUSIONS Although survival was extremely poor in patients with brain metastasis (BM) from HCC, GKS was shown to lead to prolongation of the survival time. Accordingly, GKS can be considered as a valuable treatment option for proper patients with HCC BM.
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Affiliation(s)
- Qingsheng Xu
- Department of Neurosurgery, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, P. R. China
- * E-mail:
| | - Pan Wu
- Department of Neurosurgery, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, P. R. China
| | - Yiping Feng
- Department of Neurosurgery, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, P. R. China
| | - Ke Ye
- Department of Neurosurgery, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, P. R. China
| | - Ying Tong
- Department of Neurosurgery, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, P. R. China
| | - Yongqing Zhou
- Department of Neurosurgery, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, P. R. China
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Han JH, Kim DG, Chung HT, Paek SH, Park CK, Kim CY, Kim YH, Jung HW. Stereotactic radiosurgery for brain metastases from hepatocellular carcinoma. J Neurooncol 2013; 115:45-51. [PMID: 23813231 DOI: 10.1007/s11060-013-1192-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 06/23/2013] [Indexed: 01/11/2023]
Abstract
The purpose of this study is to investigate the possible role of stereotactic radiosurgery (SRS) in the management of patients with brain metastases from hepatocellular carcinoma (HCC). Thirty-two consecutive patients with 80 brain metastases from HCC were treated with SRS. Twenty-eight (87.5 %) patients were male, and the mean age of the patients was 54 ± 12 years (range 22-73). Twenty-seven (84.4 %) patients were classified as RTOG RPA Class 2. The mean tumor volume was 6.14 ± 11.3 cm(3) (range 0.01-67.3). The mean marginal dose prescribed was 20.1 ± 3.6 Gy (range 10.0-25.0). The median overall survival time after SRS was 11.3 ± 5.8 weeks (95 % CI 0-22.7). A greater total volume of brain metastases (>14 cm(3)) was the only independent prognostic factor (HR = 2.419; 95 % CI 1.040-5.624; p = 0.040). The actuarial control rate of brain metastases was 51.3 % at 4 months after SRS. The prescribed marginal dose (>18 Gy) was significantly related with the actuarial tumor control (HR = 0.254; 95 % CI 0.089-0.725; p = 0.010). The prognosis of patients with brain metastases from HCC is dismal even with the modern technology of radiosurgery. The marginal dose prescribed should be reevaluated to improve upon the current poor local control rates.
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Affiliation(s)
- Jung Ho Han
- Department of Neurosurgery, Seoul National University Bundang Hospital, Gyeonggi-do, Seongnam, Korea
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Blanco AI, Teh BS, Amato RJ. Role of radiation therapy in the management of renal cell cancer. Cancers (Basel) 2011; 3:4010-23. [PMID: 24213122 PMCID: PMC3763407 DOI: 10.3390/cancers3044010] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Revised: 10/11/2011] [Accepted: 10/19/2011] [Indexed: 12/11/2022] Open
Abstract
Renal cell carcinoma (RCC) is traditionally considered to be radioresistant; therefore, conventional radiotherapy (RT) fraction sizes of 1.8 to 2 Gy are thought to have little role in the management of primary RCC, especially for curative disease. In the setting of metastatic RCC, conventionally fractionated RT has been an effective palliative treatment in 50% of patients. Recent technological advances in radiation oncology have led to the clinical implementation of image-guided radiotherapy, allowing biologically potent doses to the tumors intra- and extra-cranially. As predicted by radiobiologic modeling, favorable outcomes have been observed with highly hypofractionated schemes modeled after the experience with intracranial stereotactic radiosurgery (SRS) for RCC brain metastases with reported local control rates averaging 85%. At present, both primary and metastatic RCC tumors may be successfully treated using stereotactic approaches, which utilize steep dose gradients to maximally preserve function and avoid toxicity of adjacent organs including liver, uninvolved kidney, bowel, and spinal cord regions. Future endeavors will combine stereotactic body radiation therapy (SBRT) with novel targeted therapies, such as tyrosine kinase inhibitors and targeted rapamycin (mTOR) inhibitors, to maximize both local and systemic control.
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Affiliation(s)
- Angel I. Blanco
- Department of Radiation Oncology, The Methodist Hospital, The Methodist Hospital Research Institute, Houston, TX 77030, USA; E-Mails: (A.I.B.); (B.S.T.)
- Department of Radiation Oncology, The Methodist Hospital, Houston, TX 77030, USA
| | - Bin S. Teh
- Department of Radiation Oncology, The Methodist Hospital, The Methodist Hospital Research Institute, Houston, TX 77030, USA; E-Mails: (A.I.B.); (B.S.T.)
- Department of Radiation Oncology, The Methodist Hospital, Houston, TX 77030, USA
| | - Robert J. Amato
- Division of Oncology, University of Texas Health Science Center at Houston, Memorial Hermann Cancer Center, Houston, TX 77030, USA
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +1-832-325-7702; Fax: +1-179-512-7132
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